Study: Improving continuity of care could also improve appropriate prescribing

Key takeaways:

• Three personal continuity measures were associated with fewer potentially inappropriate prescriptions.
• Older patients with chronic conditions especially benefitted from personal continuity of care.

Several different measures of care continuity were linked to more appropriate prescribing in primary care, indicating that bettering the practice may also reduce harms by improving prescription quality, according to researchers.

Personal continuity between physicians and their patients is a “core value of primary care,” Marije T. te Winkel, MS, MD, a PhD candidate and general practice trainee at Vrije Universiteit Amsterdam, and colleagues wrote in Annals of Family Medicine.

“This form of continuity, also known as relational continuity, implies familiarity and mutual confidence between patient and physician that can and usually do arise from repeated contacts over time,” they wrote. “In recent years, personal continuity has declined in primary care. This decline has been due to a variety of changes in society and health care, including family physicians increasingly working part time and in larger practices.”

Previous research has highlighted the benefits of continuity of care; the practice has been linked to better health care utilization and lower costs. Prior studies have also indicated that continuity of care is linked to fewer potentially inappropriate prescriptions, the researchers wrote, but the evidence on prescribing and continuity in primary care is scarce.

So, they conducted an observational cohort study to identify connections between personal continuity of care and family physicians issuing potentially inappropriate prescriptions — which include potential prescribing omissions (PPOs) and potentially inappropriate medications (PIMs) — to older patients.

The researchers analyzed routine care data from 25,854 patients aged 65 years or older enlisted in 48 Dutch family practices from 2013 to 2018. To identify potentially inappropriate prescriptions, they used the Screening Tool of Older Person’s Prescriptions and the Screening Tool to Alert doctors to Right Treatment specific to the Netherlands version 2 criteria. To measure continuity, they used three established measures: the Bice-Boxerman Index (BBI), the Herfindahl Index (HI) and the usual provider of care measure (UPC).

Of the participants, 74.3% and 72.2% had at least one PPO and PIM, respectively, and 34.2% and 30.9% had at least three PPOs and PIMs, respectively.

te Winkel and colleagues found that all three measures of personal continuity were significantly and positively linked to fewer potentially inappropriate prescriptions, they wrote. The mean values were as follows:

• 0.55 (SD = 0.24) for the BBI;
• 0.59 (SD = 0.22) for the HI; and
• 0.7 (SD = 0.19) for the UPC.

In the total population, the cutoffs for the low, intermediate and high tertiles were 0, 0.42, and 0.65 for the BBI; 0.09, 0.47 and 0.67 for the HI and 0.12, 0.6 and 0.8 for the UPC, the researchers noted. Additionally, the mean numbers of PPOs and PIMs were lower in the groups with fewer chronic conditions.

The researchers said the findings add “to the currently known benefits of personal continuity in primary care.” Therefore, they “recommend that family physicians improve personal continuity,” te Winkel and colleagues wrote.

“Team-based care with multiple clinicians may be detrimental,” te Winkel and colleagues wrote. “In particular, older patients with many chronic conditions could benefit from personal continuity to reduce inappropriate prescribing and possibly prevent adverse events.”