Importance of continuity of care from a patient perspective – a cross-sectional study in Swedish health care

Abstract

Objective

The primary objective of this study was to evaluate the patients’ view on continuity of care (CoC), including preference for a certain general practitioner (GP) and importance and access to a regular general practitioner (RGP).

Design

Cross-sectional study.

Setting

Primary care center in Halland County, in the western part of Sweden.

Subjects

Patients ≥18 years old and having at least one appointment at the primary care center during October–December 2022.

Main outcome measures

Preference for a certain GP and importance of and accessibility for an RGP.

Results

The study included 404 patients. Importance of having an RGP was considered by 86% of the patients. Preference for a certain GP was thought by 73% of the patients, and when asked as a bivariate question, 69% considered having an RGP. Both the importance of an RGP and preference for a certain GP were more often considered by patients ≥65 years (p < .0001). Regarding accessibility, 67% of the patients reported having access to their RGP ‘always/most of the time or a lot of the time’ and 62% reported seeing their RGP at last visit.

Conclusions

In conclusion, this study showed that the majority of patients value CoC in terms of importance of having an RGP. Older patients were more likely to have a preference for a certain GP. Two-third of the patients succeeded in seeing their RGP always or a lot of the time. The results in this study provide evidence that CoC is important for most patients, regardless of age and gender.

Key points

• Previous studies have showed that continuity of care (CoC) is important regarding mortality and morbidity. In primary care, there is a current debate regarding CoC, accessibility and the strive for CoC. This study showed that the majority of patients, regardless of age and gender, value CoC and consider it being important. However, there was a statistically significant difference regarding age, where patients above 65 years old thought it was more important to have a regular general practitioner and more often had a preference for a certain GP.

Keywords:

• Continuity of care
• general practice
• general practitioner
• primary health care
• family practice

Introduction

Continuity of care (CoC) is a fundamental principle in primary care [1,2]. There is increasing evidence that a high level of CoC, including relational continuity with a regular general practitioner (RGP), covariates with better health outcomes, including reduced morbidity and overall mortality rates [3]. Studies from several countries acknowledge that patients value CoC [3–5]. Relational continuity with a patient-centered approach is furthermore associated with core patient values including greater feeling of security, trust and patient satisfaction [4,6]. It is further an essential part of qualitative care from the clinician’s perspective, facilitating consistent advice and safe care. General practitioners (GPs) in different health care systems have agreed on the valuable aspect of CoC to patients [7]. The benefits of familiarity with the patient’s history and taking responsibility for the patient’s medical needs are both time-effective and improve the quality of care. Overall, several studies have shown that the correlation is stronger for certain vulnerable populations such as the elderly and patients with long-term illness [8,9]. Furthermore, high CoC is associated with fewer secondary care referrals including decreased emergency department visits, less overuse of medical procedures and fewer hospital admissions [10–14].

However, despite the benefits of CoC, several countries experience difficulties with CoC including coordination between primary and secondary care [15]. Many countries, including Norway, apply to a system based on listing patients on GPs in order to increase CoC [3]. Yet, with modern healthcare, including effective systems, the urge for access, increase in part-time work and changes in organizations, there is a risk of decline in CoC [16,17]. A study from the UK revealed that although the majority of patients value CoC, only a minority saw their RGP [16]. Similar trends could be seen in other countries [3,4,18]. The proportion of patients in Sweden considering having an RGP is considerably low as reported by national surveys [12,19,20]. However, with the increased burden of diseases and need for better quality of care, professional and policy initiatives promoting CoC and the RGP system are highly topical [17,21].

Many studies focus on objective outcomes such as morbidity and mortality [22,23]. Furthermore, the majority of previous studies have focused on the importance of CoC and RGP in the elderly population or patients with chronical diseases [3,6,22,24]. Only a few studies discuss the CoC from a patient’s perspective [4,6,25]. While most of the studies discuss attributes important for the patients, only a scarce number evaluate to what extent patients actually consider themselves having an RGP and access to the RGP. Exploring and measuring the quality of CoC require dependable studies on patient views. There is a need of studies considering the patient’s perspectives and experiences of relational continuity in the general practice setting, in order to continue the important work of increasing the quality of healthcare.

