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The Effect of Continuity of Care on Emergency Department Use
James M. Gill, MD, MPH;
Arch G. Mainous III, PhD;
Musa Nsereko, BDS, MPH
Arch Fam Med. 2000;9:333-338.
ABSTRACT
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Objective To examine whether continuity of care with an individual health care provider is associated with the number of hospital emergency department (ED) visits in a statewide Medicaid population.
Design A cross-sectional study based on a 100% sample of Delaware Medicaid claims for 1 year (July 1, 1993, to June 30, 1994). Continuity with a single provider during the year was computed for each participant.
Setting The state of Delaware.
Participants Continuously enrolled Medicaid clients aged 0 to 64 years who had made at least 3 physician office visits during the study year (N=11,474).
Intervention None.
Main Outcome Measures Likelihood of making a single ED visit or multiple ED visits during the study year.
Results In multivariate analysis, continuity is associated with a significantly lower likelihood of making a single ED visit (odds ratio, 0.82; 95% confidence interval, 0.70-0.95), and is even more strongly associated with a lower likelihood of making multiple ED visits (odds ratio, 0.65; 95% confidence interval, 0.56-0.76).
Conclusions This study demonstrates that high provider continuity is associated with lower ED use for the Medicaid population. This suggests that strategies to improve continuity of care may result in lower ED use and possibly reduced health care costs. Such strategies may be more acceptable than current managed care policies that attempt to control costs by denying access to emergency care.
INTRODUCTION
THE CONTINUOUS relationship between a patient and a physician has long been thought to have a positive effect on health care use and outcomes.1-2 Previous studies have shown that patients with high provider continuity are more satisfied with their care,3-4 are more likely to take medications correctly,3 and are more likely to have problems identified by their physician.3 Recent studies have indicated that high provider continuity is also associated with a decreased likelihood of hospitalization.5-6 An explanation for this finding is that continuity with a physician leads to increased knowledge and trust between a patient and a physician.2 This increased knowledge and trust may make it easier for the physician to manage medical problems in the office or over the telephone and thereby avoid hospitalization.
If continuity is associated with fewer hospitalizations, it may also be associated with lower use of other expensive health care services such as hospital emergency department (ED) visits. Emergency departments are frequently used for visits that do not warrant emergency medical care.7-10 This is true even for persons who have a regular physician.11-12 One reason could be that ED use depends not only on having a regular physician, but also on having a high level of continuity with that physician. It could be hypothesized that if continuity results in greater knowledge and trust between a patient and a physician, that this knowledge and trust would make patients more likely to seek care from their regular physician rather than the ED, and would make physicians more likely to feel comfortable managing problems in the office or over the telephone rather than referring patients to the ED.13
While the hypothesized link between continuity and ED visits makes intuitive sense, the evidence supporting this hypothesis is scant. Several studies have examined the effect of having a regular physician or regular source of care on ED visits.11-12,14-15 However, these studies did not examine how ED visits were affected by the level of continuity that patients had with these physicians. One recently published study demonstrated an inverse association between continuity and ED visits; however, this study was limited to pediatric patients in a single residency teaching clinic.16 The purpose of this study is to examine whether higher continuity with a health care provider is associated with fewer ED visits for a large statewide Medicaid population.
PATIENTS AND METHODS
This study analyzed paid claims to the Delaware Medicaid program over the 1-year period from July 1, 1993, to June 30, 1994. A detailed description of this data and population is provided elsewhere.5 In brief, we selected patients aged 0 to 64 years who were continuously enrolled in Medicaid through Supplemental Security Income, Aid to Families With Dependent Children, or extended eligibility for pregnant women and children (the 2 latter categories were combined because they were demographically similar). These restrictions were required so that claims data would most accurately reflect total use, because claims are not available for services rendered when patients are disenrolled, when patients have limited Medicaid coverage, or when full payments are made by alternative payers (eg, Medicare for patients older than 64 years). During this period, all services were paid on a fee-for-service basis, except in the case of a small number of children who enrolled in a voluntary managed care pilot program; these children were excluded from the study. Patients were also excluded if they had made fewer than 3 ambulatory physician visits (excluding ED visits) during the study year because it was felt that continuity would be difficult to measure for patients with such a small number of visits. All of the remaining patients were included in the study, which resulted in a study sample of 11,474 patients.
