Monday, May 23, 2016

Does convenience outweigh continuity of care?

Several years ago, after leaving my scientific position at AHRQ and feeling that my patient care skills had become rusty, I took a part-time job as a staff physician at a rapidly growing chain of urgent care centers. I thought that urgent care's relatively limited scope of practice would ease my transition back into the clinic, and though the pace was often intense, I quickly became comfortable sewing up lacerations, draining abscesses, diagnosing fractures, and fishing various objects out of ears and noses. All in all, it was a rewarding experience: my physician colleagues were friendly and experienced, the support staff skilled and professional, and since we stayed open from from 7 AM to 10 PM every day of the year, our walk-in patients were generally grateful to be seen.

After about a year of this work, I decided to return to academic medicine. During my interview, I mentioned to the then-Department Chair that I had been working in urgent care. He visibly grimaced, then said something about urgent care centers "skimming the cream" of primary care and leaving full-service family practices with the more complex and less lucrative types of visits. And I couldn't really disagree. If there's one axiom at the heart of family medicine, it's the importance of continuity of care - meaning, whether you feel sick or well, seeing a doctor who knows you will make it more likely you will get the care you need. A systematic review in the Journal of Family Practice and a more recent review in the Journal of Evaluation in Clinical Practice both concluded that increased continuity was associated with higher quality care, better outcomes, and higher patient satisfaction.

The problem with prioritizing continuity of care is ensuring access. My current practice is open until 8 PM two evenings per week and, until recently, we also saw patients on Saturday mornings. But none of us really like to work on Saturdays, and we recently learned that of all the primary care practices in our health system, we are the only ones who ever even try be open on that day. Further, the nature of an academic practice is that my colleagues and I are only each at the office a day or two per week, further limiting the ability of patients to see the same doctor every time. Can continuity of care be said to have the same value if it's only with the same office, rather than the same person? It's a question that needs answering, as a study from the Robert Graham Center found that an increasing proportion of Americans identify an office or facility, rather than an individual clinician, as their usual source of health care.

Finally, retail health clinics (think CVS's Minute Clinics), like urgent care centers, have emerged and prospered as a response to deficiencies in primary care access, but handle a more limited range of acute problems and are staffed by nurse practitioners rather than physicians. On one hand, retail clinics may disrupt continuity of care, but on certain measures of quality, such as antibiotic prescribing for respiratory infections, they are more likely to adhere to national guidelines. And even a respected health policy researcher such as Dr. Aaron E. Carroll, a professor of pediatrics at Indiana University, admits that he would rather take his child to a retail clinic for a sore throat than deal with the hassle of getting a same-day appointment with their usual physician. So much for continuity of care and the patient-centered medical home that physician groups have been advocating for the past decade as the solution to excessive health spending and mediocre outcomes! Or can these concepts coexist with the convenience of urgent and retail health care?

1 comment:

  1. This commentary is an excellent summary of the present state of the healthcare industry and the staunch resistance of the medical community to the rapid changes takes place all around them.

    I started a walk-in clinic staffed by nurse practitioners in a hospital and was barraged by local doctors as competing with their practice. So we limited access to 'after hours' and quickly noted an increase in the use of the ED by the patients of those same doctors who reported they were using the ED because they couldn't get to see their regular doctor in a timely manner.

    I tried to regionalize the hospitalists so a population of inpatients would see the same physician each day during their hospitalization. After a few weeks, the hospitalists complained about the uneven case load each day and preferred that patients be reassigned daily to 'balance' the load among the doctors on duty. Our patients now see an average of 2-3 different hospitalists during their average 4.5 length of stay.

    Similarly, the use of 10-12 hour nursing shifts disrupts continuity but when I tried to change it to a combination of 8 and 10 hour shifts, the CNO predicted an exodus of nursing to the competing facility. So our patients may see 3-4 different primary nurses during their hospitalization.

    Continuity is a desirable goal but given today's reality, access is king.