Aim

The primary aim of this study was to describe how patients value the importance of having an RGP, and the proportion of patients having a preference for a certain GP and access to their RGP. Secondary aims were to investigate whether there were any differences depending on patient categories.

Methods

Study design

This was a cross-sectional study with a patient-centered survey including patients from a Swedish primary care.

Setting and participants

Data were collected prospectively during October–December 2022. The study was conducted at a single primary care center, Säröledens Familjeläkare, situated in Region Halland, in the western part of Sweden, with a mixture of urban and rural population. All patients with at least one visit at the primary care during the study period were invited to participate in the study. The patients were asked to complete a questionnaire regarding their views on CoC and RGP. The patients were allowed to either fulfill the survey at time of their appointment or, if preferable, during the study period. The patients were only allowed to fulfill the questionnaire once. Inclusion criteria were age ≥18 years old and having at least one appointment to a GP at the primary care during the study period. No exclusion criteria were applied. Written and oral information was provided at the time of appointment.

Continuity of care

Interpersonal CoC was considered to what extent the patients considered themselves having an established relational continuity. The definition of RGP used in the study was having an established continuity with a named GP. As patients may have a preference for a certain GP, yet not an established RGP, the study included both aspects of having an RPG and having preference for a certain GP. Hence, CoC in this study included three aspects: preference for a certain GP, importance of and accessibility to an RGP.

Variables and survey

Patient experience was assessed using a patient-centered survey. The questionnaire was constructed by a reference group and contained of several steps according to guidelines in order to design a validated and reliable survey [26]. Previously validated questionnaires from international and national patient surveys on the same subject were reviewed. Items relevant to CoC in the setting of primary care were assessed and a questionnaire was conducted according to the purpose of the study. To increase the content and construct validity of the questionnaire, the first draft was discussed by an expert group consisting of specialist GPs, and was further compared with other similar previously validated instruments. The final version was pilot tested on a small group of patients. In order to increase the internal consistency, reliability, Cronbach’s alpha was calculated with an overall value of 0.82 for concerned items.

Questionnaire

The questionnaire has two sections. The first section contains 10 items including demographic data, age, gender, employment, health history, prescribed medication, presence of chronical disease, health services used in the last 12 months and self-estimated overall health. Section two includes different dimensions of interpersonal CoC. The section includes questions regarding preference for (two items), importance of (one item) and access to (two items) having an RGP. The questions regarding preference for a certain GP was first asked as ‘preference for’ and then a main item regarding having an RGP conducted as a bivariate question (yes/no). The main item regarding importance of RGP was conducted as a Likert scale with five options.

Data analysis

All data were analyzed using Statistical Package for the Social Sciences (SPSS) version 25 (SPSS Inc., Chicago, IL). Descriptive data were presented as numbers and percentage (%). Patient age was divided into eight categories and then further dichotomized into <65 and ≥65, agreeing with the threshold for geriatrics in Sweden. Missing values were excluded listwise and the patient was omitted from the analysis regarding that item. To evaluate the association between gender, age, preference for a certain GP and the importance of having an RGP, logistic regression was performed. For the logistic regression regarding preference, preference was used as dependent variable and gender and age group (≥65 or <65 years old) were used as independent variables. The question regarding importance was dichotomized into either ‘important’ or ‘not important/do not care’. Importance was used as dependent variable and gender and age group were used as independent variables. In order to estimate the sufficient study sample, a power analysis was conducted a priori. Since there are no previously similar studies, the calculation was based on the percentage of RGP to be approximately 50% and the risk of selection error being 5% with a confidence interval of 95%. A p value of <.05 was regarded as significant.

Ethical considerations

This study was approved by the Swedish Ethical Review authority with diary number 2022-03806-01. All participants had given written informed consent to be included in the study.

Results

A total of 404 out of 450 invited patients participated in the study, with an overall response rate of 90%. Female gender accounted for 60%, and 53% of the patients were above 65 years old. Non-acute visits were most common (89%) and 66% of the patients considered themselves in a good health (Table 1).

Table 1. Demographic data.

