Litaker DG (Louis Stokes Cleveland DVAMC)
Ober S (Louis Stokes Cleveland DVAMC)
Aron DC (Louis Stokes Cleveland DVAMC)
Continuity of care is viewed by some as a requisite for high quality care. Its importance across diverse organizational settings and its association with desired treatment outcomes remains unclear, however. The purpose of this study was to explore both processes and outcomes of preventive care in relation to continuity of primary care at a large VA outpatient clinic.
We identified 4486 veterans with >=2 visits to the outpatient primary care clinic at the Cleveland VA Medical Center during 2003. Taking note of the VA physician (PCP) providing care at each visit from the electronic medical record, we identified the PCP responsible for the greatest proportion of visits during the study year. Use of services, laboratory tests, and medications reflected selected aspects of patients’ preventive care for cardiovascular disease. Analytic techniques that accounted for clustering of patients within provider practices yielded robust estimators for the association between primary care continuity and treatment processes and outcomes.
Veterans with greater primary care continuity had more diagnoses, were more likely to have been on lipid-lowering (LLA) therapy initially, and had fewer office visits during the study period (all p values<.001). These individuals, however, had fewer referrals to a nutritionist (Odds ratio [OR] .69; 95% confidence intervals [CI] .56, .85), were assessed less frequently for current smoking status (OR .40; CI .20, .80), and received tobacco cessation counseling less often (OR .39; CI .27, .56). Lipid screening, use of LLA among those not at goal, and LLA dose intensification was not associated with continuity of care (all p values >.05). We also found no association between continuity and the proportion of patients at recommended treatment goals for blood pressure or lipids.
Greater continuity of care in the VA does not guarantee higher quality of preventive care and may be associated with the delivery of fewer recommended services. Having a regular site rather than a single source of care may offer benefits similar to those reported in non-VA settings.
Use of systems-wide tools such as clinical reminders may counterbalance potential disadvantages associated with low continuity to better enable guideline-consistent care.