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Abstract

Background. Continuity between doctors and patients likely affects patient satisfaction.

Objective. To assess the current evidence on the relationship between continuity and patient satisfaction.

Methods. Systematic review of studies of adults in general, family, or internal medicine practices with ongoing, direct, face-to-face contact with their physician. Measures of the relationship between continuity and patient satisfaction were examined.

Results. A MEDLINE search covering 1984–2007 and a Cumulative Index to Nursing and Allied Health Literature search covering 1981–2007 identified 263 relevant studies and 12 studies met inclusion criteria. There were 12 different continuity measures and 9 different satisfaction measures.

Conclusions. Continuity has a variable effect on patient satisfaction.

Introduction

As health care systems in the USA and the UK evolve, continuity between doctors and patients appears more difficult to achieve. In the USA, there have been documented disruptions in the relationships between doctors and patients.1,2 In the UK, the development of group practices and walk-in centres are seen as likely to have reduced continuity.3,4

Continuity has been defined in numerous ways. Saultz5 proposed a hierarchical definition of continuity from informational to longitudinal to interpersonal. Continuity has also been described from the patients' point of view.6,7 Despite calls to develop uniform terminology and measurement techniques for three decades,5,8,9 neither has been accomplished. Measurement techniques for continuity are more numerous than the definitions.5,10

The effect of continuity on preventive measures11–13 and for control of chronic diseases14–17 is inconsistent. Patient and health care system variables operating outside the ongoing doctor–patient relationship are likely to be involved in these outcomes. In contrast, patient satisfaction seems more likely to be affected by an ongoing direct relationship between a patient and their physician.

Although continuity is not uniformly valued by all patients,18 continuity is important to the medical community,19 but does continuity lead to more satisfied patients? Four prior systematic reviews examining this question concluded that there is a consistent positive relationship between continuity and patient satisfaction,9,20–22 but three of these reviews included studies in which continuity was not actually measured.9,20,21 This review differs in that it requires that continuity be measured, distinguishes between the quantitative and subjective continuity measures and their relationships to satisfaction and focuses on adult patients. Our goal for this systematic review is to assess the evidence since the early 1980s for the relationship between continuity, characterized by ongoing, direct and face-to-face contact between adult patients and a physician and patient satisfaction.

Methods

We systematically searched MEDLINE for original research articles from 1984 to 2007 utilizing the following MeSH terms: primary health care, continuity of patient care, patient satisfaction and all adults >19 years. Using the same search terms, we also searched Cumulative Index to Nursing and Allied Health Literature from 1981 to 2007. Studies were considered eligible for inclusion if they reported measures of continuity, patient satisfaction and the relationship between continuity and satisfaction or provided sufficient data to derive these measures. The continuity and satisfaction measures had to reflect ongoing, direct, face-to-face contact between a patient and a physician practicing general, family or internal medicine. The search terms we used were purposely broad in scope, a reflection of the myriad ways in which continuity and satisfaction have been measured. Our search was limited to the past 24–29 years as this was an adequate amount of time for changes in the health care systems of the UK and the USA to be reflected in the medical literature that examined the relationship between continuity and patient satisfaction. We supplemented our computerized literature search by manually searching the bibliographies of identified articles. Two investigators (R.A. and N.B.) evaluated potential articles to decide if they were eligible for inclusion and resolved any disagreements by discussion. Any type of study design was eligible. Because we were interested in the direct relationship between a physician and patient, articles were excluded that measured continuity between patients and practice sites and health care teams. Articles that used only telephone contact rather than direct contact were also excluded. Although an important tool for physicians, telephone contacts are not included in any of the described continuity measures and are inconsistently documented by physicians. We focused on adult medical patients and studies of obstetrical, paediatric, psychiatric and surgical patients were excluded.

Results

Figure 1 outlines the flow of article retrieval for the review. Two studies reported results from the 1996–97 Community Tracking Study Household Survey.23,24 We retained the original with the larger number of subjects.23 The 12 articles, one randomized controlled trial (RCT)25 and 11 cross-sectional studies23,26–35 are summarized in Table 1.

