Patient Satisfaction and Continuity of Care

Continuity of care in family practice was first described by Hennen in 1975 and has been recognized since then as one of the core values in health care that contribute to patient and doctor satisfaction, as well as improved patient outcomes.¹ However, spiraling health care costs, the global financial crisis, changing practice patterns and other systemic pressures have seen the erosion of comprehensive care into more focused and fragmented models. As Dr. Jeffrey Turnbull, past president of the Canadian Medical Association, told the audience at the CMA's Annual General Meeting on Aug. 23, 2011: "Mediocrity has become the accepted norm ... illnesses prolonged because of unaffordable medications ... operations cancelled because of hospital overcapacity ... a lack of timely access to effective care ... a cumbersome system that supports some services but not others."²

One of the many new primary care models that is now in vogue features expanded multidisciplinary teams that can provide quicker access to care, but patients rarely see the same health care provider on subsequent visits. For most patients, continuity of care means that "their doctor" knows them. This is a social / psychological concept that necessitates the doctor remembering the patient and respecting their individual needs, beliefs and values so that a relationship based on trust and confidence lasts over the long term. Continuity in this context is defined as "the degree to which a series of discrete healthcare events is experienced as coherent, connected and consistent with the patient's healthcare needs and personal context."³

Recognition is the cornerstone of these relationships and is reinforced through ongoing interaction. As long as there is a positive relationship that establishes continuity, it may not matter much if continuity of care leads to patient satisfaction or patient satisfaction leads to continuity of care.⁴

Doctors of chiropractic have always excelled in the area of patient satisfaction. A recent survey of 45,000 Consumer Reports subscribers [for more information, read "Consumer Reports Surveys Readers on Alternative Health Care Use"] noted that 75 percent of survey participants used alternative therapies. Of particular interest, chiropractic was ranked as the most effective treatment for back pain; 21 percent of patients who reported using chiropractic were referred by their family physician.⁵

So, why are our utilization rates not higher? In the most recently published longitudinal study of chiropractic use among older adults in the United States, Weigel, et al., reported very interesting results that suggest that chiropractic patients comprise a unique subset of individuals seeking care. According to the study, which revealed a 4.8 percent mean annual prevalence of chiropractic use:

"Chiropractic patients were most often Caucasian; more educated with higher incomes; married and rural Chiropractic patients most often had zero comorbidities; few if any problems with activities of daily living; fewer depressive symptoms and higher cognitive functioning Chiropractic patients were rarely hospitalized in the previous 12-month period and had less access to traditional medical care."⁶

Attachment theory might provide some clues as to the reasons many patients stay with their medical practitioner even if they have a poor relationship and are not satisfied with their care. Generally speaking, younger, healthy patients with simple, nonthreatening complaints prefer quick access to any health care provider and do not really care about continuity. They are also more easily satisfied. However, patients confronting a major illness, one with life-altering impact, feel scared and vulnerable. They are more likely to maintain an attachment to a knowledgeable and trusted "caregiver" who helps them feel safe and secure despite any underlying behavioral shortcomings.⁷

A recent statement from researchers at Dalhousie University sums up the issue quite succinctly: "Long-term relationships were important for developing trust so that patients would share sensitive issues, for establishing appropriate boundaries, and for overcoming difficult relationships."⁸

References

1. Hennen BK. Continuity of care in family practice. Part 1: dimensions of continuity. J Fam Pract, 1975;2(5):371-2.
2. "Mediocrity Has Become the Norm, Turnbull Asserts in Valedictory Address." CMAJ News, Aug. 29, 2011; doi: 10.1503/cmaj.109-3982
3. Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ, Nov. 3, 2003;327(7425):1219-21.
4. Bogelund Frederiksen H, Kragstrup J, Dehlholm-Lambertsen H. It's all about recognition! Qualitative study of the value of interpersonal continuity in general practice. BMC Fam Pract, 2009;10:47. doi: 10.1186/1471-2296-10-47
5. Survey of alternative health use by Consumer Reports subscribers. Visit [url=http://www.consumerreports.org/health/natural-health/alternative-treatments/overview/index.htm]http://www.consumerreports.org/health/natural-health/alternative-treatments/overview/index.htm[/url] for an overview of survey findings. You can also review our Sept. 23 article, "Latest Consumer Survey: More of the Status Quo?" at DynamicChiropractic.com to learn more.
6. Weigel P, Hockenberry JM, Bentler SE, Obrizan M, Kaskie B, Jones MP, Ohsfeldt RL, Rosenthal GE, Wallace RB, Wolinsky FD. A longitudinal study of chiropractic use among older adults in the United States. Chiropractic & Osteopathy, 2010;18:34. doi: 10.1186/1746-1340-18-34
7. Bogelund Frederiksen H, Kragstrup J, Dehlholm-Lambertsen B. Attachment in the doctor-patient relationship in general practice: a qualitative study. Scan J Prim Health Care, 2010;28:185-90.
8. Delva D, Kerr J, Schultz K. Continuity of care. Differing conceptions and values. Can Fam Physician, August 2011;57:915-21