For each patient, we measured provider continuity during the study year, using a previously published continuity index called the "modified modified continuity index" (MMCI).17 The equation for this index is as follows:
Continuity Score=1 - (No. of Ambulatory
Providers/[No. of Ambulatory Visits + 0.1])/
1 - (1/[No. of Ambulatory Visits + 0.1])
This continuity score ranges from approximately 0 (if each visit is to a different provider) to 1 (if all visits are to the same provider). We chose this index for our main analysis rather than the more commonly used "usual provider continuity" (UPC) index because we thought it to be a more sound measure of continuity. Specifically, the UPC is a simple ratio of the number of visits to the predominant provider divided by the total number of visits, while the MMCI also accounts for the degree of dispersion among different providers. Several other authors have also suggested that the UPC is not a particularly sound measure of continuity, and that other more sound measures should be used if possible.2, 16, 18-19 However, because the UPC is a well-known and commonly used measure of continuity, we ran an additional analysis using the UPC index in place of the MMCI. Ambulatory care visits were defined by paid claims for office or clinic visits to physicians, nurse practitioners, or physician assistants. We excluded ED visits because these visits constituted our dependent variable. We also excluded special procedures (eg, outpatient surgery) and visits to other providers such as chiropractors, optometrists, and psychologists. When data on individual providers were missing (approximately 10% of visits), we used the conservative assumption that the provider for this visit was different than the provider for any other visit. Previous analyses had shown that using alternative assumptions did not substantially affect the model and, therefore, these alternative assumptions were not tested for this analysis.5 A more detailed description is provided elsewhere regarding how claims data were used to define ambulatory visits.5
We examined ED visits during the study year as our dependent variable. For each patient, ED use was categorized into 3 levels: no ED visit, 1 ED visit, or multiple ED visits. This categorization scheme allowed us to measure the effect of continuity on single ED visits and multiple ED visits in the same model. We could not examine ED visits as a continuous variable because the extreme bias and kurtosis of the data violated the assumptions required for linear regression. Several transformations along the Tukey ladder of powers could not adequately correct for the heavy right tails. We examined ED visits in the same year as continuity visits because of the assumption that the decision of where to seek care depended on the current relationship with a physician. However, it is understood that measuring ED visits and continuity in the same year has the potential problem that one cannot determine whether continuity preceded or followed ED use. Therefore, we ran a separate analysis with the dependent variable being ED visits in the year after the study year. Emergency department visits were determined by either a physician claim or a hospital claim with a code indicating an ED visit. Multiple claims for the same visit were checked and eliminated.
Control variables included age (categorized as 0-4, 5-14, 15-24, 25-44, or 45-64 years), sex, race (white, African American, Hispanic, and other or unknown as defined by Medicaid), county of residence (New Castle, Kent, or Sussex County), Medicaid eligibility category (Supplemental Security Income or Aid to Families With Dependent Children/extended eligibility), number of ambulatory visits, and case mix. Case mix was defined by "ambulatory diagnostic groups"(ADGs).20-21 Each of 34 ADGs represents a group of related medical conditions. Patients are categorized according to whether they had a diagnosis in each ADG during the first year of the study.
DATA ANALYSIS
In our main analysis, we measured the association between continuity and ED visits. We used a polychromatous logistic regression, with the 3-level categorization of ED visits as the dependent variable. We used the LOGISTIC procedure of the Statistical Analysis System to construct the models.22 We used the categorical data modeling procedure because this assumption of proportionality of odds among the different levels of the predictors had not been met.
