Top

Published in:

Open Access 01-12-2021 | Care | Study protocol

Optimising personal continuity for older patients in general practice: a study protocol for a cluster randomised stepped wedge pragmatic trial

Authors: Lex J. J. Groot, Henk J. Schers, Jako S. Burgers, Francois G. Schellevis, Martin Smalbrugge, Annemarie A. Uijen, Peter M. van de Ven, Henriëtte E. van der Horst, Otto R. Maarsingh

Published in: BMC Primary Care | Issue 1/2021

Abstract

Background

Continuity of care, in particular personal continuity, is a core principle of general practice and is associated with many benefits such as a better patient-provider relationship and lower mortality. However, personal continuity is under pressure due to changes in society and healthcare. This affects older patients more than younger patients. As the number of older patients will double the coming decades, an intervention to optimise personal continuity for this group is highly warranted.

Methods

Following the UK Medical Research Council framework for complex Interventions, we will develop and evaluate an intervention to optimise personal continuity for older patients in general practice. In phase 0, we will perform a literature study to provide the theoretical basis for the intervention. In phase I we will define the components of the intervention by performing surveys and focus groups among patients, general practitioners, practice assistants and practice nurses, concluded by a Delphi study among members of our group. In phase II, we will test and finalise the intervention with input from a pilot study in two general practices. In phase III, we will perform a stepped wedge cluster randomised pragmatic trial. The primary outcome measure is continuity of care from the patients’ perspective, measured by the Nijmegen Continuity Questionnaire. Secondary outcome measures are level of implementation, barriers and facilitators for implementation, acceptability and feasibility of the intervention. In phase IV, we will establish the conditions for large-scale implementation.

Discussion

This is the first study to investigate an intervention for improving personal continuity for older patients in general practice. If proven effective, our intervention will enable General practitioners to improve the quality of care for their increasing population of older patients. The pragmatic design of the study will enable evaluation in real-life conditions, facilitating future implementation.

Trial registration number

Netherlands Trial Register, trial NL8132. Registered 2 November 2019.

Available only for authorised users

Guthrie B, Saultz J, Freeman G, Haggerty J. Continuity of care matters. BMJ. 2008;337(aug07 1):a867. https://doi.org/10.1136/bmj.a867.CrossRefPubMed

Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ. 2003;327(7425):1219–21. https://doi.org/10.1136/bmj.327.7425.1219.CrossRefPubMedPubMedCentral

Haggerty JL, Roberge D, Freeman GK, Beaulieu C. Experienced continuity of care when patients see multiple clinicians: a qualitative metasummary. Ann Fam Med. 2013;11(3):262–71. https://doi.org/10.1370/afm.1499.CrossRefPubMedPubMedCentral

Uijen AA, Schers HJ, Schellevis FG, van den Bosch WJ. How unique is continuity of care? A review of continuity and related concepts. Fam Pract. 2012;29(3):264–71. https://doi.org/10.1093/fampra/cmr104.CrossRefPubMed

Schers H, Maat C, van de Ven C, van den Hoogen H, Grol R, van den Bosch W. General practitioners’ views on continuity of care. Huisarts Wet. 2002;45(9):450–4.CrossRef

Schers H, Webster S, van den Hoogen H, Avery A, Grol R, van den Bosch W. Continuity of care in general practice: a survey of patients' views. Br J Gen Pract. 2002;52(479):459–62.PubMedPubMedCentral

Pereira Gray D, Sidaway-Lee K, White E, Thorne A, Evans P. Improving continuity: THE clinical challenge. InnovAiT. 2016;9(10):11.CrossRef

Björkelund C, Maun A, Murante A, Hoffman K, De Maeseneer J, Farkas-Pall Z. Impact of continuity on quality of primary care: from the perspective of citizens’ preferences and multimorbidity – position paper of the European forum for primary care. Qual Prim Care. 2013;21(3):193–204.PubMed

Kringos DS, Boerma WG, Hutchinson A, van der Zee J, Groenewegen PP. The breadth of primary care: a systematic literature review of its core dimensions. BMC Health Serv Res. 2010;10(1):65. https://doi.org/10.1186/1472-6963-10-65.CrossRefPubMedPubMedCentral

10.

