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Time in Continuity Clinic as a Predictor of Continuity of Care for Pediatric Residents

Patricia G. McBurney, MD^*, Colleen M. Moran, MD^*, Walton L. Ector, MD^*, Thomas G. Quattlebaum, MD and Paul M. Darden, MD^*

^* Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
Charleston Pediatrics, Charleston, South Carolina

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Objective. In 1996, the Residency Review Committee–Pediatrics recommended doubling time in continuity clinic to 2 half days per week. It has yet to be demonstrated that increased time in clinic yields greater continuity of care. The objective of this study was to determine whether increasing the number of half days spent in clinic improves continuity of care for residents.

Methods. We reviewed computerized encounter records for all Medical University of South Carolina pediatric residents from 1982 to 1998. Depending on the year and the resident’s training level, house staff spent varying amounts of time in continuity clinic. Time in clinic was estimated from grants and materials generated in the residency program. We calculated continuity of care from the resident’s perspective for each individual resident per year using the Continuity for Physician (PHY) formula.

Results. Continuity for 488 resident-years (200 residents) was evaluated. Residents spent from 10% to 30% of their time per year in clinic. Mean PHY was 57% (interns), 62% (second-year residents), and 52% (third-year residents). The correlation coefficient (R) between PHY and percentage of time in clinic was .22. In multivariable modeling, percentage of time in clinic, training level, and year predicted continuity. An increase of 1 half day in clinic was associated with an 11% increase in physician continuity. When analyses were limited to sick visits, R improved to .58. The effect size remained 11%. However, training level and academic year were no longer significant.

Conclusion. Increasing time spent in clinic improves continuity and may indeed enhance the quality of this fundamental experience.

Key Words: continuity clinic • residency • Residency Review Committee for Pediatrics

Abbreviations: ACGME, Accreditation Council for Graduate Medical Education • COC, Continuity of Care • PHY, Continuity for Physician • MUSC, Medical University of South Carolina • WCC, well-child care

For today’s house staff in primary care specialties, the continuity experience is a fundamental aspect of their training. Designated, weekly time in a continuity clinic setting is mandated for every pediatric resident in all accredited programs.

Since 1989, the Accreditation Council for Graduate Medical Education’s (ACGME) Resident Review Committee for Pediatrics has stated that residents must spend 1 half day per week in a continuity clinic during all 3 years of training. In 1996, the ACGME suggested an additional half day per week for a total of 2 half days per week for second- and third-year residents. Most recently and effective as of June 2001, the ACGME recommended that pediatric residents at all 3 years of training spend 2 half days per week in continuity clinic. Furthermore, continuity clinic "must receive priority" over other clinical responsibilities.^1,2 Indeed, the emphasis is on longitudinality, and the goal is improved primary care.

Continuity of care is following a panel of patients on a first-contact basis for all of their health care needs. The ACGME mandates that the patient experience be on a "regular and continuing basis, rather than on a single occasion." The continuity clinic experience is intended to allow the resident "the opportunity to develop an understanding of and appreciation for the longitudinal nature of general pediatric care."¹

Emphasizing the continuity clinic is an effort to align pediatric resident training with the common practice of the general pediatrician, where >95% of pediatric provider encounters are outpatient.^3,4 The continuity clinic ideally offers opportunities to learn "aspects of physical and emotional growth and development, health promotion/disease prevention, management of chronic and acute medical conditions, family and environmental impacts, and practice management."¹

Continuity clinics afford residents the chance to witness the positive results of a developing longitudinal relationship with a child and a family. Greater continuity of care is associated with higher ratings on quality of care from parents.⁵ It generates greater patient, physician, and staff satisfaction.⁶ Furthermore, continuity of care is associated with decreased hospitalizations, decreased emergency department use, and improved coordination of care for pediatric patients.^7–10

