Continuity of Care and the Physician-Patient Relationship

What is special about the physician-patient relationship over time for patients with asthma? Our findings suggest that for these patients, understanding of their disease and treatment and a feeling of comanagement with the physician are crucial and seem to be directly related to continuity of care. The patterns we saw in the patients with asthma are consistent with previous work that suggests the importance of continuity of care to patients with chronic illnesses. These patients have reported valuing continuity more than do patients with acute problems,²² and persons with asthma have reported willingness to wait more days for care from their regular physician for moderately serious acute illnesses.¹⁴ Studies from the 1980s found that patients with chronic illnesses maintained greater continuity with individual physicians.^23,24 The respondents with asthma in this 1997 survey did not report greater continuity than those who did not have it. This makes the prominent role of continuity in their evaluations of the physician-patient relationship more interesting, because differences in the level of continuity do not explain the importance of continuity. The respondents with asthma did report significantly more health care visits than those without asthma. Thus, they maintained high levels of continuity across a more challenging number of visits.

When patients concentrate their care with a single physician, those physicians are more likely to develop an accumulated knowledge about their patients’ medical conditions. This knowledge goes beyond simply knowing the patient’s diagnoses and medications. It includes a finer understanding of the severity of each medical problem and how multiple problems interact. More important, it includes the development of a relationship between the patient and the physician and awareness of the patient’s knowledge of the disease and personal preferences for medical treatment.

It has been argued that the importance of continuity of care cannot be conceptualized simply as the frequency of seeing one physician versus another.²⁵ However, personal continuity suggests an ongoing therapeutic relationship between the patient and the physician. In this case, the nature and quality of the contacts are more important than the number. The current data suggest that perhaps the importance of continuity to the ongoing therapeutic relationship is heightened for patients with asthma. It may be that the immediately perceptible morbidity of an asthma exacerbation and the relief provided by the physician contribute to the patient’s evaluation of the relationship. Positive qualities of physician-patient interaction have been linked to satisfaction for patients with ongoing medical problems²⁶ and to “better health” in chronically ill patients.¹⁵ Policies and practices that encourage continuity and an effective therapeutic relationship between the patient and the physician should be investigated and implemented. In the current environment of proposals for disease management treatment teams for diseases such as asthma, it is important that continuity of care between the patient and the physician is not completely eliminated through the use of multiple providers.

Limitations

Our study has several limitations. First, the data were based on self-reports. We did not independently validate either the diagnosis of asthma or reported utilization of care. However, chronic diseases have been successfully assessed through self-reports in a variety of large-scale surveys, such as the National Health Interview Survey. Moreover, the utilization questions are based on reliable and valid items from the CAHPS. Continuity of care was also assessed using a single item asking respondents about the level of continuity they experienced with an individual physician in the past year. The merits of this item as an assessment of perceived continuity include its distinct reference to continuity rather than asking whether the respondent has a regular or usual physician. Single-item reports of having a regular or usual physician have been interpreted as continuity of care.^21,27,28 However, having a regular or usual physician is not the same as maintaining continuity of care with an individual provider over time. For example, a patient who reports having a regular physician may see other physicians in that practice for a majority of visits because that regular provider is frequently unavailable when the patient needs acute care. A second limitation of our study is that the data came from a survey of participants in a Medicaid program, thereby potentially affecting the generalizability of the results to a more affluent population. In the Kentucky Medicaid fee-for-service program, recipients may have greater choice of physicians than participants in more restrictive health care plans.

Conclusions

The results of our study of an existing data set suggest several directions for future research. One direction would be to look more specifically at the patient-physician relationship and its impact on outcomes. Patients’ trust in their physicians may be particularly important in understanding continuity of care for chronically ill patients.²⁹ Further research into the mechanisms linking continuity of care and characteristics of the physician-patient relationship could begin to discern the direction of influence between them and their combined impact on health outcomes.