Hussey PS, Schneider EC, Rudin RS, Fox DS, Lai J, Pollack CE. Continuity and the costs of care for chronic disease. JAMA Intern Med. 2014;174(5):742–8. https://doi.org/10.1001/jamainternmed.2014.245.CrossRefPubMedPubMedCentral

11.

Cabana MD, Jee SH. Does continuity of care improve patient outcomes? J Fam Pract. 2004;53(12):974–80.PubMed

12.

Hansen RA, Voils CI, Farley JF, Powers BJ, Sanders LL, Sleath B, et al. Prescriber continuity and medication adherence for complex patients. Ann Pharmacother. 2015;49(3):293–302. https://doi.org/10.1177/1060028014563266.CrossRefPubMed

13.

Chen CC, Tseng CH, Cheng SH. Continuity of care, medication adherence, and health care outcomes among patients with newly diagnosed type 2 diabetes: a longitudinal analysis. Med Care. 2013;51(3):231–7. https://doi.org/10.1097/MLR.0b013e31827da5b9.CrossRefPubMed

14.

Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med. 2005;3(2):159–66. https://doi.org/10.1370/afm.285.CrossRefPubMedPubMedCentral

15.

Frederiksen HB, Kragstrup J, Dehlholm-Lambertsen B. Attachment in the doctor-patient relationship in general practice: a qualitative study. Scand J Prim Health Care. 2010;28(3):185–90. https://doi.org/10.3109/02813432.2010.505447.CrossRefPubMedPubMedCentral

16.

Schers H, van den Hoogen H, Bor H, Grol R, van den Bosch W. Familiarity with a GP and patients' evaluations of care. A cross-sectional study. Fam Pract. 2005;22(1):15–9. https://doi.org/10.1093/fampra/cmh721.CrossRefPubMed

17.

Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med. 2004;2(5):445–51. https://doi.org/10.1370/afm.91.CrossRefPubMedPubMedCentral

18.

Ridd M, Shaw A. Salisbury C: 'Two sides of the coin'--the value of personal continuity to GPs: a qualitative interview study. Fam Pract. 2006;23(4):461–8. https://doi.org/10.1093/fampra/cml010.CrossRefPubMed

19.

Adair CE, McDougall GM, Mitton CR, Joyce AS, Wild TC, Gordon A, et al. Continuity of care and health outcomes among persons with severe mental illness. Psychiatr Serv. 2005;56(9):1061–9. https://doi.org/10.1176/appi.ps.56.9.1061.CrossRefPubMed

20.

Chen HM, Tu YH, Chen CM. Effect of continuity of care on quality of life in older adults with chronic diseases: a Meta-analysis. Clin Nurs Res. 2017;26(3):266–84. https://doi.org/10.1177/1054773815625467.CrossRefPubMed

21.

Hanninen J, Takala J, Keinanen-Kiukaanniemi S. Good continuity of care may improve quality of life in type 2 diabetes. Diabetes Res Clin Pract. 2001;51(1):21–7. https://doi.org/10.1016/S0168-8227(00)00198-4.CrossRefPubMed

22.

Romano MJ, Segal JB, Pollack CE. The association between continuity of care and the overuse of medical procedures. JAMA Intern Med. 2015;175(7):1148–54. https://doi.org/10.1001/jamainternmed.2015.1340.CrossRefPubMedPubMedCentral

23.

van Walraven C, Oake N, Jennings A, Forster AJ. The association between continuity of care and outcomes: a systematic and critical review. J Eval Clin Pract. 2010;16(5):947–56. https://doi.org/10.1111/j.1365-2753.2009.01235.x.CrossRefPubMed

24.

Hansen AH, Halvorsen PA, Aaraas IJ, Forde OH. Continuity of GP care is related to reduced specialist healthcare use: a cross-sectional survey. Br J Gen Pract. 2013;63(612):482–9. https://doi.org/10.3399/bjgp13X669202.CrossRefPubMed

25.

Barker I, Steventon A, Deeny SR. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data. BMJ. 2017;356:j84.CrossRef

26.