We first ran the model using continuity as the only predictor variable. We then ran the model after controlling for the number of office visits made during the study year, as previous analyses had shown the number of office visits to be a strong negative confounder of the association between continuity and hospital use (ie, office visits are positively associated with the dependent variable but negatively associated with the independent variable, so they would result in an apparent negative association between the independent and dependent variables).5 Third, we ran the model with continuity and all control variables forced into the model to determine the effect of continuity independent of other factors. Finally, we ran the model using a stepwise technique, to determine the best predictive model. For this stepwise technique, we considered for inclusion into the final model predictors that were associated with ED visits in univariate analysis at P<.25 or that were considered to be clinically relevant. Stepwise selection was then done at P<.05. Variables were added back to the model if they were significant confounders, defined as changing the coefficient of other variables by more than 15%. The final model had good predictive accuracy (c=0.81).
RESULTS
As demonstrated in Table 1, the study population consists primarily of children, women, minorities, and recipients of Aid to Families With Dependent Children. This is consistent with the demographics of the Medicaid population. The study population made a mean of 7.5 office visits during the study year (median, 6; range, 3-93). The mean number of providers seen during the year was 3.03 (median, 3; range, 1-90), and 99% of the subjects had fewer than 12 providers and all but 1 had fewer than 37 providers. The mean continuity score for the population was 0.64 using both the MMCI and UPC indices.
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Table 1. Characteristics of Study Population*
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The mean number of ED visits during the study year was 1.07. Twenty-five percent of patients made a single ED visit during the study year, and another 25% made multiple visits. In univariate analysis, continuity was not significantly associated with the likelihood of making a single ED visit (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.79-1.07), but was associated with a decreased likelihood of making multiple ED visits (OR, 0.84; 95% CI, 0.73-0.98). However, after adding office visits to the model, continuity is associated with a significantly lower likelihood of making a single ED visit (OR, 0.82; 95% CI, 0.70-0.95) and was more strongly associated with a lower likelihood of making multiple ED visits (OR, 0.65; 95% CI, 0.56-0.76). After adding other control variables to the model, these associations did not change substantially for the single ED visit (OR, 0.81; 95% CI, 0.68-0.95) or the multiple ED visit (OR 0.62; 95% CI, 0.51-0.75). The results for the stepwise regression model were almost identical for the single ED visit (OR, 0.81; 95% CI, 0.68-0.96) and the multiple ED visit (OR, 0.62; 95% CI, 0.51-0.76). This final stepwise regression model is provided in Table 2.
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Table 2. Predictors of Emergency Department Use During Study Year*
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When the MMCI was replaced with the UPC index, the effect of continuity pointed in the same direction but was lower in magnitude. This was expected because the UPC is not as sound as the MMCI in that it does not account for scattering of visits among multiple providers. In the final logistic model, continuity did not reach statistical significance in its association with the likelihood of a single ED visit (OR, 0.92; 95% CI, 0.75-1.12) or multiple ED visits (OR, 0.82; 95% CI, 0.65-1.03).
The mean number of ED visits in the year after the study year was 1.24, with 17% of patients making a single ED visit and 29% making multiple ED visits. In univariate analysis, continuity was not significantly associated with the likelihood of making a either a single ED visit (OR, 1.15; 95% CI, 0.97-1.36) or multiple ED visits (OR, 0.94; 95% CI, 0.82-1.08). After adding office visits to the model, continuity is associated with a significantly lower likelihood of making multiple ED visits (OR, 0.80; 95% CI, 0.69-0.92), but not a single ED visit (OR, 1.06; 95% CI, 0.89-1.26). The results are similar after adding other control variables to the model for a single ED visit (OR, 1.14; 95% CI, 0.95-1.37) or for multiple ED visits (OR, 0.84; 95% CI 0.72-0.98). The results of the final stepwise logistic regression model are given in Table 3.
