family Practice O Oxford UniversitY Press 1992

Vol. 9, No. 1 Printed in Great Britain

Continuity of Care: General Practitioners' Knowledge About, and Sense of Responsibility Toward Their Patients Hjortdahl P. Continuity of care: General practitioners' knowledge about and sense of responsibility toward their patients. Family Practice 1992; 9: 3-8. The aim of the present study was to examine the relations between continuity of care and the general practitioners' accumulated knowledge about their patients. A further objective was to evaluate the link between continuity of care and the doctors' sense of medical responsibility towards the patients. Emphasis was placed on the chronological, or longitudinal component of continuity of care. In a cross-sectional record study a representative sample of 133 Norwegian general practitioners each registered 30 consecutive consultations. Two aspects of longitudinal care were recorded: the duration of the patient-doctor relationship, measured as time from the first visit to the present, and the density, measured as the number of consultations (office or home visits) within the last 12 months. The physicians subjectively evaluated their accumulated knowledge about the patient's medical history, personality, and social network, on multinomic scales. Their sense of medical responsibility was indicated as one of three alternatives. Of 3990 possible recordings, 3918 (98%) were evaluated. In about one-third of all encounters the doctors reported extensive knowledge about their patients. It took at least one, and often 5 years, or at least 4-5 visits last year, to create such an extensive knowledge base. The physician's sense of responsibility increased more rapidly, and to a higher degree with the density of visits, than with duration of the relationship. The findings indicate firm links between longitudinal care and accumulated knowledge, and between longitudinal care and the doctors' sense of responsibility towards their patients.

Continuity of care, defined as medical care provided over time by one health care worker, has long been a hallmark of general practice.1 While it appears intuitively evident that continuity is important, there has been little validation of this assumption,2 partly due to lack of a generally accepted definition and partly due to difficulties making the concept operational. Continuity of care has traditionally been divided into five dimensions; chronological, geographical, interdisciplinary, interpersonal and informational.3 Much of the interest and research has to date been placed upon the chronological, or longitudinal component. Several quantitative indices have been developed that in one way or another measure the uninterrupted care provided by a specific doctor within a given period.4 These quantitative indices are valuable when evaluating organizational aspects of health care systems, but Department of General Practice, University of Oslo, Frederik Sttngs gate 11/13, N. 0264 Oilo 2, Norway.

are less suited to exploring qualitative aspects of the doctor-patient relationship. Here it may be that the results of having met before, such as accumulated knowledge and the development of mutual trust and responsibility, are more important. The decision-making process in the consultation is based upon the clinical situation and modified by background factors,5 among which are prior knowledge about the patient's medical history, personality, and social network. This may in turn influence the use of resources, patient and doctor satisfaction, and the quality of care. Mutual knowledge may aJso lead to a sense of commitmeni, or an attitudinal contract between doctor and patient.6 In some countries, such as Great Britain and Denmark, administrative systems enhance continuity of care, defining the primary physician's responsibility toward the patient. In Norway, as in the USA and other countries, the patients are, in principle free to go to any primary care physicians,7 this system also implies

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PER HJORTDAHL

FAMILY PRACTICE—AN INTERNATIONAL JOURNAL

that the physicians can, to some extent choose their own patients. With increasing public and political scrutiny, and economic pressure on the health care system,8'9 there is need to develop relevant parameters to evaluate the qualitative effect of continuity of care. Accumulated knowledge and degree of responsibility are two such possible elements. The aim of the present study is to establish the connection between longitudinal care and the doctor's accumulated knowledge about the patient, and to evaluate the doctor's sense of responsibility toward his patients.