Bayliss EA, Ellis JL, Shoup JA, Zeng C, McQuillan DB, Steiner JF. Effect of continuity of care on hospital utilization for seniors with multiple medical conditions in an integrated health care system. Ann Fam Med. 2015;13(2):123–9. https://doi.org/10.1370/afm.1739.CrossRefPubMedPubMedCentral

27.

Menec VH, Sirski M, Attawar D, Katz A. Does continuity of care with a family physician reduce hospitalizations among older adults? J Health Serv Res Policy. 2006;11(4):196–201. https://doi.org/10.1258/135581906778476562.CrossRefPubMed

28.

Raddish M, Horn SD, Sharkey PD. Continuity of care: is it cost effective? Am J Manag Care. 1999;5(6):727–34.PubMed

29.

Shin DW, Cho J, Yang HK, Park JH, Lee H, Kim H, et al. Impact of continuity of care on mortality and health care costs: a nationwide cohort study in Korea. Ann Fam Med. 2014;12(6):534–41. https://doi.org/10.1370/afm.1685.CrossRefPubMedPubMedCentral

30.

Weiss LJ, Blustein J. Faithful patients: the effect of long-term physician-patient relationships on the costs and use of health care by older Americans. Am J Public Health. 1996;86(12):1742–7. https://doi.org/10.2105/AJPH.86.12.1742.CrossRefPubMedPubMedCentral

31.

Hoertel N, Limosin F, Leleu H. Poor longitudinal continuity of care is associated with an increased mortality rate among patients with mental disorders: results from the French National Health Insurance Reimbursement Database. Eur Psychiatry. 2014;29(6):358–64. https://doi.org/10.1016/j.eurpsy.2013.12.001.CrossRefPubMed

32.

Maarsingh OR, Henry Y, van de Ven PM, Deeg DJ. Continuity of care in primary care and association with survival in older people: a 17-year prospective cohort study. Br J Gen Pract. 2016;66(649):e531–9. https://doi.org/10.3399/bjgp16X686101.CrossRefPubMedPubMedCentral

33.

Leleu H, Minvielle E. Relationship between longitudinal continuity of primary care and likelihood of death: analysis of national insurance data. PLoS One. 2013;8(8):e71669. https://doi.org/10.1371/journal.pone.0071669.CrossRefPubMedPubMedCentral

34.

Wolinsky FD, Bentler SE, Liu L, Geweke JF, Cook EA, Obrizan M, et al. Continuity of care with a primary care physician and mortality in older adults. J Gerontol A Biol Sci Med Sci. 2010;65(4):421–8.CrossRef

35.

Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018;8(6):e021161. https://doi.org/10.1136/bmjopen-2017-021161.CrossRefPubMedPubMedCentral

36.

Baker R, Freeman GK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. Br J Gen Pract. 2020;70(698):e600–11. https://doi.org/10.3399/bjgp20X712289.CrossRefPubMedPubMedCentral

37.

Gray DP, Evans P, Sweeney K, Lings P, Seamark D, Seamark C, et al. Towards a theory of continuity of care. J R Soc Med. 2003;96(4):160–6. https://doi.org/10.1177/014107680309600402.CrossRefPubMedPubMedCentral

38.

Hill AP, Freeman GK: Promoting continuity of Care in General Practice. In. Edited by Practitioners TRCoG; 2011.

39.

Brabers A, de Jong J. Toekomst van de huisartsenzorg Het perspectief van de burger: Nivel; 2019.

40.

General Practice Workforce: digital dashboard [https://app.powerbi.com/view?r=eyJrIjoiNmY4NGNiMWQtMGVkZi00MzU2LThiZGMtMTFlZjY2NGE0NTZmIiwidCI6IjUwZjYwNzFmLWJiZmUtNDAxYS04ODAzLTY3Mzc0OGU2MjllMiIsImMiOjh9].

41.

Vis E, Kenens R, Duijkers B, Batengurg R, Keuper J. Cijfers uit de registratie van huisartsen, vol. 2020. Utrecht: Nivel; 2020.

42.