TABLE 1

Continuity and patient satisfaction

Author Year Study design Sample size and subjects Satisfaction measure Continuity measure Relationship between satisfaction and continuity
Wasson et al. 25 1984 RCT 776 men attending a VA general medical clinic randomized to: 490: continuity; 238: discontinuity Patient Satisfaction Scale36 UPCa 0.56 versus 0.34, P < 0.001 Overall satisfaction (score not reported), P > 0.05, continuity versus discontinuity
COCa 0.42 versus 0.21, P < 0.001
Satisfaction with continuity subscale (highest possible score = 8) SECONa 0.48 versus 0.35, P = 0.004 continuity versus discontinuity 5.9 versus 4.5, P < 0.001, continuity versus discontinuity
Flocke26 1997 Cross-sectional 2899 patients attending the offices of 138 family physicians in Ohio Medical Outcomes Study Visit Rating Form UPCa r = 0.08, P < 0.01
Longitudinality (mean = 2.54 years, SD ± 1.51) r = 0.07, P < 0.01
Baker et al. 27 2003 Cross-sectional 650 UK and 418 US patients attending general and family physicians' offices in the UK, Kentucky and South Carolina General satisfaction subscale of Consultation Satisfaction Questionnaire UPCa (mean = 0.4, SD ± 0.3) β = −0.02, P = 0.57
Longitudinality (29%, >10 years, range, <1 to >10 years) β = −0.05, P = 0.26
Saw regular physician (75%) β = 0.10, P = 0.008
Chao28 1988 Cross-sectional 147 randomly selected patients of a private family practice in Ohio Patient Satisfaction Scale36 UPCa (mean = 0.4, SD ± 0.3) r = 0.04, P > 0.05
COCa (mean = 0.50, SD ± 0.38) r = 0.06, P > 0.05
Perception of Continuity Scale (mean = 3.6, range 1–5, SD ± 0.6) r = 0.66, P < 0.01
Hill et al. 29 1992 Cross-sectional 70 randomly selected patients attending a rheumatology clinic in Leeds, UK Continuity subscale of Leeds Satisfaction Questionnaire36 Saw the same person at each visit, with at least three visits to the clinic: 36 with continuity, 34 without continuity RR = 1.13 among continuity patients Satisfaction scores: 3.30 among patients with versus 2.93 among patients without continuity
Weyrauch30 1996 Cross-sectional 1146 randomly selected patients enrolled in a health maintenance organization in Washington state Patient Satisfaction Scale36 Seeing one's own doctor or getting choice of doctor RR = 1.67, 40% with continuity reported excellent satisfaction versus 23.9% without continuity
Hjortdahl and Laerum31 1992 Cross-sectional 3918 Norwegian primary care patients attending the offices of 133 randomly selected general practitioners Overall satisfaction Duration of relationship >5 years OR 1.85, 95% CI 1.07–3.19 compared to patients with first contact
Personal doctor for most of my health problems; OR 2.62, 95% CI 1.87–3.64, P = 0.001
Personal doctor for all my health problems OR 6.95, 95% CI 4.89–9.90, P = 0.001
Donahue, et al. 32 2005 Cross-sectional 3176 randomly selected patients from the US Southern Rural Access Program Dissatisfaction with overall health care Years with physician OR 2.34, 95% CI 1.39–3.93 among patients with ≤1 year with same physician, P = 0.001 compared to patients with 3–5 years
Forrest et al. 23 2002 Cross-sectional 19 415 randomly selected patients from the US Community Tracking Study Household Survey 1996–97 Patient-PCP relationship scale PCP is specific clinician β (SE) = 0.17 (0.02), P < 0.001
Relationship with PCP ≥12 months β (SE) = 0.05 (0.01), 0.001 ≤ P ≤ 0.01
Love et al. 33 2000 Cross-sectional 1726 randomly selected patients in the Kentucky Medicaid program: 1322 non-asthmatics, 404 asthmatics MD listened Patient reported perception of seeing same providerNon-asthmatics: 59.1% always same provider Asthmatics: 57.5% always same provider Non-asthmatics: β = 0.143, P = 0.0001 Asthmatics: β = 0.147, P = 0.01
Patient influence on MD treatment Non-asthmatics: β = 0.144, P = 0.0001 Asthmatics: β = 0.144, P = 0.02
Fan, et al. 34 2005 Cross-sectional 21 684 general medical patients in a VA RCT of quality improvement interventions at seven VA medical centres Humanistic scale of SOSQ scale score 0–100 Patient reported perception of seeing same provider: 39% always same provider SOSQ score: 79.4 versus 58.1, P < 0.0001 always versus rarely/never saw same provider
Guillford et al. 35 2007 Cross-sectional 156 patients with diabetes attending 19 family practices in London, UK Satisfaction with overall diabetes care ECC-DM scale score 0–100 Most satisfied patients: ECC-DM score = 68.9, P = 0.001 compared to least satisfied patients: ECC-DM score = 60.9