At least 10 ways to measure continuity are described in the literature. Some formulas measure continuity from the perspective of the patient. The Usual Provider of Care and Continuity for Patients consider the number of times the patient is seen by his or her own provider divided by the number of visits the patient is seen.^3,11 The Bice Index, or Continuity of Care (COC) Index, not only considers continuity from the perspective of the patient but also takes into account the number of different providers seen. Thus, the COC Index is a measure of dispersion. The COC Index is not linearly related to the number of providers seen.^3,12 The Modified, Modified Continuity Index is essentially a version of the COC Index that acts more linearly.^3,13

For the purposes of studying continuity from the perspective of the resident physician, the Continuity for the Physician (PHY) measure is most appropriate. It is the ratio of the total number of patients (patient visits) seen by a provider who are the provider’s assigned patients divided by the total number of patients (patient visits) the provider has seen. This measure requires the patient to have a known provider of care. The ratios for all physicians in a group are summed and the divided by the total number of physicians in that group.³

Previous studies have demonstrated that greater time in a continuity setting leads to an increase in the number of patients seen: in 1993, Osborn et al¹⁴ reported that by increasing the number of half-day sessions from 1 to 2, the Department of Pediatrics at the University of Utah more than doubled the number of patients encountered by residents in a university clinic setting. This current project extends previous work by seeking to answer the following question: does increased time in continuity clinic translate into increased continuity of care?

	METHODS

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The setting for this cross-sectional review was the Medical University of South Carolina’s (MUSC’s) pediatric resident continuity clinic. The years examined were 1982–1998. This practice generally serves patients who range in age from newborn to 19 years. Residents in continuity clinic see health maintenance and acute-visit patients. There are no after-hours or weekend hours at this practice site: patients are instructed to seek care in the MUSC pediatric emergency center for after-hours care. Telephone calls (24 hours a day for 7 days per week) are handled by residents, and there is no nurse telephone triage system in place.

Continuity of care particularly for well-child care (WCC) visits has always been emphasized in this resident practice. There are mechanisms in place to make the assigned resident physician known to the scheduling office when a patient/parent asks for an appointment. The schedulers are encouraged to make appointments for patients at times when the assigned resident physician is available in clinic and with priority given to health supervision visits. This resident clinic is structured for scheduled visits only; however, in reality, walk-in visits are seen. With rare exceptions, these walk-in visits are for acute problems.

For the current study, data were extracted from computer billing and appointment records. MUSC’s pediatric resident continuity clinic uses OverSite (Medical Micro Systems, Inc, Charleston, SC). This system was used for the entire course of the years examined. For each visit, data included the name and medical record number of the patient, the name of the examining physician, and the name of the assigned physician (patient’s regular provider).

In this practice, all patients were assigned to 1 specific resident physician. In the 1980s, attending physicians did have assigned patients: these visits were excluded because we are interested in studying only resident continuity.

There were AM and PM sessions. During Christmas and New Year, the practice was open but was staffed only for acute visits. Residents were excused from clinic only for illnesses, out-of-town rotations, and vacations.

Over the 17 years of this study, the number of half-day clinic sessions per week required of residents varied depending on the academic year and the resident’s level of training. We equated 1 half-day session to 10% of the resident’s time. A review of the primary care training grants allowed us to estimate for each academic year and each level of resident training (eg, postgraduate levels) how many half days were scheduled for residents to be in clinic. Academic years started on July 1 and ended on June 30. We reviewed records maintained by the residency office to determine at which level of training each resident was for each academic year (eg, postgraduate year [PGY] 1, 2, or 3). We were not able to determine when residents took vacation and did not account for AM or PM sessions.

Patient Population
In the early 1980s, 40% of the patient population were enrolled in Medicaid or were self-pay patients; in the late 1980s, 25% to 35% were. In the 1990s, an estimated 50% to 60% of the patients were enrolled in Medicaid and 4% to 6% were self-pay.