Statistics

Except for frequencies, all results are expressed as mean values with 95% confidence intervals (Cl), using the Student's procedure. Tests were performed two tailed. Differences were considered statistically significant at a P-value ^ 5 % . For comparison between groups multiple and logistic regression analyses were used.1011 RESULTS The 133 participating physicians were representative as to age, geographic distribution and means of reimbursement when compared to the total general practitioner population of Norway. Of 3990 possible records 3918 (98%) were returned. The patients showed similar age, gender and morbidity patterns to those found in previous Norwegian general practice surveys.12-13 Longitudinal Care and Knowledge The mean number of contacts (home or office visits), including the present, was 3.9 during the previous 12 months (median 3, inter-quartile range 1.2-4.9, min-max 1-60). In 393 (10%) encounters the doctors recorded no previous knowledge, in 24% slight, 27% some, 26% good, and in 13% excellent previous knowledge about the patient's medical history. The bivariate relationships between the physicians' accumulated knowledge and the duration and density, are shown in Table 1. The doctor had prior knowledge about 219 of the patients with whom he had had no previous encounters. In 49% of these situations the information came from other parts of the health care system such as previous records, colleagues or visiting nurses, in 42% from relatives, and in 9% from the patient in previous non-medical contacts with the physician. Multiple regression analysis indicated that duration and density of the relationship, and the age and gender of the patient explained 54% of the sum score of knowledge (Table 2). Duration and density alone explained 52%. The type of illness did not significantly influence these results and was omitted from the final analysis. Longitudinal Care and Responsibility The doctors felt no responsibility beyond the present consultation in 7%, limited responsibility in 19%, and a general medical responsibility in 74% of all encounters. The bivariate relationships between the

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SUBJECTS AND METHODS A random sample of general practitioners was drawn from the membership list of The Norwegian Medical Association, which organizes 95% of all physicians in the country. One hundred and thirty-three practitioners each agreed to record 30 consecutive consultations. Both scheduled and unscheduled consultations with patients of all ages were included. Telephone contacts, house calls, and organized preventive work such as well-baby-clinics, were excluded. The physicians completed their recordings within 2-5 days. As patients with two or more visits within the registration period were only recorded once, the number of records equals the number of different patients seen. Immediately after each consultation the doctor completed a two-page questionnaire related to the patient, longitudinal care, previous knowledge and sense of responsibility. Two aspects of longitudinal care were defined and recorded: the duration of the patient-doctor relationship, measured as time from the first visit to the present, aryd_ the density, measured as the number of consultations (office or home visits) within the last 12 months. There were five categories of duration: the first visit with this doctor, less than 3 months, 3-12 months, 1-5 years, and more than 5 years. Density was also divided into five groups; first visit, two or three, four or five, six to eleven, and 12 or more visits to this doctor during the last 12 months. The physicians subjectively evaluated their accumulated knowledge about the patient's medical history, personality, and social network on five point multinomic scales, ranging from none to excellent knowledge. These three scores were evaluated separately, and as a sum score of knowledge for each patient. The doctor's sense of medical responsibility was indicated as one of three alternatives; a) feeling no medical responsibility beyond the present consultation; b) limited either to the present episode of illness, or to a limited problem area for patients using several general practitioners; c) having an overall, direct or coordinative responsibility for the patient's different medical needs. In the logistic regression analysis the physicians' sense of responsibility was dichotomized into none or limited, and extensive.

The reason for encounter was classified as new if the patient had not seen the physician previously for this problem. Follow-up encounters related to medical problems first presented to the doctor less than 6 months ago. Chronic problems were defined as those having lasted ^ 6 months or those which were exacerbations of a chronic disease. Preventive work included maternity care and general health checks carried out as part of the doctor's regular surgery.

CONTINUITY OF CARE

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TABLE 1 The physicians' average knowledge about the patients' medical history, personality and social network related to duration and density of the doctor-patient relationship in 3918 encounters Patient personality

Social network

Sum score

Mean (95% CI)

Mean (95% CI)

Mean (95% CI)

Mean (95% CI)

0.42 1.23 1.69 2.20 2.92

(0.35-0.48) (1.14-1.31) (1.61-1.77) (2.15-2.25) (2.87-2.97)

0.27 1.15 1.59 2.06 2.77

(0.21-0.32) (1.06-1.24) (1.51-1.68) (2.00-2.11) (2.72-2.82)

0.48 1.04 1.45 1.84 2.54

(0.41-0.56) (0.94-1.14) (1.36-1.55) (1.78-1.89) (2.49-2.60)

0.39 1.14 1.58 2.03 2.74

(0.36-0.44) (1.06-1.22) (1.50-1.65) (1.98-2.08) (2.69-2.79)

Density (number of contacts last 12 months): 1.07 The present only 899 (23) 1.99 1324 (34) 2-3 2.49 4-5 735 (19) 2.79 709 (18) 6-11 >12 3.14 251 (6)

(1.00-1.14) (1.94-2.05) (2.42-2.56) (2.73-2.86) (3.03-3.26)

0.90 1.87 2.37 2.66 3.02

(0.83-0.97) (1.81-1.93) (2.30-2.44) (2.60-2.73) (2.91-3.14)