Author Year Study design Sample size and subjects Satisfaction measure Continuity measure Relationship between satisfaction and continuity
Wasson et al. 25 1984 RCT 776 men attending a VA general medical clinic randomized to: 490: continuity; 238: discontinuity Patient Satisfaction Scale36 UPCa 0.56 versus 0.34, P < 0.001 Overall satisfaction (score not reported), P > 0.05, continuity versus discontinuity
COCa 0.42 versus 0.21, P < 0.001
Satisfaction with continuity subscale (highest possible score = 8) SECONa 0.48 versus 0.35, P = 0.004 continuity versus discontinuity 5.9 versus 4.5, P < 0.001, continuity versus discontinuity
Flocke26 1997 Cross-sectional 2899 patients attending the offices of 138 family physicians in Ohio Medical Outcomes Study Visit Rating Form UPCa r = 0.08, P < 0.01
Longitudinality (mean = 2.54 years, SD ± 1.51) r = 0.07, P < 0.01
Baker et al. 27 2003 Cross-sectional 650 UK and 418 US patients attending general and family physicians' offices in the UK, Kentucky and South Carolina General satisfaction subscale of Consultation Satisfaction Questionnaire UPCa (mean = 0.4, SD ± 0.3) β = −0.02, P = 0.57
Longitudinality (29%, >10 years, range, <1 to >10 years) β = −0.05, P = 0.26
Saw regular physician (75%) β = 0.10, P = 0.008
Chao28 1988 Cross-sectional 147 randomly selected patients of a private family practice in Ohio Patient Satisfaction Scale36 UPCa (mean = 0.4, SD ± 0.3) r = 0.04, P > 0.05
COCa (mean = 0.50, SD ± 0.38) r = 0.06, P > 0.05
Perception of Continuity Scale (mean = 3.6, range 1–5, SD ± 0.6) r = 0.66, P < 0.01
Hill et al. 29 1992 Cross-sectional 70 randomly selected patients attending a rheumatology clinic in Leeds, UK Continuity subscale of Leeds Satisfaction Questionnaire36 Saw the same person at each visit, with at least three visits to the clinic: 36 with continuity, 34 without continuity RR = 1.13 among continuity patients Satisfaction scores: 3.30 among patients with versus 2.93 among patients without continuity
Weyrauch30 1996 Cross-sectional 1146 randomly selected patients enrolled in a health maintenance organization in Washington state Patient Satisfaction Scale36 Seeing one's own doctor or getting choice of doctor RR = 1.67, 40% with continuity reported excellent satisfaction versus 23.9% without continuity
Hjortdahl and Laerum31 1992 Cross-sectional 3918 Norwegian primary care patients attending the offices of 133 randomly selected general practitioners Overall satisfaction Duration of relationship >5 years OR 1.85, 95% CI 1.07–3.19 compared to patients with first contact
Personal doctor for most of my health problems; OR 2.62, 95% CI 1.87–3.64, P = 0.001
Personal doctor for all my health problems OR 6.95, 95% CI 4.89–9.90, P = 0.001
Donahue, et al. 32 2005 Cross-sectional 3176 randomly selected patients from the US Southern Rural Access Program Dissatisfaction with overall health care Years with physician OR 2.34, 95% CI 1.39–3.93 among patients with ≤1 year with same physician, P = 0.001 compared to patients with 3–5 years
Forrest et al. 23 2002 Cross-sectional 19 415 randomly selected patients from the US Community Tracking Study Household Survey 1996–97 Patient-PCP relationship scale PCP is specific clinician β (SE) = 0.17 (0.02), P < 0.001
Relationship with PCP ≥12 months β (SE) = 0.05 (0.01), 0.001 ≤ P ≤ 0.01
Love et al. 33 2000 Cross-sectional 1726 randomly selected patients in the Kentucky Medicaid program: 1322 non-asthmatics, 404 asthmatics MD listened Patient reported perception of seeing same providerNon-asthmatics: 59.1% always same provider Asthmatics: 57.5% always same provider Non-asthmatics: β = 0.143, P = 0.0001 Asthmatics: β = 0.147, P = 0.01
Patient influence on MD treatment Non-asthmatics: β = 0.144, P = 0.0001 Asthmatics: β = 0.144, P = 0.02
Fan, et al. 34 2005 Cross-sectional 21 684 general medical patients in a VA RCT of quality improvement interventions at seven VA medical centres Humanistic scale of SOSQ scale score 0–100 Patient reported perception of seeing same provider: 39% always same provider SOSQ score: 79.4 versus 58.1, P < 0.0001 always versus rarely/never saw same provider
Guillford et al. 35 2007 Cross-sectional 156 patients with diabetes attending 19 family practices in London, UK Satisfaction with overall diabetes care ECC-DM scale score 0–100 Most satisfied patients: ECC-DM score = 68.9, P = 0.001 compared to least satisfied patients: ECC-DM score = 60.9