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Table 3. Predictors of Emergency Department Use During Subsequent Year*
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COMMENT
This study demonstrates another outcome for which a continuous relationship between a patient and a provider is beneficial. Having continuity with a specific provider is significantly associated with a decreased likelihood of ED use. As would be expected, continuity has a much greater effect on the likelihood of making multiple ED visits than on making a single ED visit. This association persists even after controlling for demographics, case mix, and ambulatory use, all of which are themselves predictors of ED use. It was somewhat surprising that the effect of continuity increased dramatically after controlling for the number of office visits. However, this is consistent with findings from our previous studies.5-6 We believe that office visits are a proxy for severity of illness. Although we are controlling for case mix via ADGs, these measure only the presence of disease, rather than the severity of an individual diagnosis. For example, it is likely that patients with severe congestive heart failure would make more office visits even though they would fall into the same ADG as someone with mild heart failure. Because sicker patients tend to have higher continuity and are also more likely to make ED visits, it makes sense that the number of office visits (as a proxy for severity) would negatively confound the relationship between continuity and ED visits.
The findings of this study corroborate several previous studies that have found that patients with a regular source of care visit the ED less frequently than those who do not have a regular source of care,12, 14-15 as well as one study that found that children in one clinic who had higher continuity visited the ED less frequently than those who had lower continuity.16 This inverse association between continuity and ED visits makes intuitive sense. When patients concentrate their care with a single physician, these 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 medical problems interact. Even more importantly, it includes a personal understanding of the patient's propensity to seek care when needed, and the patient's personal preferences for medical treatment. All of these components of personal knowledge are important for physicians to interpret a patient's symptoms and to make a judgment about whether urgent care is needed or whether the problem can wait for an office visit.
Continuity of care can affect the patient's decision-making process as well as that of the physician. In most cases it is the patient rather than the physician who decides when to seek emergency care. When patients have a continuity relationship with their physician, it is likely that they will develop a sense of trust in the physician's knowledge and medical judgment. Therefore, it could be that when the need for urgent care is questionable, patients with high continuity are more likely to seek the opinion of their physician before going to an ED. Given this explanation for why continuity affects ED use, it makes sense that it would have a greater effect on ED visits in the concurrent year than in the following year. One would imagine that the decision to seek care from one's physician rather than the ED would depend primarily on the current patient-physician relationship. While patients who have high continuity in one year are more likely to have high continuity in the subsequent year, this is not always true. Therefore, it would be expected that the effect of continuity on ED visits would decrease over time.
This study was conducted in 1993 and 1994, when the Delaware Medicaid program and most other Medicaid programs used traditional fee-for-service reimbursement models that were relatively unrestricted. However, the relationship between continuity and ED use has substantial implications for health care today, and may be even more important in the future because of the emergence of managed care. Many ED visits are for conditions that are not considered true medical emergencies and that could wait for an office visit with a primary care physician.7-10,23-24 Although there is some debate about the true cost of ED care,24-25 it is generally agreed that care for these problems is more costly in ED settings than in primary care settings.26-27 Managed care organizations have attempted to limit the use of the ED because of this unnecessary cost.28-30 These strategies include requiring preapproval for ED visits28, 31 or screening patients who present to an ED and diverting nonurgent patients to a primary care physician.30, 32-34 In general, these strategies have been successful in reducing ED use.28, 30, 32 However, they have also met with resistance because of perceived barriers to appropriate ED care and the potential for adverse outcomes.24, 31, 35
The results of this study suggest an alternative approach to reducing ED use that may be more acceptable and less confrontational. If continuity is associated with fewer ED visits, it could be that increasing continuity would result in a reduction in ED visits. Instead of instituting policies that deny access or payment for ED visits, managed care organizations could institute policies that encourage continuity of care. For example, insurers could offer lower copayments for patients and higher reimbursement for physicians when visits are made to one's regular provider. Previous studies have examined the effect of programs that attempt to reduce ED use by providing patients with a regular provider. Some of these programs have resulted in reductions in ED use,29, 36 while others have not.34, 37 One reason for this mixed success could be that providing patients with a physician does not always increase continuity. Future studies are needed that examine the effect of programs specifically designed to improve continuity of care.
