Continuity of ambulatory care and health outcomes in adult patients with type 2 diabetes in Korea
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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Continuity of care and multimorbidity in the 50+ Swiss population: An analysis of claims data: Association between multimorbidity and care continuity in Switzerland
2022, SSM - Population HealthCitation Excerpt :In fact, COC has two core elements (Haggerty et al., 2003): care of an individual patient and care over time, distinguishing it from care coordination and integration (Rijken et al., 2018). Research has shown that poor COC is associated with not only higher health care costs and more hospitalizations (Bazemore et al., 2018; CDKnight, Dowden, Worrall, Gadag, & Murphy, 2009; Chen, Yamada, Smith, & Chiu, 2011; Cho, Lee, et al., 2015; Chu, Chen, & Cheng, 2012; Hong & Kang, 2013; Hong, Kang, & Kim, 2010; Jung, Cho, Lee, & Kim, 2018; Kao & Wu, 2016, 2017; Lin & Wu, 2017; Pollack, Weissman, Lemke, Hussey, & Weiner, 2013; Romaire, Haber, Wensky, & McCall, 2014), but with worse health outcomes, especially in chronic and multimorbid patients (Cho, Kim, et al., 2015; Gruneir et al., 2016; Jang, Choy, Nam, Moon, & Park, 2018; Weir, McAlister, Majumdar, & Eurich, 2016; Ye et al., 2016). However, the meaning behind COC can vary depending on the used definitions (Gulliford, Naithani, & Morgan, 2006; Haggerty et al., 2003; Saultz, 2003; Saultz & Albedaiwi, 2004; Shortell, 1976), COC measurement methods and data sources.
Assessing quality of primary diabetes care in South Korea and Taiwan using avoidable hospitalizations
2018, Health PolicyCitation Excerpt :On the other hand, there are differences in organizing and financing primary diabetes care and related recent reforms [8,9]. There have been studies in each country related to DRAHs [10–13], but none have compared DRAHs across the two countries using comparable micro-data about the health status of people while considering health system-related factors, a gap this study intended to address. The objective of this study was to compare the performance of primary diabetes care using avoidable hospitalizations as a measure of the quality of primary care in South Korea and Taiwan.
Effects of long-term high continuity of care on avoidable hospitalizations of chronic obstructive pulmonary disease patients
2017, Health PolicyCitation Excerpt :Previous studies have used two methods to examine the relationship between COC and outcomes: (1) the concurrent method, where COC and outcome are measured for the same duration [13,16,18–20], and (2) the sequence method, where COC and outcome are measured for different durations. COC is examined before outcomes [12,17,21,22] to prevent the resulting time-dependent bias [23]. Gill and Mainous [24] have reported that COC was significantly associated with ED visits in the same year but not the subsequent year.
Effects and Factors Related to Adherence to A Diabetes Pay-for-Performance Program: Analyses of a National Health Insurance Claims Database
2016, Journal of the American Medical Directors AssociationCitation Excerpt :Patients with longer durations of diabetes and higher continuity of care scores were more likely to have good medication adherence.8,40 Gender, continuity of care, and time since diagnosis of diabetes were identified as factors related to healthcare utilization/costs, and adherence to practice guidelines/dispensed medications.8,35−40 In this study, relationships between program adherence and these factors were found.
South Korea: An interesting case to study
2016, Health PolicyGreater continuity of care reduces hospital admissions in patients with hypertension: An analysis of nationwide health insurance data in Korea, 2011-2013
2016, Health PolicyCitation Excerpt :In terms of outpatient services, clinics compete against other clinics, hospitals, and some general hospitals. Given the context, to efficiently manage chronic diseases with limited resources, policymakers are becoming interested in continuity of care (COC), which can reduce the risk of complications [7], improve preventive care [8,9], increase patient satisfaction [10] and compliance [6,11], and decrease emergency and inpatient medical services and care costs [12–17]. In primary care, especially, COC is being introduced to improve quality and to cope with the increased workload associated with chronic diseases [18].