OR, odds ratio; PCP, primary care physicians; CI, confidence interval; VA, Veterans Administration; SOSQ, Seattle Outpatient Satisfaction Questionnaire.

a

Range = 0 to 1.

TABLE 1

Continuity and patient satisfaction

Author Year Study design Sample size and subjects Satisfaction measure Continuity measure Relationship between satisfaction and continuity
Wasson et al. 25 1984 RCT 776 men attending a VA general medical clinic randomized to: 490: continuity; 238: discontinuity Patient Satisfaction Scale36 UPCa 0.56 versus 0.34, P < 0.001 Overall satisfaction (score not reported), P > 0.05, continuity versus discontinuity
COCa 0.42 versus 0.21, P < 0.001
Satisfaction with continuity subscale (highest possible score = 8) SECONa 0.48 versus 0.35, P = 0.004 continuity versus discontinuity 5.9 versus 4.5, P < 0.001, continuity versus discontinuity
Flocke26 1997 Cross-sectional 2899 patients attending the offices of 138 family physicians in Ohio Medical Outcomes Study Visit Rating Form UPCa r = 0.08, P < 0.01
Longitudinality (mean = 2.54 years, SD ± 1.51) r = 0.07, P < 0.01
Baker et al. 27 2003 Cross-sectional 650 UK and 418 US patients attending general and family physicians' offices in the UK, Kentucky and South Carolina General satisfaction subscale of Consultation Satisfaction Questionnaire UPCa (mean = 0.4, SD ± 0.3) β = −0.02, P = 0.57
Longitudinality (29%, >10 years, range, <1 to >10 years) β = −0.05, P = 0.26
Saw regular physician (75%) β = 0.10, P = 0.008
Chao28 1988 Cross-sectional 147 randomly selected patients of a private family practice in Ohio Patient Satisfaction Scale36 UPCa (mean = 0.4, SD ± 0.3) r = 0.04, P > 0.05
COCa (mean = 0.50, SD ± 0.38) r = 0.06, P > 0.05
Perception of Continuity Scale (mean = 3.6, range 1–5, SD ± 0.6) r = 0.66, P < 0.01
Hill et al. 29 1992 Cross-sectional 70 randomly selected patients attending a rheumatology clinic in Leeds, UK Continuity subscale of Leeds Satisfaction Questionnaire36 Saw the same person at each visit, with at least three visits to the clinic: 36 with continuity, 34 without continuity RR = 1.13 among continuity patients Satisfaction scores: 3.30 among patients with versus 2.93 among patients without continuity
Weyrauch30 1996 Cross-sectional 1146 randomly selected patients enrolled in a health maintenance organization in Washington state Patient Satisfaction Scale36 Seeing one's own doctor or getting choice of doctor RR = 1.67, 40% with continuity reported excellent satisfaction versus 23.9% without continuity
Hjortdahl and Laerum31 1992 Cross-sectional 3918 Norwegian primary care patients attending the offices of 133 randomly selected general practitioners Overall satisfaction Duration of relationship >5 years OR 1.85, 95% CI 1.07–3.19 compared to patients with first contact
Personal doctor for most of my health problems; OR 2.62, 95% CI 1.87–3.64, P = 0.001
Personal doctor for all my health problems OR 6.95, 95% CI 4.89–9.90, P = 0.001
Donahue, et al. 32 2005 Cross-sectional 3176 randomly selected patients from the US Southern Rural Access Program Dissatisfaction with overall health care Years with physician OR 2.34, 95% CI 1.39–3.93 among patients with ≤1 year with same physician, P = 0.001 compared to patients with 3–5 years
Forrest et al. 23 2002 Cross-sectional 19 415 randomly selected patients from the US Community Tracking Study Household Survey 1996–97 Patient-PCP relationship scale PCP is specific clinician β (SE) = 0.17 (0.02), P < 0.001
Relationship with PCP ≥12 months β (SE) = 0.05 (0.01), 0.001 ≤ P ≤ 0.01
Love et al. 33 2000 Cross-sectional 1726 randomly selected patients in the Kentucky Medicaid program: 1322 non-asthmatics, 404 asthmatics MD listened Patient reported perception of seeing same providerNon-asthmatics: 59.1% always same provider Asthmatics: 57.5% always same provider Non-asthmatics: β = 0.143, P = 0.0001 Asthmatics: β = 0.147, P = 0.01
Patient influence on MD treatment Non-asthmatics: β = 0.144, P = 0.0001 Asthmatics: β = 0.144, P = 0.02
Fan, et al. 34 2005 Cross-sectional 21 684 general medical patients in a VA RCT of quality improvement interventions at seven VA medical centres Humanistic scale of SOSQ scale score 0–100 Patient reported perception of seeing same provider: 39% always same provider SOSQ score: 79.4 versus 58.1, P < 0.0001 always versus rarely/never saw same provider
Guillford et al. 35 2007 Cross-sectional 156 patients with diabetes attending 19 family practices in London, UK Satisfaction with overall diabetes care ECC-DM scale score 0–100 Most satisfied patients: ECC-DM score = 68.9, P = 0.001 compared to least satisfied patients: ECC-DM score = 60.9