Guthrie B, Wyke S. Personal continuity and access in UK general practice: a qualitative study of general practitioners' and patients' perceptions of when and how they matter. BMC Fam Pract. 2006;7(1):11. https://doi.org/10.1186/1471-2296-7-11.CrossRefPubMedPubMedCentral

43.

Uijen AA, van de Lisdonk EH. Multimorbidity in primary care: prevalence and trend over the last 20 years. Eur J Gen Pract. 2008;14(Suppl 1):28–32. https://doi.org/10.1080/13814780802436093.CrossRefPubMed

44.

Anderson G, Knickman JR. Changing the chronic care system to meet people's needs. Health Aff (Millwood). 2001;20(6):146–60. https://doi.org/10.1377/hlthaff.20.6.146.CrossRef

45.

Starfield B, Lemke KW, Herbert R, Pavlovich WD, Anderson G. Comorbidity and the use of primary care and specialist care in the elderly. Ann Fam Med. 2005;3(3):215–22. https://doi.org/10.1370/afm.307.CrossRefPubMedPubMedCentral

46.

Nutting P, Goodwin M, Flocke S, Zyzanski S, Stange K. Continuity of primary care: to whom does it matter and when? Ann Fam Med. 2003;1(3):149–55. https://doi.org/10.1370/afm.63.CrossRefPubMedPubMedCentral

47.

World Population Ageing 2013. In. New York: Department of Economic and Social Affairs; 2013: 114.

48.

Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655.CrossRef

49.

Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, et al. Framework for design and evaluation of complex interventions to improve health. BMJ. 2000;321(7262):694–6. https://doi.org/10.1136/bmj.321.7262.694.CrossRefPubMedPubMedCentral

50.

Uijen AA. Continuity of care. Perspective of the patient with a chronic illness; 2012.

51.

Stokes T, Tarrant C, Mainous AG III, Schers H, Freeman G, Baker R. Continuity of care: is the personal doctor still important? A survey of general practitioners and family physicians in England and Wales, the United States, and the Netherlands. Ann Fam Med. 2005;3(4):353–9. https://doi.org/10.1370/afm.351.CrossRefPubMedPubMedCentral

52.

Schers HJ. Continuity of care in general practice. Exploring the balance between personal and informational continuity; 2004.

53.

Hjortdahl P, Laerum E. Continuity of care in general practice: effect on patient satisfaction. BMJ. 1992;304(6837):1287–90. https://doi.org/10.1136/bmj.304.6837.1287.CrossRefPubMedPubMedCentral

54.

Saultz JW. Defining and measuring interpersonal continuity of care. Ann Fam Med. 2003;1(3):134–43. https://doi.org/10.1370/afm.23.CrossRefPubMedPubMedCentral

55.

Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009;7(2):100–3. https://doi.org/10.1370/afm.971.CrossRefPubMedPubMedCentral

56.

Hjortdahl P. Continuity of care: general practitioners' knowledge about, and sense of responsibility toward their patients. Fam Pract. 1992;9(1):3–8. https://doi.org/10.1093/fampra/9.1.3.CrossRefPubMed

57.

Freeman G, Anwar S, Dala A, Duncan J, Jiandani H, Osborne B et al: RCGP continuity of care toolkit - helping clinicians and practices maximise relationship continuity. In. Edited by RCGP; 2013.

58.

Improving Patient Care. The Implementation of Change in Health Care. 2nd ed: Wiley-Blackwell; 2013.

59.

Survalyzer Front page [https://www.survalyzer.com/].

60.

Praktijkkostenonderzoek huisartsen 2015 [https://puc.overheid.nl/nza/doc/PUC_3629_22/].

61.

Salkind N. Encyclopedia of measurement and statistics. CA: SAGE Publications; 2007. https://doi.org/10.4135/9781412952644.

62.

Jirwe M, Gerrish K, Keeney S, Emami A. Identifying the core components of cultural competence: findings from a Delphi study. J Clin Nurs. 2009;18(18):2622–34. https://doi.org/10.1111/j.1365-2702.2008.02734.x.CrossRefPubMed

63.

Radestad M, Jirwe M, Castren M, Svensson L, Gryth D, Ruter A. Essential key indicators for disaster medical response suggested to be included in a national uniform protocol for documentation of major incidents: a Delphi study. Scand J Trauma Resusc Emerg Med. 2013;21(1):68. https://doi.org/10.1186/1757-7241-21-68.CrossRefPubMedPubMedCentral

64.

