Small changes can lead to big rewards. That's the key learning from new research that looks at the relationship between continuity of care among Medicare patients with certain chronic diseases and four cost/quality indicators: health care costs, complications, hospitalizations and ER visits.
Authors of the article "Continuity and the Costs of Care for Chronic Disease,"(archinte.jamanetwork.com) which was published online early by JAMA Internal Medicine, concluded that, "Modest differences in care continuity for Medicare beneficiaries are associated with sizable differences in costs, use and complications."
Study authors looked at 2008-09 retrospective insurance claims data for a sample of 241,722 Medicare patients who experienced a 12-month episode of care for three chronic conditions: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or type 2 diabetes mellitus (DM).
Researchers counted only patient visits to physicians most likely to be involved in outpatient management for those three conditions. That makes the findings particularly significant for family physicians, who assume responsibility for managing those health conditions for millions of patients.
- New research in JAMA Internal Medicine finds that small improvements in continuity of care reap big rewards in terms of lowering cost and improving care quality.
- Researchers studied retrospective insurance claims data for more than 241,000 Medicare patients with congestive heart failure, chronic obstructive pulmonary disease or type 2 diabetes mellitus.
- They measured how continuity of care affected health care costs, complications, hospitalizations and ER visits.
"It was pretty striking that it only took a fairly small change in continuity to get a pretty sizeable cost impact," said corresponding author Peter Hussey, Ph.D, a senior policy researcher at the RAND Corp.
Cutting-edge Family Physicians
In an interview with AAFP News, Hussey said family physicians who embrace the patient-centered medical home model and participate in innovative models such as accountable care organizations -- both of which call for targeted, team-based care -- should find the study results encouraging.
"I suspect this will confirm what they already know: that coordinating care for these patients is extremely important. Investing in ways that we can manage patients through all the care they receive is likely to have a big impact among this population," said Hussey.
Furthermore, with all the changes coming as a result of health care reform, there's bound to be an increasing emphasis on how physicians can proactively coordinate care for patients. "This research provides some evidence that it's a worthwhile activity," he added.
Deciphering the Details
To measure continuity of care, researchers used the Bice-Boxerman Continuity of Care (COC) index that reflects the relative share of all of a patient's visits during the year that are billed by a distinct physician and/or practice. The index ranges from zero (each visit involves a different physician) to one (all visits are billed by a single physician).
"A patient bouncing around in a totally uncoordinated way to lots of various physicians would have a low COC index," said Hussey. Conversely, highly coordinated care and a corresponding high COC reflect the work of one central physician orchestrating care with other selected physicians.
When looking at total episode costs, researchers found that just a 0.1-unit increase in the COC index was associated with 4.7 percent lower costs for CHF, 6.3 percent lower costs for COPD and 5.1 percent lower costs for DM.
Translated into actual dollars, that slight increase in the COC index translated into a
- $66 decrease in cost (out of $1,437 total cost) for a patient with CHF,
- $64 decrease in cost (out of $1,062 total cost) for a patient with COPD, and a
- $52 decrease in cost (out of $1,047 total cost) for a patient with DM.
And increasing the COC index was fairly simple. For example, authors pointed out that for patients with seven total office visits, decreasing the number of physicians caring for them from three to two increased the COC index by 0.1 unit. The same increase was achieved by increasing the number of patient visits with a primary care professional from four visits to five.
Researchers also took into account the number of a patient's comorbidities using CMS' 2008 hierarchical condition categories.
Planning Future Research
Hussey said bending the cost curve in health care is tough, and that's why the headline news of this study was unexpected. "If we see something where there's a small difference associated with a big change in costs, that's a little unusual," he acknowledged.
The study didn't answer the "why" of the research findings, but Hussey suggested that perhaps more continuous care offered fewer opportunities for communication errors. "Obviously, the more information exchanges that physicians have, the more opportunities there are for a ball to get dropped," said Hussey. For instance, a lab report that never arrived at the receiving physician's office probably influenced a health care decision.
Hussy said the new research affirmed that physicians should embrace care coordination. "A pretty small change in continuity can have a pretty big impact. So next, we need to figure out exactly how to best do this.
"But just because we're looking at small changes doesn't mean making those changes will be easy," he cautioned.
More From AAFP
AAFP Policy: Definition of Continuity of Care