Author Year Study design Sample size and subjects Satisfaction measure Continuity measure Relationship between satisfaction and continuity
Wasson et al. 25 1984 RCT 776 men attending a VA general medical clinic randomized to: 490: continuity; 238: discontinuity Patient Satisfaction Scale36 UPCa 0.56 versus 0.34, P < 0.001 Overall satisfaction (score not reported), P > 0.05, continuity versus discontinuity
COCa 0.42 versus 0.21, P < 0.001
Satisfaction with continuity subscale (highest possible score = 8) SECONa 0.48 versus 0.35, P = 0.004 continuity versus discontinuity 5.9 versus 4.5, P < 0.001, continuity versus discontinuity
Flocke26 1997 Cross-sectional 2899 patients attending the offices of 138 family physicians in Ohio Medical Outcomes Study Visit Rating Form UPCa r = 0.08, P < 0.01
Longitudinality (mean = 2.54 years, SD ± 1.51) r = 0.07, P < 0.01
Baker et al. 27 2003 Cross-sectional 650 UK and 418 US patients attending general and family physicians' offices in the UK, Kentucky and South Carolina General satisfaction subscale of Consultation Satisfaction Questionnaire UPCa (mean = 0.4, SD ± 0.3) β = −0.02, P = 0.57
Longitudinality (29%, >10 years, range, <1 to >10 years) β = −0.05, P = 0.26
Saw regular physician (75%) β = 0.10, P = 0.008
Chao28 1988 Cross-sectional 147 randomly selected patients of a private family practice in Ohio Patient Satisfaction Scale36 UPCa (mean = 0.4, SD ± 0.3) r = 0.04, P > 0.05
COCa (mean = 0.50, SD ± 0.38) r = 0.06, P > 0.05
Perception of Continuity Scale (mean = 3.6, range 1–5, SD ± 0.6) r = 0.66, P < 0.01
Hill et al. 29 1992 Cross-sectional 70 randomly selected patients attending a rheumatology clinic in Leeds, UK Continuity subscale of Leeds Satisfaction Questionnaire36 Saw the same person at each visit, with at least three visits to the clinic: 36 with continuity, 34 without continuity RR = 1.13 among continuity patients Satisfaction scores: 3.30 among patients with versus 2.93 among patients without continuity
Weyrauch30 1996 Cross-sectional 1146 randomly selected patients enrolled in a health maintenance organization in Washington state Patient Satisfaction Scale36 Seeing one's own doctor or getting choice of doctor RR = 1.67, 40% with continuity reported excellent satisfaction versus 23.9% without continuity
Hjortdahl and Laerum31 1992 Cross-sectional 3918 Norwegian primary care patients attending the offices of 133 randomly selected general practitioners Overall satisfaction Duration of relationship >5 years OR 1.85, 95% CI 1.07–3.19 compared to patients with first contact
Personal doctor for most of my health problems; OR 2.62, 95% CI 1.87–3.64, P = 0.001
Personal doctor for all my health problems OR 6.95, 95% CI 4.89–9.90, P = 0.001
Donahue, et al. 32 2005 Cross-sectional 3176 randomly selected patients from the US Southern Rural Access Program Dissatisfaction with overall health care Years with physician OR 2.34, 95% CI 1.39–3.93 among patients with ≤1 year with same physician, P = 0.001 compared to patients with 3–5 years
Forrest et al. 23 2002 Cross-sectional 19 415 randomly selected patients from the US Community Tracking Study Household Survey 1996–97 Patient-PCP relationship scale PCP is specific clinician β (SE) = 0.17 (0.02), P < 0.001
Relationship with PCP ≥12 months β (SE) = 0.05 (0.01), 0.001 ≤ P ≤ 0.01
Love et al. 33 2000 Cross-sectional 1726 randomly selected patients in the Kentucky Medicaid program: 1322 non-asthmatics, 404 asthmatics MD listened Patient reported perception of seeing same providerNon-asthmatics: 59.1% always same provider Asthmatics: 57.5% always same provider Non-asthmatics: β = 0.143, P = 0.0001 Asthmatics: β = 0.147, P = 0.01
Patient influence on MD treatment Non-asthmatics: β = 0.144, P = 0.0001 Asthmatics: β = 0.144, P = 0.02
Fan, et al. 34 2005 Cross-sectional 21 684 general medical patients in a VA RCT of quality improvement interventions at seven VA medical centres Humanistic scale of SOSQ scale score 0–100 Patient reported perception of seeing same provider: 39% always same provider SOSQ score: 79.4 versus 58.1, P < 0.0001 always versus rarely/never saw same provider
Guillford et al. 35 2007 Cross-sectional 156 patients with diabetes attending 19 family practices in London, UK Satisfaction with overall diabetes care ECC-DM scale score 0–100 Most satisfied patients: ECC-DM score = 68.9, P = 0.001 compared to least satisfied patients: ECC-DM score = 60.9

