Medicare recipients see declines in continuity of care

According to a study by researchers at the University of Texas Medical Branch at Galveston, elderly Medicare recipients transitioning from outpatient to hospital settings were more likely to experience lapses in continuity of care in 2006 than 1996.

The researchers ascribe part of the reduction in continuity of care to the increasing use of hospitalists, physicians who specialize in the care of hospitalized patients.

Dr. Gulshan Sharma, an assistant professor in the department of internal medicine at UTMB, was first author on the study, appearing in the April 22 issue of the Journal of the American Medical Association . The members of the study research team examined data on more than 3 million hospital admissions of people over 66 years old.

According to the study, in 1996, 50.5 percent of hospitalized Medicare patients were seen by at least one physician who had seen them in an outpatient setting at least once during the previous year. By 2006, however, that percentage had declined to 39.8 percent. Similarly, in 1996, 44.3 percent of patients who were hospitalized were visited at least once by a primary care physician who had seen them prior to hospitalization. By 2006, this percentage had declined to 31.9 percent.

"Approximately one-third of the decrease in continuity [of care] between 1996 and 2006 was associated with growth in hospitalist activity," according to the study. Continuity of care consists of three dimensions: Continuity in information, continuity in management and continuity in the patient-physician relationship.

In addition to the increased use of hospitalists, the study notes that Medicare payment formulas discourage primary care physicians from continuing to care for their patients when a hospitalist becomes involved. Direct communication between primary care physicians and hospitalists occurred less than 20 percent of the time.

The researchers recommended additional study on the effect of reduced continuity of care on patient outcomes and whether interventions could be developed to minimize any detrimental effects.

In a New England Journal of Medicine article published March 12, UTMB researchers described how they used the same Medicare database to calculate that the percentage of internal medicine physicians practicing as hospitalists jumped from 5.9 percent in 1995 to 19 percent in 2006. That study marked the first quantitative survey of the increase in hospitalist care, and raised questions about the effects of the growth of hospitalist care on continuity of patient care, the role of the primary care physician, patient satisfaction and the patient-physician relationship.