Continuity of Care Calculations
Continuity of care was calculated from the resident’s perspective using the PHY formula. PHY is the most appropriate measure for continuity in studies concerning educational experiences. This measure is calculated for each clinician (resident) individually. This measure requires patients to have a known primary provider. It is the proportion of visits for each clinician in which he or she sees his or her own patients. It can be summed for a group of physicians (eg, all residents working in 1 academic year) and divided by the number of physicians in that group.³ PHY results were determined for each resident for each academic year, so each resident could have 3 measures of PHY (if the resident spent 3 years in training between 1982 and 1998).

Visits that could not result in continuity were excluded (eg, nurse-only visits, study trial visits). Visits that occurred between Christmas and New Year were excluded because this resident practice is staffed for only acute visits during this period. Visits to clinicians who did not have assigned patients (eg, nonresident physicians) were excluded. Visits to nonresident physicians were excluded because these visits could not result in continuity (no resident was allowed the opportunity to see the patient). Visits with inadequate identifying information (eg, no valid medical record number) were dropped.

The Model
Correlation analysis and multivariate linear regression were used to model the relationship between percentage of time spent in clinic and continuity from the resident’s perspective (PHY formula). In the multivariate analysis, academic year and postgraduate level of training for the resident were included as categorical covariables. The main independent variable was percentage of time in clinic, and the dependent variable was continuity (PHY formula).

If the resident spent 3 years in this training program during 1982–1998, then he or she had 3 measures for PHY. Because of the repeated measures for each resident during his or her training (PGY 1, PGY2, and PGY3), a generalized estimating equation method that accounted for clustering was used (Proc GENMOD, SAS Version 8.02; SAS Institute, Inc, Cary, NC).

Both sick and WCC visits were included in the analyses. Because of the mechanisms in place in this clinic to ensure continuity of care at WCC visits, we repeated the analyses with sick visits alone. All patients were deidentified in the final statistical analyses. This research was reviewed and approved by the MUSC Institutional Review Board for Human Subjects.

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Data were analyzed for 17 academic years (1982–1998). During this period, there were 200 residents and 488 resident-years. Each academic year, the number of residents ranged from 20 to 38 (Fig 1). The percentage of time in clinic for 1-year periods (academic years) for PGY levels ranged from 10% to 30%.

View larger version (35K): [in this window] [in a new window]   Fig 1. Number of patients, number of patient visits, and number of residents per academic year.

Our initial analysis included all visits (sick and well). We found continuity to vary with percentage of time in clinic (Table 1). It was highest (65.3%) when the percentage of time in clinic was 30% (3 half-day sessions per week). There was a significant correlation between continuity and the percentage of time in clinic (r = .22, P < .01).

When limited to sick visits, the correlation coefficient between continuity and the percentage of time in clinic improved to .58 (P < .01). When limited to sick visits only, postgraduate level of training and academic year were no longer significant predictors of continuity. The effect size of percentage of time in clinic on continuity remained 11%. When limited to WCC visits only, there was no significant correlation between continuity and the percentage of time in clinic.

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
A continuous relationship between patient/family and a health care provider has been long esteemed. In fact, Starfield¹⁵ considers this longitudinal relationship to be 1 of the 4 critical features of primary care (we use the term "continuity of care" for what Starfield refers to as longitudinality). The other 3 features are first-contact care, comprehensiveness, and coordination.

Increased time in continuity clinic necessarily means decreased time spent on inpatient services, in the emergency department, and with subspecialists. Therefore, the continuity experience must be of extremely high quality and representative of the "real world" practice of general pediatrics. Quality of the time spent by residents is extremely important in light of the new limitations on the resident work hours.¹⁶

Very little is known about the quality of the continuity experience for residents, and quality of care is difficult to measure and ensure in ambulatory settings.¹⁷ We know a little more about improving the quality of the clinic visit for parents and patients. Christakis et al⁵ demonstrated that quality perception by parents is different for parents with children in the lowest and highest quartiles of continuity. For instance, they reported that the difference between the 25th and 75th percentiles of continuity scores yielded a 10% increased probability that parents would respond positively on a question representing quality.