OR, odds ratio; PCP, primary care physicians; CI, confidence interval; VA, Veterans Administration; SOSQ, Seattle Outpatient Satisfaction Questionnaire.

a

Range = 0 to 1.

FIGURE 1

Flow of studies in the review

Flow of studies in the review

The 12 studies included a total of 56 186 subjects, ranging from less than 100 to almost 22 000 subjects per study. The average age of the subjects ranged from 39 to 65 years old25,31 and 61% were women. Although patients were predominantly white and insured, all socioeconomic levels were represented. The percentage of US patients with Medicaid insurance varied from <10%23,26 to 100%33 and one study reported 24% uninsured patients.32 Four studies (33%) had European subjects, two were in subjects from the UK,29,35 one had patients from both the UK and USA27 and one study was in Norwegian subjects.31

The continuity measures were both numerous and heterogeneous. There were 12 continuity measures consisting of five quantitative and seven subjective measures. The quantitative measures consisted of either indices that measure patterns of visits or measures of the length of time in years that a patient has been seen by a physician. The subjective measures of continuity are based on patients' self-report and may yield a numeric score if based on multiple-item questionnaires. The quantitative indices of continuity were Usual Provider Continuity (UPC), Continuity of Care (COC) and Sequential Continuity (SECON). The UPC, used in four studies,25–28 requires that the patient have an assigned or primary provider and quantifies how a patient's pattern of visits relates to the patient's usual assigned provider. The COC, used in two studies25,28 does not require patient assignment to a specific provider and measures the number of providers seen, with a larger number of visits to a smaller number of providers producing a higher continuity score. The SECON, used in one study25 quantifies the number of sequential visits to the same provider. Longitudinality, which quantifies the length of a patient's relationship with their physician, was used in five studies.23,26,27,31,32 The fifth quantitative measurement defined continuity as seeing the same provider at each visit with at least three previous clinic visits.29

The subjective measures of continuity included asking patients if they saw their regular physician on the day they were surveyed,27 if they saw their own physician on the day they were surveyed and also had been offered a choice of physicians,30 if the doctor they saw was their personal doctor for some, most or all of their medical problems31 and if their primary care provider was a specific physician.23 Two studies asked patients about their perceptions of always seeing the same provider.33,34 Two studies used different multiple-item questionnaires to measure patients' perceptions and experiences of continuity.28,35

Patient satisfaction was measured in nine different ways. Of the 12 studies, four 25,28–30 used modifications of Ware's measure of satisfaction.36 Four used different, though previously validated satisfaction scales.26,27,32,34 Another measure was the Patient-primary care physicians scale using seven items from the Community Tracking Study 1996–1997.23 One study measured satisfaction by asking if the provider listened to the patient and about the patient's ability to influence treatment.33 Two studies reported overall satisfaction and did not use or modify a previously validated satisfaction instrument.31,35

The only RCT found mixed results for the effect of continuity on satisfaction.25 There was no difference in overall satisfaction between the two groups even though the experimental continuity group scored significantly higher on three indices of continuity. On the satisfaction with continuity subscale, the experimental group was significantly more satisfied.

