Elsevier

Health Policy

Volume 109, Issue 2, February 2013, Pages 158-165
Health Policy

Continuity of ambulatory care and health outcomes in adult patients with type 2 diabetes in Korea

https://doi.org/10.1016/j.healthpol.2012.09.009Get rights and content

Abstract

Objectives

Continuity of ambulatory care in chronic disease affects the quality of care and the efficiency of healthcare spending. We assessed the relationship between initial continuity of ambulatory care and subsequent health outcomes (hospitalization, mortality and healthcare costs).

Methods

This was a retrospective cohort study of 68,469 patients enrolled in the Korean National Health Insurance Program, who were 20 years of age or older and first diagnosed with type 2 diabetes in 2004. Patients were followed for 4 years using claims data to measure continuity of ambulatory care for the initial 3 years after first diagnosis and to investigate hospitalization, mortality, and healthcare costs in the fourth year of follow-up.

Results

In the group of patients with COCI < 0.4, the risk of hospitalization for all causes was higher (odds ratio: 1.37, 95% CI: 1.28–1.47) and healthcare costs increased (β = 0.037, P < 0.001) compared with the reference group (COCI = 1.0), after adjusting for patient risk factors, such as age, gender, and comorbidity index.

Conclusions

Policies that promote a continuing relationship with the same physician seem to enhance the quality of care and the efficiency of spending in the treatment of diabetic patients.

Introduction

New treatments, high specialization, and consumerism can induce patients to see a variety of different types of healthcare providers in a variety of places to ensure their rapid recovery or to keep them healthy [1].

However, the fragmentation or discontinuity of care among patients with chronic disease may have a significant negative impact on healthcare expenditures. To spend limited resources more efficiently, policymakers have been paying more attention to continuity of care, especially focusing on a continuing relationship with the same physician over time [2].

In the Korean National Health Insurance (KNHI) scheme, most practitioners are specialists. Indeed, 91% of medical practitioners in clinics were specialists in 2009 [3]. Clinical practitioners publicize their specialty and patients opt to visit a clinic with the specialty to which they think their symptoms are related. Patients experience almost no restriction in selecting a healthcare provider within the KNHI [4].

Given these circumstances, the concept of continuity of care has attracted Korean health policymakers’ attention as a fundamental issue for designing more efficient strategies for managing patients with chronic diseases who receive care from multiple medical institutions by their preference.

Previous studies have found that enhanced continuity of ambulatory care for patients with chronic diseases, such as diabetes mellitus, can result in more efficient expenditures or better health outcomes in terms of lower hospitalization and mortality [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]. Especially in the treatment of type 2 diabetes mellitus, a cooperative relationship between the patient and healthcare provider is considered to be a crucial factor, and thus enhancing continuity of care is important for improving the quality of care and the efficiency of expenditures [14], [15], [16], [17], [18].

In the KNHI scheme, annual medical care costs for diabetic patients aged 20–79 were estimated at 3185.3 billion Korean Won (KRW), representing 19.2% of the total medical expenditures for those 20–79 years of age [19]. As the Korean healthcare system is characterized by a rapidly aging population, a Westernized diet, and reimbursement on a fee-for-service basis, experts expect a continued increase in the prevalence of diabetics and their medical care costs. Thus, a need for active plans to induce more effective care and more efficient expenditures for diabetics exists.

Although the conceptual framework of continuity of ambulatory care is spreading, it is still uncertain whether continuity of ambulatory care is in fact associated with patient health outcomes or financial efficiency because continuity of care is concerned with those over a longitudinal timeframe [20].

In this study, we examined the effects of continuity of ambulatory care on the health outcomes of adult patients who were newly diagnosed with type 2 diabetes mellitus throughout 4 years of follow-up. Our results can be used as empirical evidence on which policymakers should base a more efficient delivery system for managing and treating chronic diseases, including diabetes.

Section snippets

Study data and design

This study used the KNHI claims database for 2004–2008. It was a retrospective cohort study of new adult-diabetes patients to examine the relationship between continuity of ambulatory care and hospitalization, mortality, and healthcare costs through follow up for 4 years. In this study, “new adult-diabetes patients” refers to patients who were 20 years of age or older and newly diagnosed with type 2 diabetes (International Classification of Disease, 10th edition [ICD-10], E11) according to the

Comparison of COCI by patient characteristics

The COCI for the study population, type 2 diabetes (n = 68,469), was 0.752 (SD 0.265; Table 1). A higher COCI was seen in patients who were male (0.757 ± 0.263), who ranged in age from 45 to 54 (0.762 ± 0.262), who had over 25 outpatient visits within 3 years after diagnosis (0.767 ± 0.241), and who visited a tertiary general hospital as the main attending medical institution (0.772 ± 0.265). The COCI decreased as the Charlson index increased.

Relationship between continuity of care and health outcomes

The relationship between continuity of care and health outcomes

Discussion

Policies for the effective and efficient management of diabetes, a disease with which at least 190 million patients worldwide have been estimated to suffer, are being implemented around the world [22]. As cross-societal programs to effectively manage major chronic diseases, such as diabetes, the Australian Practice Incentive Program (2001), the British Quality and Outcome Framework (2003), a U.S. Private Organization's Bridges to Excellence's Diabetes Care Link (2003), and the U.S. Centers for

Conclusions

Increased ambulatory COCI in type 2 diabetes significantly reduced the risk of hospitalization and medical care costs. The number of hospitalizations and healthcare costs, both for all causes and for specific diseases, were significantly higher for all four groups with a COCI below 1.0. As a result, policies that encourage diabetic patients to concentrate their ambulatory care on the same physician could improve the quality of care and lead to more efficient spending for their treatment. Our

Acknowledgments

The authors thank the Health Insurance Review and Assessment Service (HIRA) of Korea. This study was conducted using data from the Korea National Health Insurance Claims Database of the HIRA.

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