Our study results show that an increase in percentage of time in clinic of 10% or 1 half day per week for a resident yields an increase in resident physician continuity of 11%. How much continuity makes a difference for resident physicians? Would residents report a difference in the quality of their experience with an 11% increase in their continuity scores? We know that when continuity is emphasized through the structure of the clinic scheduling, pediatricians report greater quality of the clinic experience, greater efficiency, greater perceived quality of patient care, and greater projected ease of finding other future employment,⁶ but how much continuity does a resident need to experience these positive outcomes? The amount of continuity that should be standard or that is meaningful is unknown.

It is easier to improve continuity for WCC visits than for sick visits, because WCC visits generally are scheduled in advance, and apparently patients/parents are more willing to wait for health supervision. However, there are visits for which rapid entry into the clinic takes priority in the patient’s or the parent’s mind.^3,18 How does one balance the needs and desires of the patient–parent dyad with those of the physician and, more specific, the educational needs of the resident? Also, the needs and desires of the patient/parent and physician must be balanced with the demands of the health care system. There have been efforts to set quality standards for access and continuity in patient care on the basis of patient preferences.¹⁹ These standards would answer the question of how much access and continuity are acceptable.

In our clinic, the real "tension" between rapid medical care access and continuity of care is in sick visits. If parents prefer rapid access for sick visits, then the most obvious solution to improving physician continuity is by increasing resident physician availability.

Our study is limited because we looked at 1 resident continuity clinic at 1 tertiary care center. Continuity in this resident practice has been previously studied in comparison with 2 private practices in the same city of Charleston, SC. The PHY formula was used to make these comparisons. Continuity in this resident practice is not as high as the continuity in the private medical homes studied. However, for WCC visits only, the continuity in the resident practice was equal to 1 private practice and greater than the other private practice.³

We believe that continuity in this resident clinic compares well to other resident clinics. Christakis et al⁷ reported a mean continuity of 0.30 for patients who were seen by resident physicians in a outpatient teaching clinic at the University of Washington. The Bice Index (COC) was used to calculate continuity in their study. Continuity for pediatric residents at MUSC was 0.24 by the Bice Index.³

Although the pediatric continuity clinic at MUSC is structured like a private practice, we do not know whether the results will generalize for residency programs that place trainees in private practices for the continuity experience. Also, we do not know whether the results will generalize to other medical specialties.

An additional limitation of our study is that we were unable to account for walk-in visits. This clinic is structured for scheduled visits only; however, in reality, walk-in visits are seen for acute problems. These visits were not uniformly recorded over the 17 years of this study.

Previous reports have demonstrated that pediatric residents who are placed in the community for continuity clinic see increased acute visits but have less likelihood of "repeat patient encounters."²⁰ In large-volume practices, scheduling efforts are even more critical to ensuring that the continuity experience is not diluted for residents. Furthermore, our study is based on continuity calculated by a formula that depends on clinicians’ having assigned patients: we did not count "repeat encounters."

	CONCLUSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
More time in continuity clinic does indeed improve continuity for resident physicians. The increased continuity is achieved through sick visits in our clinic. A next step is to determine the outcomes for residents with varying amounts of physician continuity: how much continuity is enough? Also, how does increasing percentage of time in continuity clinic affect the quality of learning experiences in other training settings (eg, general wards, subspecialty rotations)?

	ACKNOWLEDGMENTS

 
This work was supported in part by a grant from Health Resources and Services Administration (6DO8HP50101-03).

Portions of this work were presented at the American Federation of Medical Research and Participating Societies, Southern Regional Meeting, New Orleans, LA, February 21–23, 2002; and at the Pediatric Academic Societies Meeting in Baltimore, MD, May 3–7, 2002.

This work was performed while Dr McBurney was a Generalist Academic Fellow, Center for Health Care Research, Medical University of South Carolina, Charleston, SC.

	FOOTNOTES

 
Accepted Dec 4, 2003.