In the three cross-sectional studies that used indices to quantify the pattern of visits to a provider, there was a statistically significant, but weak association in one,26 and two studies showed no association between patient satisfaction and continuity.27,28 A fourth cross-sectional study measured the pattern of visits without using a formal index and found a weak relationship between continuity and satisfaction.29 Among the five cross-sectional studies23,26,27,31,32 that used the duration of the doctor–patient relationship to measure continuity, only two found a moderate relationship between duration and patient satisfaction.31,32

The subjective measures of continuity were all significantly associated with satisfaction and the strength of the associations to satisfaction were variable. For patients seeing their regular doctor on the day they were surveyed27 and for patients who reported that their primary care physician was a specific clinician,23 the relationship of these two continuity measures to satisfaction, although statistically significant, was weak. In a study of health maintenance organization patients, satisfaction was increased when patients saw their own doctor or got a choice of physicians.30 In another study, patients who responded that the doctor they saw on the day they were surveyed was their personal doctor for 'most' or 'all' of their health problems were three and seven times, respectively, more likely to be satisfied than patients who did not consider the doctor to be their personal physician.31

Two studies used patients' reported perceptions of seeing the same provider.33,34 In the largest study included in this review, 39% of patients always saw the same provider and there was a strong relationship to satisfaction for this group.34 Another study using the same measure compared continuity for asthmatics and non-asthmatics with satisfaction and the relationship of continuity to satisfaction was weak for both groups, although statistically significant.33 Two small studies measured continuity by addressing patients' perceptions or experiences of continuity using multiple-item scales. In a 1988 study, the Perception of Continuity Scale with 23 items divided into two factors, interpersonal and structural, was moderately related to satisfaction for 147 patients in a mid-Western US family practice.28 The Experienced Continuity of Care—Diabetes Mellitus (ECC-DM) scale with 19 items divided into four factors consisting of longitudinal, relational, flexible and team and cross-boundary continuity was recently validated.37 Overall ECC-DM scores for 156 family practice patients from London were significantly associated with satisfaction with their diabetes care.35

Discussion

Although continuity is one of the tenets of primary care and is valued by physicians, the evidence establishing a relationship between continuity and satisfaction for adults over the past 25 years is quite variable. Of the two types of continuity measures, the subjective measures were found to be consistently and significantly associated with satisfaction. The quantitative measures, which include the various indices and longitudinality, were not consistently associated with satisfaction and we concluded that the relationship between continuity and satisfaction was variable.

Interpretation of the results

Reflecting not only the numerous definitions and measures of continuity but also the lack of consensus in the medical literature on how to define and measure continuity, there were 12 different continuity measures among the 12 studies that met our inclusion criteria. Only one study using an index to measure continuity showed a significant, but weak relationship between continuity and satisfaction.26 Overall, the lack of a relationship between the continuity indices and satisfaction is possibly related to their inability to capture important elements of the doctor–patient relationship. Longitudinality, used in five studies,23,26,27,31,32 reflects the duration of a relationship between patients and their physicians and is the only continuity measure that accounts for time. Among the five studies, two showed a moderately strong relationship with satisfaction,31,32 two showed weak, but statistically significant relationships,23,26 and one showed no relationship.27 The duration of patients' relationships with their physicians across the five studies that used longitudinality was from <1 year to >10 years.

The subjective measures of continuity are by definition qualitative and do not require a mathematical calculation. Subjective measures, employed in eight studies,23,27,28,30,31,33–35 were variable in the strength of their relationship to continuity, but all were found to be statistically significant. While causality cannot be determined, this association may reflect the importance of continuity to patients and their actions to obtain what they need. These subjective measures may also capture important elements of the relationship that elude measurement with continuity indices or longitudinalty. The correlation between patients' subjective reports of continuity and the UPC has been found to be moderate (R = 0.30).38 Patient's subjective reports and the UPC were significantly associated with the quality of patient–physician interactions, as measured by the Ambulatory Care Experiences Survey,39 but the effect size for patients' report was five times larger compared with the UPC.38 Subjective measures may better reflect the quality of the doctor–patient relationship compared with the quantitative measures.

Strengths and limitations of the study

Having searched two databases, our search was more extensive than previous systematic reviews on this topic. As an attempt to make our study relevant to current practice, we limited the time frame of our MEDLINE search to 1984–2007. In addition, none of the previously published reviews9,20–22 included any articles published prior to 1984 that would have met our inclusion criteria. We relied on bibliographic citations and abstracts to eliminate many articles, which may have included measures of continuity and satisfaction that were not included in the abstracts. Only studies meeting all the criteria were included and thus only high-quality studies met our inclusion criteria.

