Assessing the effect of continuity of care on patient outcomes and hospital resourcing to improve efficiency and effectiveness of patient care

Background “Continuity of care” is defined as a patient seeing the same doctor or team of doctors throughout their stay. This is widely believed to affect both patient care quality and hospital efficiency.

Doctors shift patterns and bed moves can both lead to poor continuity, which has several potential disadvantages for patients and hospitals.

Each new doctor must spend time understanding what has happened to that patient so far during their hospital stay, reducing the time available to see other patients. This may increase the risk that important facts are forgotten and may lead to unnecessary repetition of tests. Patients may be asked to repeat information, which is frustrating and may reduce trust in the clinical team.

In addition, each bed move places demands on hospital portering and cleaning staff, and may increase the risk that a patient becomes disoriented, in turn potentially increasing the risk of delirium and falls.

Despite these perceived disadvantages of poor continuity of care, there has been no quantification of these effects in UK hospitals, meaning it is unclear whether hospitals should prioritise maintaining continuity of care in e.g. bed management plans.

Aim We aim to assess the causal effects of three dimensions of continuity of care (continuity of responsible consultant; continuity of reviewing doctor; and continuity of location) in a single UK hospital (Cambridge University Hospitals), and quantify the size of these effects if they exist.

Methods We will use de-identified electronic health record (EHR) data on all adult patients admitted for medical care during a 2-year period (estimated 36,000 patients). Comprehensive EHR data are available about each patient (e.g. laboratory tests, diagnoses).

We will assess the effects of continuity of care on hospital length of stay, mortality, complications, re-admission, the use of hospital resources (laboratory tests, investigations) and associated costs.

In Work Package 1, we will describe the current extent of continuity in the hospital through numerical summaries and graphical visualisations.

In Work Packages 2-4, building on the trial emulation framework, we will estimate causal effects from the observational data using marginal structural models. We will initially consider each dimension of continuity separately.

In Work Package 2 we will consider only short-term continuity (during the 24 hours after a patient s “post-take ward round”), and then extend the analysis to longer-term continuity in Work Package 3.

In Work Package 4 we will consider the joint effects of changes in responsible consultant, reviewing doctor and ward moves to disentangle the relative contribution of each. Finally in Work Package 5, we will design follow-up studies.

We have consulted the Cambridge PPI panel about the choice and prioritisation of outcomes, and will meet them regularly to discuss our findings.

Anticipated Impact and Dissemination We will present our results to local clinicians, hospital managers and PPI panel members; and nationally at conferences and medical journals.

If clear evidence were to show large patient benefits and potential efficiency savings, then continuity could be improved e.g. by redesigning doctors rotas or reprioritising bed management plans.