Brown CA, Lilford RJ. The stepped wedge trial design: a systematic review. BMC Med Res Methodol. 2006;6(1):54. https://doi.org/10.1186/1471-2288-6-54.CrossRefPubMedPubMedCentral

65.

Uijen AA, Schellevis FG, van den Bosch WJ, Mokkink HG, van WC SHJ. Nijmegen continuity questionnaire: development and testing of a questionnaire that measures continuity of care. J Clin Epidemiol. 2011;64(12):1391–9. https://doi.org/10.1016/j.jclinepi.2011.03.006.CrossRefPubMed

66.

Uijen AA, Schers HJ, Schellevis FG, Mokkink HG, van Weel C, van den Bosch WJ. Measuring continuity of care: psychometric properties of the Nijmegen continuity questionnaire. Br J Gen Pract. 2012;62(600):e949–57. https://doi.org/10.3399/bjgp12X652364.CrossRefPubMedPubMedCentral

67.

Saunders RP, Evans MH, Joshi P. Developing a process-evaluation plan for assessing health promotion program implementation: a how-to guide. Health Promot Pract. 2005;6(2):134–47. https://doi.org/10.1177/1524839904273387.CrossRefPubMed

68.

Fleuren M, Wiefferink K, Paulussen T. Determinants of innovation within health care organizations: literature review and Delphi study. Int J Qual Health Care. 2004;16(2):107–23. https://doi.org/10.1093/intqhc/mzh030.CrossRefPubMed

69.

Gale N, heath G, cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117. https://doi.org/10.1186/1471-2288-13-117.

70.

National General Practice Research Agenda [https://www.nhg.org/sites/default/files/content/nhg_org/uploads/national_general_practice_research_agenda_2018_web.pdf].

71.

Patsopoulos N. A pragmatic view on pragmatic trials. Dialogues Clin Neurosci. 2011;13(2):217–24.CrossRef

72.

Treweek S, Zwarenstein M. Making trials matter: pragmatic and explanatory trials and the problem of applicability. Trials. 2009;10(1):37. https://doi.org/10.1186/1745-6215-10-37.CrossRefPubMedPubMedCentral

73.

Datta J, Petticrew M. Challenges to evaluating complex interventions: a content analysis of published papers. BMC Public Health. 2013;13(1):568. https://doi.org/10.1186/1471-2458-13-568.CrossRefPubMedPubMedCentral

Title: Optimising personal continuity for older patients in general practice: a study protocol for a cluster randomised stepped wedge pragmatic trial
Authors: Lex J. J. Groot
Henk J. Schers
Jako S. Burgers
Francois G. Schellevis
Martin Smalbrugge
Annemarie A. Uijen
Peter M. van de Ven
Henriëtte E. van der Horst
Otto R. Maarsingh
Publication date: 01-12-2021
Publisher: BioMed Central
Keyword: Care
Published in: BMC Primary Care / Issue 1/2021
Electronic ISSN: 2731-4553
DOI: https://doi.org/10.1186/s12875-021-01511-y

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Optimising personal continuity for older patients in general practice: a study protocol for a cluster randomised stepped wedge pragmatic trial

Abstract

Background

Methods

Discussion

Trial registration number

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Discussion

Trial registration number

Please log in to get access to this content

Other articles of this Issue 1/2021

Printed educational materials directed at Ontario family physicians do not improve adherence to guideline recommendations for diabetes management: a pragmatic, factorial, cluster randomized controlled trial [ISRCTN72772651]

A comparative assessment of two tools designed to support patient safety culture in UK general practice

The impacts of the COVID-19 pandemic on the mental health and residency training of family medicine residents: findings from a nationwide cross-sectional survey in Turkey

Early detection of anaemia in primary care with haemoglobinometry: ANHEMOG clinical trial protocol

Long term clinical outcomes of patients with ischemic stroke in primary care – a 9-year retrospective study

Management of penicillin allergy in primary care: a qualitative study with patients and primary care physicians