Variable	Number = n	%
Gender	n = 403
Male	161	40
Female	242	60
Age groups, years	n = 404
18–24	14	3
25–34	22	5
35–44	41	10
45–54	59	15
55–64	55	14
65–74	92	23
75–84	102	25
≥85	19	5
Age geriatrics, years	n = 404
<65	191	47
≥65	213	53
Other diseases	n = 385
No other diseases	119	31
At least one chronical disease	266	69
Self-assessed health status	n = 400
Good	266	66
Neither good or bad	115	29
Bad	19	5
Cause for visit at GP	n = 401
Acute problem	43	11
Non-acute	358	89

GP: general practice.

Preference of a certain GP and considering having an RGP

Regarding preference for seeing a certain GP, 73% of all the patients agreed they preferred a certain GP. When asked as a bivariate question, 69% considered having an RGP. When further dividing into age groups, patients ≥65 years old were more likely to have a preference for a certain GP (p < .0001). There was no difference in preference of seeing a certain GP between gender (Table 2).

Table 2. Prevalence of patients considering having an RGP and logistic regression results for the variable having an RGP (dependent variable), and gender and age (independent variables).

Characteristics	Prevalence	Adjusted OR (95% CI)	Significance
RGP	n = 399
Yes, n (%)	277 (69)	N/A
No, n (%)	122 (31)	N/A
RGP, gender	n = 398
Women, yes/no	170/69 (71/29)	1.571; 95% CI (0.985–2.597)	p = .58
Men, yes/no	106/53 (67/33)
RGP, age	n = 399
Age <65, yes/no	103/87 (54/46)		p < .0001
Age ≥65, yes/no	174/35 (83/17)	3.552; 95% CI (1.899–6.643)

CI: confidence interval; N/A: non-applicable; OR: odds ratio; RGP: regular general practitioner.

Importance of an RGP

Importance of having an RGP was considered by 86% of the patients, with no differences between gender. However, there was a statistical significant difference regarding importance of having an RGP when dividing into age groups, where patients above 65 years old more often considered it being important (p < .0001) (Table 3).

Table 3. Prevalence of patients considering it important having an RGP and logistic regression results for the variable importance of having an RGP (dependent variable), and gender and age (independent variables).

Characteristics	Prevalence	Adjusted OR (95% CI)	Significance
Importance of RGP	n = 399
Yes, n (%)	342 (86)	N/A
No, n (%)	13 (3)	N/A
Neutral, n (%)	44 (11)	N/A
Importance of RGP, gender	n = 398
Women yes, n (%)	210 (87)	1.620; 95% CI (0.901–2.911)	p = .107
Men yes, n (%)	131 (83)
Importance of RGP, age	n = 399
<65 yes, n (%)	149 (78)		p < .0001
≥65 yes, n (%)	193 (92)	3.552; 95% CI (1.899–6.643)

CI: confidence interval; OR: odds ratio; RGP: regular general practitioner.

The question regarding importance of RGP was asked as a Likert scale and was dichotomized for OR.

Accessibility for RGP

Regarding accessibility, 47% of the patients reported having access to their RGP ‘always or most of the time’ and 62% reported seeing their RGP at last visit (Table 4).

Table 4. Accessibility to RGP.

Variable	Number = n	%
Overall access to GP	n = 394
Always/almost always	186	47
A lot of the time	80	20
Some of the time	51	13
Never or almost never	21	6
Not tried at this GP	56	14
Access at last visit	n = 395
Yes	246	62
No, doctor not in service	39	10
No, booked appointment to another doctor	8	2
No, long wait time to RGP	10	3
Preferred no specific doctor	92	23

GP: general practitioner; RGP: regular general practitioner.

Discussion

The most important finding of this study was that having an RGP is highly valued by the patients regardless of age and gender. This study evaluated three aspects of the RGP system: preference for, importance of, and access to an RGP. The majority of patients both prefer and value having a personal patient–doctor relationship. Furthermore, 69% of the patients considered themselves having an RGP and 67% of the patients considered an overall good access to seeing their RGP.