The continuity measures and satisfaction measures were as heterogeneous as the studies themselves and data could not be combined to create a summary statistic that might precisely describe the relationship between continuity and satisfaction. This limitation is shared with the previous reviews.9,20–22

Restricting our study to adult medical patients allowed us to calculate demographic data for the study population of 56 000 subjects. Overall, the patients in these studies were mostly younger, white and almost 100% insured. The limitations these characteristics place on the generalizability of our findings are clear as medical care is likely to be different for patients who are ethnically diverse, have multiple serious chronic illnesses or lack health insurance.

Meaning of the study

Regardless of the how continuity is measured, continuity serves as proxy for the doctor–patient relationship and the effect of continuity on satisfaction may be moderated by the value an adult patient places on continuity. Research has begun to identify subgroups of patients who place a high value on continuity. In cross-sectional studies from both the UK and The Netherlands, patients valued a personal doctor–patient relationship for serious, long-term or complex medical problems or psychological health problems.4,40,41 In US studies that assessed the relationship between the value patients place on continuity and patient satisfaction, those patients who valued continuity and saw their regular physician had the highest satisfaction and continuity was especially important for older more vulnerable patients.2,42 A discrete choice study from the UK exploring patient preferences for continuity found that patients prefer to wait to see a doctor who knows them well when they have a problem causing uncertainty or for a routine visit.43

Although continuity is important to both physicians and patients, having a familiar doctor may not necessarily lead to care that satisfies patients' expectations or that produces other quality outcomes. A qualitative study on patients' perceptions of personal care found that patients did not perceive care as personal when documentation from previous visits was not used by their physician to inform successive visits.44 In another study, 15% of new diabetics were diagnosed only when they were evaluated by a new GP demonstrating that continuity of care does not guarantee the early diagnosis of a chronic disease.45 More evidence is needed to understand how continuity affects the timing of important diagnoses.6

Among the studies included in our review, we also found three variables that had stronger associations to satisfaction than the continuity measures. These factors, specifically interpersonal communication,26 trust27 and choice23,41 may qualify important aspects of the doctor–patient relationship and the health care delivery system that are not captured when continuity is measured using quantitative indices, longitudinality or subjective perception. In the UK and USA, choice of physician is valued by patients.4,23,30,46 The issues surrounding choice of physician seem likely to remain important as primary health care delivery systems continue to evolve.

Unanswered questions and future research

Continuity, which we defined for this review as ongoing, direct,and face-to-face contact between doctors and patients, had been found to have a variable association to patient satisfaction. Thus, the current evidence seems out of sync with the importance of continuity, both to the medical community19 and to some groups of patients.4,40–42,46 One possible explanation may lie in the continuity measures themselves, which have been the subject of two systematic reviews. Saultz5 concluded that the continuity measures do not actually measure interpersonal continuity. Jee and Cabana10 not only grouped similar continuity measures but also went further to describe what aspects of the doctor–patient relationship and medical care that each category was describing and considered the subjective measures to be the best at describing the more subtle qualities of the doctor–patient relationship. In our review, the subjective measures were all significantly associated with patient satisfaction and may be the most appropriate measure to use when examining the relationship between continuity and patient satisfaction. Health services researchers might consider development of a single subjective continuity measure that could be used in future studies assessing patient satisfaction.

Apart from the continuity measures themselves, this review raises some broader questions about the relationship between continuity and patient satisfaction. Does greater continuity lead to greater satisfaction and is the reverse true? This question cannot be answered without understanding the causal direction of the association between continuity and patient satisfaction. Only one of the 12 studies in this review explored this question, RCT of Wasson et al. 25, and showed mixed results. This one study alone cannot answer the question about the causal direction between continuity and patient satisfaction.

Without this knowledge, how can the effects of health care system changes on continuity and patient satisfaction and the relationship between continuity and patient satisfaction be interpreted? Changes in health care over the past 25 years have been perceived as leading to decreased continuity3 and have actually decreased continuity for patients,1,2 but how have these changes affected the relationship between continuity and patient satisfaction? This question cannot be answered unless continuity and patient satisfaction are measured by studies that follow patients over time. The development of new primary care delivery systems such as the advanced medical home47 may provide an opportunity to perform this type of longitudinal research in which patients will be an important source of information for evaluating the outcomes of care not only for individual physicians but also for health care systems.39

Declaration

Funding: none.

Conflict of interest: None.

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American College of Physicians

The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care

Philadlephia, PA

American College of Physicians

2005. Position paper

© The Author 2010. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org.

© The Author 2010. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org.