Several limitations to this study need to be discussed. First, the study is based on data from Medicaid patients in only 1 state. In an attempt to have the most accurate use information from the universe of paid claims, we examined data only from patients who were under the age of 65 years and were continuously enrolled. Additionally, patients with fewer than 3 visits in the year were excluded because of the inherent instability of estimates of continuity among these individuals. Second, as with any cross-sectional study, we cannot be certain whether the independent variable of continuity preceded or followed the dependent variable of ED visits. This is less of a concern in our study than in others because a second analysis measuring ED visits in the subsequent year (where we can be certain that ED visits followed continuity) found similar results. However, the only way to fully address this limitation is to use a different study design (such as a case-control study or prospective cohort study design), which is beyond the scope of this study. Third, because the patients were not randomized according to continuity level, but were identified as naturally existing groups, there may be other explanations for the effect of provider continuity. For instance, patients in the high provider continuity group may tend to have other health-seeking behaviors that improved their health status, thereby lowering their probability of an ED visit. Finally, while we examined all Medicaid patients as a single group, it could be that the effect of continuity differs for patients with specific medical problems. For example, it has been thought that hospitalizations and ED visits may be particularly avoidable for persons with asthma and other ambulatory case-sensitive conditions.37-38 However, a separate analysis on patients in our population with asthma showed that the effect of continuity was no greater than for the general population.39 Also, a previous study showed that continuity had no greater effect on hospitalizations for ambulatory care–sensitive conditions than for other conditions.5 Studies are needed to further examine the effect of continuity on ED use for specific conditions.
The policy implications of this study are particularly critical as health care in the United States moves toward managed care. Patient-physician relationships are important and have an effect on health outcomes. Encouraging continuity with a provider may be a benign but successful intervention to decrease ED use.
AUTHOR INFORMATION
Accepted for publication August 9, 1999.
This study was funded in part by grants from the Anna P. Dillon Foundation, and the DuPont Company, Wilmington, Del.
We thank Stephanie McClellan, MA, and Yingxia Chen, MA, for their assistance with data analysis and interpretation, and Cheryl Mongillo for her assistance with manuscript preparation.
Reprints: James M. Gill, MD, MPH, Department of Family and Community Medicine, Christiana Care Health Services, 1401 Foulk Rd, Wilmington, DE 19803 (e-mail: Jgill{at}christianacare.org).
From the Departments of Family and Community Medicine (Dr Gill) and Performance Improvement (Mr Nsereko) Christiana Care Health Services, Wilmington, Del; and the Medical University of South Carolina, Charleston (Dr Mainous).
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Saultz
Ann Fam Med 2003;1:134-143.
ABSTRACT
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On Being New to an Insurance Plan: Health Care Use Associated With the First Years in a Health Insurance Plan
Franks et al.
Ann Fam Med 2003;1:156-161.
ABSTRACT
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Impact of Provider Continuity on Quality of Care for Persons With Diabetes Mellitus
Gill et al.
Ann Fam Med 2003;1:162-170.
ABSTRACT
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Towards a theory of continuity of care
Gray et al.
JRSM 2003;96:160-166.
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Racial and Ethnic Disparities in the Primary Care Experiences of Children: A Review of the Literature
Stevens and Shi
Med Care Res Rev 2003;60:3-30.
ABSTRACT
Continuity of Care for Children in Foster Care
DiGiuseppe and Christakis
Pediatrics 2003;111:e208-213.
ABSTRACT
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Emergency Department Use Among the Homeless and Marginally Housed: Results From a Community-Based Study
Kushel et al.
AJPH 2002;92:778-784.
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