0.98 1.75 2.11 2.31 2.76

(0.91-1.05) (1.68-1.81) (2.03-2.18) (2.24-2.40) (2.63-2.90)

0.98 1.87 2.32 2.60 2.98

(0.92-1.05) (1.81-1.93) (2.26-2.39) (2.53-2.65) (2.86-3.09)

n (%) Duration (time since first contact): First contact today 475 (12) 313 (8) < 3 months 434 (11) 3-12 months 1-5 years 1390 (36) >5 years 1305 (33)

Knowledge is rated on a five point progressive scale ranging from 0 to4: 0-1 = none or slight, 1-2 = some, 2-3 = good, 3-4 = excellent previous knowledge. A sum score of knowledge is constructed for each patient by adding each of the individual scores and dividing by a factor of three. 95% confidence intervals are given in parenthesis.

TABI I 2

The influence of duration and density of the doctor-patient relationship on the doctor's overall accumulated knowledge about the patient (sum score), controlled for background factors, in 3918 consultations B

SE B

(95% CI)

T

SigT

Duration (time since first contact) First contact today < 3 months 3-12 months 1-5 years >5 years

0 0.13 0.44 0.97 1.68

0.07 0.06 0.05 0.05

(0.00-0.26) (0.32-0.56) (0.87-1.07) (1.58-1.78)

1.8 6.8 18.5 31.5

.06 .00 .00 .00

Density (number of contacts last 12 months) The present only 2-3 4-5 6-11 >12

0 0.57 0.88 1.09 1.41

0.04 0.05 0.05 0.07

(0.50-0.64) (0.78-0.98) (1.00-1.19) (1.27-1.55)

13.1 18.7 23.2 21.4

.00 .00 .00 .00

Sex Male Female

0 0.03

0.03

(-0.02-0.09)

1.2

.23

0 -0.03 0.23

0.03 0.05

(-0.09-0.03) (0.14-0.33)

-0.98 4.4

.33 .00

Age (years): 0-15 16-69 Je70

R2 = 0.535, constant = 1.29 The sum score of knowledge is evaluated on a continuous scale ranging from no previous knowledge = 0, to excellent overall knowledge = 4.

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Medical history

Prior knowledge

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DISCUSSION The physicians' self assessed knowledge about their patients is the key dependent variable. Previous studies have shown that physicians tend to overestimate their factual knowledge about patients.14J5 In the present study emphasis was placed on a general, tacit knowledge rather than on specific elements, making this bias less likely. Since continuity of care is a goal among general practitioners,15 a desirability bias with an overestimation of knowledge may be present. The effect of such biases, inflating the relationship between longitudinal care and accumulated knowledge, should be kept in mind when interpreting these data. Duration and density are continuous variables registered on the basis of the patient's record. They were, however, grouped, as a non-linear relationship between each of these variables and accumulated knowledge was expected. In theory knowledge would accumulate most rapidly at the beginning of the doctor-patient relationship, and then level off. Close relationships may augment knowledge and the sense of responsibility, but in some cases closeness becomes a burden rather than an asset. It thus appeared reasonable to have narrow intervals at the beginning of these scales, and wider intervals at the end. Emphasis has been placed on duration and density, and not on a third, traditional aspect of continuity; the uninterrupted care given by one doctor. Uninterrupted TABLE 3

Longitudinal Care and Knowledge The essence of clinical medicine is the integration of genera] medical knowledge with knowledge about the individual patient. '8 The amount, and diversity of knowledge is important, as is the way in which it is organized and used. An extensive knowledge implies not only an elaborate understanding of the patient's medical history, but also knowledge of the patient's personality and reactions to illness. It integrates knowledge and understanding of the patient's social network and supporting structures. With extensive knowledge the physician creates a tacit, or cognitive structure with multiple interconnections, understanding one illness in relation to other problems experienced by the patient.19 Furthermore it enables the physician to receive and interpret informal information given by the patient.