Strengths and limitations

The response rate in the present study was 90%, which is considered high, where previous studies have had response rates as low as 25%. As previous similar studies have discussed that the value of preference for seeing the same doctor could be underestimated due to the formulation of the questions, this study considered three different aspects in preference for a specific GP, importance of and accessibility to an RGP. Although performed at a single center, there is a risk of missing some patient groups due to geographic location. However, the center has a large coverage area, with over 14,000 listed patients in all socioeconomic groups. Furthermore, there are 12 GPs working at the center and the system accounts for both acute and non-acute visits with a large flow of patients. With account to these different aspects, the external validity of the study could still be considered high. The patient sample was based on consultation visits at the health unit, resulting in fewer patients who seldom consult the GP. Furthermore, some patients may have other preferences when going to the doctor, for example avoiding a specific one, seeing different doctors for different conditions. Preferences that were not accounted for in this study. Limitations to the study further include the inherited limitations of a cross-sectional study design. Furthermore, as there were no previous existing questionnaires measuring the construct of interest, this questionnaire was developed. Hence, the use of a self-constructed questionnaire could be seen as a limitation. Although not fully validated, several steps were accounted for in the development process in order to increase the reliability and validity.

Findings in relation to previous studies

The findings in this study are in line with previous studies showing that patients have a preference for seeing a particular doctor [16,25]. While the utter majority of the patients thought it was important to have an RGP, the preference for a particular one varied across ages. Patients <65 years old reported having an RGP less frequently, 54% compared with 83% in the age group ≥65 years old. Previous studies have found that younger and healthier patients as well as those who seldom consult, less frequently request or report having an RGP [17,27]. Among these patients, flexibility and accessibility have been discussed to be conflicting values. However, this study showed that patients <65 years old also value the importance of having an RGP, where 78% in this age group consider it being important. Previous studies have mostly discussed the importance of CoC for the elderly or patients with chronical diseases and that effort on CoC should be prioritized to these groups [27]. Although the elderly and those with chronical diseases might be vulnerable and in most need of CoC, relational values are thus important for the majority of patients, irrespectively of age and health status. A previous study showed that patients with lower CoC had more visits to the ER in all age groups [12]. Interestingly, another study showed that the greatest difference was for the younger age group (17–30 years old) with 2.2 times as many emergency room visits [28]. Hence, policy makers should not forget these groups when it comes to relational continuity. Efforts to increase the proportion of young patients having an RGP, such as increased knowledge of the healthcare system and building trusting relationships for this patient groups, are warranted.

Personal care is highly valued by the majority of patients and should be in balance with accessibility, which is also of great importance for the patients [25]. This study showed a high access where 67% saw their RGP ‘always or a lot of the time’. However, accessibility and freedom of choice could explain why 23% did not prefer to see a specific doctor at last visit. The need for easily accessible is sometimes essential, and access to any doctor in relation to urgent conditions or minor important conditions could be more important for these patients. However, although high access is important, it has not been shown to increase the satisfaction among patients [29]. Many argue that high accessibility is a key for effective health care. Although there is little evidence for this argument, this is usually a policy priority for the government. On the opposite, accessibility is poorly related to overall satisfaction when compared with CoC [29]. Yet, a strict RGP-system might reduce flexibility, for both patients and the primary care center. A high level of relational continuity and accessibility require employment, which is a challenge for many units, not the least in rural areas. Another challenge is a high degree of part-time work among GPs. However, while rapid access might be important for some appointments, other situations might request CoC. This is a significant, yet challenging characteristic of quality in healthcare, where units need to provide a system beneficial both for CoC and access to appointments. Furthermore, a recent study from Sweden argued that the recorded CoC was relatively low compared with studies from other countries such as Norway and England, and that the previous focus on accessibly in Swedish primary care contributes to this diversity [12]. The current study was performed at a primary care center, including both part-time work and physicians under training, with a flexible system, allowing both high access and CoC, which could be seen in the results. Although challenging, urgent access does not have to be the counterpart of maintaining CoC, as can be seen in several different models [30]. Overall, convincing evidence show that relationship continuity is a core factor in a well-balanced health care system. This study contributes to the increasing evidence that relational continuity matters to patients.

Conclusions

In conclusion, this study showed that the majority of patients value CoC in terms of importance of having an RGP. Older patients were more likely to have a preference for a certain GP. Two-third of the patients succeeded in seeing their RGP always or a lot of the time. The results in this study provide evidence that CoC is important for most patients regardless of age and gender.

Acknowledgements

The authors would like to thank the staff at Säröledens Familjeläkare for their help with distributing the questionnaires.

Disclosure statement

No potential conflict of interest was reported by the author(s).