Do continuity and co-ordination of care influence quality of care and health outcomes?

1. Do continuity and co-ordination of care influence quality of care and health outcomes? Stephen Campbell, David Reeves, Elizabeth Middleton, Martin Roland National Primary Care Research and Development Centre, University of Manchester

2. Sample National sample of 42 general practices in England Random sample of 2300 patients with asthma, diabetes and ischaemic heart disease

3. Continuity of care (from patient questionnaire) • Co-ordination of care (from patient questionnaire) • Interpersonal care (from patient questionnaire) • Quality of clinical care (from record review) • Health status (from patient questionnaire) • Co-morbidity (from patient questionnaire and record review)

4. Methods (1) Quality of care for asthma, diabetes and ischaemic heart disease. Review of 20 randomly selected medical records per practice. Application by trained researchers of review criteria developed by expert panels Campbell S et al. The development of review criteria for assessing the quality of management of stable angina, adult asthma and non insulin dependent diabetes mellitus in general practice. Quality in Health Care 1999; 8: 6-15 Campbell SM et al. Quality assessment for three common condition in primary care: validity and reliability of review criteria developed by expert panels for angina, asthma and type 2 diabetes. Quality and Safety in Health Care 2002; 11: 125-130

5. Methods (continued) Patient evaluation of inter-personal aspects of care from the General Practice Assessment Questionnaire (www.gpaq.info) Ramsay J, Campbell J, Schroter S, Green J, Roland M. The General Practice Assessment Survey (GPAS): tests of data quality and measurement properties. Family Practice 2000; 15: 272-9 Bower P, Mead N, Roland M. What dimensions underlie patient responses to the General Practice Assessment Survey? Family Practice 2002; 19: 489-495.

6. Questions on continuity of care In general, how often do you see your usual doctor? Always, almost always, a lot of the time, some of the time, almost never, never How do you rate this? Very poor, poor, fair, good, very good, excellent

7. Questions on co-ordination of care (1) In the past 12 months has your doctor referred you to another health professional inside your practice (e.g. nurse, counsellor, physiotherapists etc) How well informed was the other health professional about your problem and any treatment you were having? How well informed was your own doctor about the outcome of your referral?

8. Questions on co-ordination of care (2) In the past 12 months, has your doctor referred you to another health professional outside your practice (e.g. hospital specialist etc) How well informed was the other health professional about your problem and any treatment you were having? How well informed was your own doctor about the outcome of your referral?

9. Methods (continued) • Co-morbidity – from list of conditions in patient questionnaire • Health status (1) - disease specific questionnaires for asthma, diabetes and CHD • Health status (2) - SF6

10. Communication Continuity Co-ordination Quality of clinical care Health status

11. Significant associations (n=833) • Age and number of conditions • Age and health status • Number of conditions and number of GP visits • Number of conditions and number of nurse visits • Number of GP visits and health status • Health status (SF-6) to disease specific health status measures • Continuity, co-ordination and communication

12. Non significant associations Everything else

13. Communication Continuity Co-ordination Quality of clinical care Health status

14. .32 .58 .30 Communication Continuity Co-ordination - .04 - .05 .09 Quality of clinical care - .07 Health status n=606 2 for model = 10.2 (3df) Comparative fit index = 0.978 correlation coefficients regression coefficients

15. Explanations: No association exists Association exists but measures inadequate or inappropriate to detect it Association exists and measures adequate, but method faulty in some other way