The physician's sense of responsibility related to duration and density of the patient-doctor encounters. Results are given in absolute numbers and as row percentages

Sense of responsibility beyond present consultation

None

Total

Limited n

(%)

Duration (time since first contact) First contact today < 3 months 3-12 months 1-5 years > 5 years

193 (41) 14 (4) 16 (4) 47 (3) 8 «D

200 147 110 201 72

(42) (47) (25) (15) (6)

Density (number of contacts last 12 months) The present only 2-3 4-5 6-11 12-60

228 (25) 44 (3) 6 (1) 0 (0) 0 (0)

325 302 67 36 0

Total

278

(7)

relationship in 3918

82 152 308 1142 1226

(17) (49) (71) (82) (94)

475 313 434 1390 1306

(36) (23) (9) (5) (0)

346 (39) 978 (74) 662 (90) 673 (95) 251 (100)

899 1324 735 709 251

730 (19)

2910 (74)

3918

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care has long been the ideaJ of the family doctor and the desire of many patients. Monolithic or strict continuous care is, however, presently unrealistic and medically unsound. Increasing professional and private demands make general practitioners less available to their patients7. Denis Pereira Gray, the dedicated British general practitioner, found that he was available to his patients only 75% of his working time.17 Others have found their maximum availability to be around 60%.4 Furthermore, medicine is becoming so complex that practitioners have to rely upon referrals and second opinions. The general practitioner may thus function as a coordinator of the patient's different health needs, rather than the sole provider. With this changing emphasis it appeared logical to replace 'uninterrupted care' with 'a sense of overall, direct or coordinative responsibility for the different medical needs of the patient.'

physicians' sense of responsibility, and duration and density, are given in Table 3. The influence of duration and density of the doctorpatient relationship on the doctors' sense of medical responsibility, controlled for age and gender of the patient, and the type of illness, is given in Table 4.

CONTINUITY OF CARE TABLE 4

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The influence of duration and density of the doctor-patient relationship on the doctors' overall sense of responsibility toward the patient, controlled for background factors, in 3918 consultations Odds ratio

(95% CI)

Estimate

SE

Sense of responsibility (0 = none, or limited, no 1012; 1 = extensive. no 2916) 1.0 1.0 1.8 4.6 16.4

(0.7-1.6) (1.2-2.6) (3.3-6.4) (11.5-23.5)

0.02 0.56 1.53 2.80

.22 .21 .17 .18

Density (number of contacts last 12 months) The present only 2-3 4-5 6-11 >12

1.0 3.9 9.4 17.6 52.7

(2.9-5.1) (6.6-13.3) (11.6-26.8) (16.2-171.3)

1.36 2.24 2.87 4.00

.14 .18 .21 .60

Sex Male Female

1.0 1.06

(0.87-1.30)

0.06

.10

Age (years) 0-15 16-69 70 +

1.0 0.64 1.60

(0.26-1.56) (1.19-2.14)

-0.45 0.47

.46 .15

Type of illness New Follow up Chronic Preventive

1.0 1.02 2.19 1.05

(0.79-1.32) (1.66-2.89) (0.77-1.44)

0.02 0.79 0.05

.13 .14 .16

Odds ratios were calculated to control for the effects of the other factors, such as sex, age and type of illness. For each factor odds ratios are expressed relative to a baseline comparison group. When the 95% confidence intervals do not cover one, the odds ratios are significantly different at the 5% level.

More than half of the accumulated knowledge is accounted for by longitudinal care (Table 2). The nonaccounted-for information is accumulated from sources outside the patient, such as practising in the community where the patient lives or works, other parts of the health care system, or family members of the patient. The most extensive knowledge prior to the first visit is related to the patient's social network and to the patient's past medical history (Table 1). Knowledge about the personality of the patient has the lowest initial rating. This information is difficult to obtain from third parties. Knowledge about the social network does not accumulate as quickly and flattens out at a lower level than the other two types of knowledge. The multivariate analysis indicates that knowledge accumulates fairly slowly during the first few months of the doctor-patient relationship, increasing sharply between 3 and 12 months, then flattens out somewhat, but still increases steadily during the next few years.

Table I indicates that it takes at least one year, and usually 5 years or longer, to build a good or excellent knowledge base about a patient. Knowledge accumulates mostly rapidly during the first few contacts and the major impact of density on the accumulation of knowledge is around four or five visits a year (Table 2). When density of contact is considered, the initial, average knowledge is higher than when duration is studied (Table I): this is because longitudinal care may exist even in the first density category, with a previous visit longer than 12 months ago. Density as measured is a function of the number of visits within a given time period, but in reality may also be influenced by the duration of each encounter. Consultations by general practitioners in Norway last on an average 16 minutes, 2 " and are considerably shorter in Great Britain.21 Taking this into account, the breaking point for the number of encounters in Great Britain may be somewhat higher than the four-five found in the present study.

