Continuity and quality of care in type 2 diabetes: a Residency Research Network of South Texas study - Original Research

Journal of Family Practice, July, 2002 by Michael L. Parchman, Sandra K. Burge

KEY POINTS FOR CLINICIANS

* For patients with diabetes, continuity of care is associated with the quality of care: as continuity improves, so does the quality of care.

* Patients with diabetes who report that they have seen their usual primary care provider in the past year are more likely to have received an eye examination, a foot examination, 2 blood pressure measurements, and a lipid level analysis.

* OBJECTIVE We investigated the relationship between continuity of care and the quality of care received by patients with type 2 diabetes mellitus.

* STUDY DESIGN We used a cross-sectional patient survey and medical record review.

* POPULATION Consecutive patients with an established diagnosis of type 2 diabetes mellitus presented to 1 of 6 clinics within the Residency Research Network of South Texas, a network of 6 family practice residencies affiliated with the University of Texas Health Science Center at San Antonio.

* OUTCOMES MEASURED Continuity was measured as the proportion of visits within the past year to the patient's usual primary care provider. A quality of care score was computed based on the American Diabetes Association's Provider Recognition Program criteria from data collected through medical record review and patient surveys. Each patient was awarded points based on the presence or absence of each criterion.

* RESULTS The continuity score was associated significantly with the quality of care score in the anticipated direction (r = .15, P = .04). Patients who had seen their usual providers within tire past year were significantly more likely to have had an eye examination, a foot examination, 2 blood pressure measurements, and a lipid analysis.

* CONCLUSIONS Continuity of care is associated with the quality of care received by patients with type 2 diabetes mellitus. Continuity of care may influence provider and patient behaviors in ways that improve quality. Further research on how continuity contributes to improved quality is needed.

* KEYWORDS Continuity of patient care; diabetes mellitus; quality of health care. (J Fam Pract 2002; 51:619-624)

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Studies of the care of adult diabetic patients in the primary care setting continue to document poor adherence to current guidelines for managing diabetes. (1,2) One study of quality of care among diabetic patients in outpatient primary care offices found that Medicare patients often did not achieve recommended targets for blood glucose and lipid levels or blood pressure control and that glycosylated hemoglobin levels and cholesterol were not monitored at recommended intervals. (3) As Blonde and colleagues pointed out, these variations in quality have no clear rationale or basis in scientific fact. (4) Therefore, other explanations must be explored.

Berwick and others pointed out that quality of health care is determined most often by systems or processes rather than by individual behavior. (5) One health care process that is important to primary care is continuity of care, or the development of a sustained relationship with a provider. (6) Continuity of care is associated with favorable outcomes of care, (7) including recognition of behavioral problems, (8) patient adherence to physicians' advice, (9) being up to date on immunizations, (10) effective communication between physician and patient, and the accumulated knowledge of the physician with regard to the patient's history. (11)

In a previous study of continuity among patients with type 2 diabetes mellitus, patients with regular health care providers had improved glucose control and were more likely to have had a cholesterol measurement and influenza vaccination in the preceding year. (12) These findings suggest that an understanding of the relation between continuity and quality might provide useful insights into improving the care diabetic patients receive. The purpose of this study was to examine the relation between continuity of care and the quality of care received by adult patients with type 2 diabetes mellitus.

METHODS

Setting

The study was conducted at 6 clinics in 5 communities across south Texas. These clinics comprise the Residency Research Network of South Texas (RRNeST) and are in San Antonio, Corpus Christi, McAllen, Harlingen, and Laredo. The 174 family physicians at these sites serve a population that is predominantly Mexican American. A more detailed description of RRNeST has been published elsewhere. (13)

Participants

Patients at each site were eligible for the study if they said that they had an established diagnosis of type 2 diabetes for at least 1 year. Patients were excluded if they were younger than 18 years or pregnant. To provide adequate opportunity for continuity, patients also were excluded if they had been attending the clinic for less than 1 year. We also excluded patients who were seeing residents in their first year of training because these patients had experienced a change in their primary care provider within the past year when they were reassigned to a first-year resident.