Reprint requests to (P.G.M.) Medical University of South Carolina, Department of Pediatrics, 135 Rutledge Ave, PO Box 250561, Charleston, SC 29425. E-mail: mcburnpg{at}musc.edu

	REFERENCES

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 

1. Accreditation Council for Graduate Medical Education. Program Requirements/Pediatrics—Competencies. Accreditation Council for Graduate Medical Education; 2000. Available at: www.acgme.org/RRC/PedReq_Comp.asp. Accessed December 17, 2002
2. Charney E. The education of pediatricians for primary care: the score after two score years. Pediatrics. 1995;95 :270 –272[Abstract/Free Full Text]
3. Darden PM, Ector W, Moran C, Quattlebaum TG. Comparison of continuity in a resident versus private practice. Pediatrics. 2001;108 :1263 –1268[Abstract/Free Full Text]
4. Dumont-Driscoll MC, Barbian LT, Pollock BH. Pediatric residents’ continuity clinics: how are we really doing? Pediatrics. 1995;96(suppl) :616 –621
5. Christakis DA, Wright JA, Zimmerman FJ, Bassett AL, Connell FA. Continuity of care is associated with high-quality care by parental report. Pediatrics. 2002;109(4) . Available at: www.pediatrics.org/cgi/content/full/109/4/e54
6. Becker MH, Drachman RH, Kirscht JP. A field experiment to evaluate various outcomes of continuity of physician care. Am J Public Health. 1974;64 :1062 –1070[Free Full Text]
7. Christakis DA, Wright JA, Koepsell TD, Emerson S, Connell FA. Is greater continuity of care associated with less emergency department utilization? Pediatrics. 1999;103(suppl) :738 –742
8. Christakis DA, Mell L, Koepsell TD, Zimmerman FJ, Connell FA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001;107 :524 –529[Abstract/Free Full Text]
9. Christakis DA, Wright JA, Zimmerman FJ, Bassett AL, Connell FA. Continuity of care is associated with well-coordinated care. Ambul Pediatr. 2003;3 :82 –86[CrossRef][ISI][Medline]
10. Gill JM, Mainous AG III, Nsereko M. The effect of continuity of care on emergency department use. Arch Fam Med. 2000;9 :333 –338[Abstract/Free Full Text]
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12. Bice TW, Boxerman SB. A quantitative measure of continuity of care. Med Care. 1977;15 :347 –349[CrossRef][ISI][Medline]
13. Magill MK, Senf J. A new method for measuring continuity of care in family practice residencies. J Fam Pract. 1987;24 :165 –168[ISI][Medline]
14. Osborn LM, Sargent JR, Williams SD. Effects of time-in-clinic, clinic setting, and faculty supervision on the continuity clinic experience. Pediatrics. 1993;91 :1089 –1093[Abstract/Free Full Text]
15. Starfield B. Primary Care Concept, Evaluation, and Policy. New York, NY: Oxford University Press; 1992
16. Accreditation Council for Graduate Medical Education. Program Requirements. ACGME Duty Hours Standards Now in Effect for All Residency Programs. Accreditation Council for Graduate Medical Education; 2003. Available at: www.acgme.org/Media/news7_1_03.asp. Accessed August 7, 2004
17. Starfield B. Primary Care Balancing Health Needs, Services, and Technology. Rev. ed. New York, NY: Oxford University Press; 1998
18. Lewis C. What is the evidence? Am J Dis Child. 1971;122 :469 –474[Medline]
19. Bower P, Roland M, Campbell J, Mead N. Setting standards based on patients’ views on access and continuity: secondary analysis of data from the general practice assessment survey. BMJ. 2003;326 :258[Abstract/Free Full Text]
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This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via ISI Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by McBurney, P. G. Articles by Darden, P. M. Search for Related Content PubMed PubMed Citation Articles by McBurney, P. G. Articles by Darden, P. M. Related Collections Office Practice

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