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Duration (time since first contact) First contact today < 3 months 3-12 months 1-5 years >5 years

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1 2 3

REFERENCES McWhinney IR. A textbook of family medicine. New York: Oxford University Press, 1989. Freeman GK. Continuity of care in general practice: a review and critique. Fam Pract 1984; 1: 245-252. Hennen BK. Continuity of care in family practice: dimensions of continuity. J Fam Pract 1975; 2: 371-372.

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Ejlertsson G, Berg S. Continuity-of-care measures: an analytic and empirical comparison. Med Care 1984; 22:231-239. 5 Howie JGR. Diagnosis—the Achilles heel? J R Coll Gen Pract 1972; 22: 310-315. 6 Banahan BF Jr, Banahan BF 3rd. Continuity as an attitudinal contract. J Fam Pract 1981; 12: 245-252. 7 Hjortdahl P. General practice and continuity of care: organizational aspects. Fam Pract 1989; 6: 292-298. 8 AAFP and the Council on long range planning and development. The future of Family Practice: implications of the changing environment of medicine. JAMA 1988; 260: 1272-1279. 9 Secretaries of State for Health, Wales, Scotland and Northern Ireland. Working for patients. Working paper no. 1. London: HMSO, 1989. 10 Kendall M, Stuart A, Ord JK. The advanced theory of statistics. Vol I & II. London, Charles Griffin & Co. Ltd., 1973-1983. " Hosmer DW, Lemenshow S. Applied logistic regression. New York: John Wiley & Son, 1989. Rutle O . Pasienten fram i lyset—Analyse av legekontaktar i primmrhelsetenesta (Getting the patient into the limelight. A n analysis of encounters in primary health care). Oslo: Statens institutt for folkehelse. Rapport 1/1983, 1983. 13 Nylenna M . W h y d o our patients see us? Scand J Prim Health Care 1985; 3 : 155-162. 14 Rosenberg E E , Pless IB. Clinicians' knowledge about the families of their patients. Fam Pract 1985; 2: 23-29. 15 Andrews F M . Construct validity and error components of survey measures: A structural modeling approach. Publ Opinion Q 1984; 48: 409-412. 16 Hjortdahl P . Ideology and reality of continuity of care. Fam Med 1990: 22: 361-364. 17 Gray D P . T h e key t o personal care. J R Coll Gen Pract 1979; 29: 666-678. 18 SchOn D A . The reflective practitioner. How professionals think in action. New York, Basic Books, I n c . , Publishers, 1983. 19 Polanyi M. The tacit dimension. New York, Doubleday and C o . , 1967. 20 Aaraas I. Korte og lange konsultasjoner i almenpraksis (Short and long consultations in general practice). Tidsskr Nor Laegeforen 1981; 101: 1828-1830. 21 Porter A , Howie J G . Levinson A. Measurement of stress as it affects the works of the general practitioner. Fam Pract 1985; 2: 136-146. 12

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Longitudinal Care and Responsibility The doctors expressed an extended medical responsibility for the patient in three-quarters of all encounters. This may appear high in a health care system where primary care physicians are not officially delegated responsibility for individual patients. As people in most communities in Norway have a choice of primary care physicians, most practices have selfselected patient populations. The Norwegian doctorpatient relationships are stable, one-third of patients have known their doctors between 1 and 5 years and one-third >5 years.7 The reported level of responsibility thus appears plausible. Both duration and density of the doctor-patient relationship is important in the development of responsibility (Table 4). During the first 3 months of the relationship, however, the doctors did not indicate any significant increase in overall responsibility; after 1 year the odds doubled, and after 5 years it had increased to 16 times that of a first encounter. The odds increased more rapidly, and to a higher degree with density, than with duration of the relationship. If the patient had four or five contacts during the last year there was a 10-fold increase in the odds of the doctor having an extended responsibility, as compared to those with only one visit. Even taking into consideration possible biases, the present study indicates firm links between longitudinal care and accumulated knowledge, and between longitudinal care and the doctors' sense of responsibility toward their patients. Continuity of care thus appears to be an important qualitative parameter to consider in the evaluation of general practice.

Continuity of care: general practitioners' knowledge about, and sense of responsibility toward their patients.

The aim of the present study was to examine the relations between continuity of care and the general practitioners' accumulated knowledge about their ...
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