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Continuity of Care Increases Physician Productivity in Primary Care (with Michael Freeman and Stefan Scholtes) [Management Science]
Continuity of care, defined as an ongoing therapeutic relationship between a patient and a physician, is a defining characteristic of primary care services. However, arranging a consultation with one's regular doctor is increasingly difficult as practices seek to improve daily throughput to match rising consultation demand with an increasingly scarce supply of clinical labor. We study the implications of this reduction in care continuity on the productivity of physicians by analyzing consultation-level data of over 10 million office consultations in 381 English primary care practices over a period of 11 years. We find that continuity of care has a significant productivity benefit at the physician level. Using statistical models that account for confounding and selection bias and restricting the sample to consultations with patients who had at least three consultations over the past two years, we find that the time to a patient's next visit is on average 18.1% (95% CI:[16.9%,19.2%]) longer when the patient sees the doctor they have seen most frequently over the past two years, while there is no operationally meaningful difference in duration between consultations with this regular doctor or another doctor in the practice. The data also shows that the productivity benefit of care continuity is larger for older patients, patients with multiple chronic conditions, and patients with mental health conditions. We estimate that the total consultation demand in our sample could have fallen by up to 5.2% had all practices offered continuity of care at the level of the top decile of practices while prioritizing patients expected to yield the largest productivity benefits. We discuss operational and strategic implications of these findings for primary care practices and for third-party payers.
Links to media coverage [Guardian] [BBC News] [Telegraph] [Independent] [Daily Mail (1)] [Daily Mail (2)] [Express]
Links to media coverage [Guardian] [BBC News] [Telegraph] [Independent] [Daily Mail (1)] [Daily Mail (2)] [Express]
Continuity and locum use for acute consultations: observational study of subsequent workload (with Stefan Scholtes, Denis Pereira Gray, Kate Sidaway-Lee, Michael Freeman and Philip Evans) [British Journal of General Practice]
Background: Workload is probably the biggest challenge facing general practice and little is known about any modifiable factors. For GPs, both continuity and locum status are associated with differences in outcomes. Aim: To determine whether practice and hospital workload after an index acute consultation depend on the type of GP consulted (locums and practice GPs with [regular] and without [non-regular] continuity, and locums). Design and setting: An observational, cross-sectional analysis of consultation-level data from English general practices from the Clinical Practice Research Datalink from 2015 to 2017. Method: Antibiotic prescription was used as a marker for acute consultations with regression models to calculate adjusted relative risks for emergency department consultations and admissions, outpatient referrals, and test ordering, as well as the patients’ GP reconsultation interval following consultations with the three types of GP. Results: After adjustment, consultations with antibiotic prescriptions with regular GPs with continuity were associated with fewer subsequent hospital admissions and lower emergency department use but higher outpatient referrals relative to locums and non-regular GPs. Locums ordered tests less often (relative risk [RR] −24.3%, 95% confidence interval [CI] = −27.3 to −21.2) than regular GPs whereas non-regular GPs ordered tests more often (RR 19.1%, 95% CI = = 16.4 to 21.8). Patients seeing their regular GP had on average a 9% longer (95% CI = 8 to 10) reconsultation interval than if they saw any other GP. Conclusion: The differences in outcomes were associated more with having continuity than with GP locum status. Seeing a GP with whom the patient had continuity of care was associated with reduced workload within the practice and in hospital.
Working papers
Strength in Teams: Named Physician Pairs Improve Continuity of Care in Primary Care Amid Workforce Pressures (with Laura M. Poreschack and Stefan Scholtes) [Major Revision at Management Science]
Continuity of care-a sustained relationship between a patient and their primary care physician-improves outcomes and reduces healthcare utilization, but workforce pressures threaten its sustainability. Building on the Named Physician model in England, this study proposes a Named Physician Pair model, where two physicians jointly ensure continuity, with a secondary physician covering when the primary physician is unavailable.
Workforce Composition as a Key Determinant of Continuity of Care in Primary Care (with Michael Freeman) [In preparation for submission]
Primary care practices have responded to the workforce crisis by altering the composition of their workforce, specifically, by hiring more part time and locum physicians and have. But, this is counterproductive as research suggests that providing continuity of care is productivity-enhancing, which is difficult to offer with such a fragmented workforce. Consequently, the trend suggests that continuity of care has been declining over the past decade. This paper examines this question from an operations management perspective by exploring the relative importance of workforce composition related operational factors that may explain variation in rates of COC between practices and over time. This paper provides the first empirical study on the antecedents of COC in the primary care context. Using the insights from this analysis, practice managers can identify the root cause of low rates of COC at their own practice and the key operational levers that they can use to promote RC. Using advanced panel data analysis methods, we find that a sustained increase in workforce fragmentation - due to a shift to part-time work, agency work as well as a shifting of workload to non-physician clinical workforce induces significant heterogeneity between practices in their ability to provide RC. In fact, these factors alone can also explain more than 32% of the decline in continuity over the past decade, with part-time and agency work having a relatively greater impact than task-shifting. Practice managers must improve the attractiveness of full-time salaried employment to create a core established workforce if they wish to promote RC.
Black Swans in Hospital Costs and Implications for Hospital Management (with Michael Freeman, Paul Kattuman and Stefan Scholtes)
Healthcare costs are rising amidst an aging and complex patient population coupled with a workforce shortage, which has made the situation worse. Containing healthcare costs without sacrificing quality is therefore a vital policy concern for the healthcare system. Efficiency in the use of resources is an important dimension in the ability of hospitals to provide high quality care while containing costs, but what do efficient hospitals do differently to deliver adequate care compared to less efficient hospitals. In other words, we seek to understand how higher performing hospitals keep their mean and variance in their patient-level cost distributions low? Since the mean and variance of patient-level cost is driven by the probability of extremely costly events, we use a unique dataset from the UK, to analyse cost distributions that govern hospital "product lines" or Healthcare Resource Groups (HRG). Results suggest that over 20% of the HRGs have heavy upper tails, implying unacceptably high likelihoods of very large and positive cost deviations in these HRGs. We show that cost variability can be reduced by managing length-of-stay (LOS) variability, and/or managing cost elasticity of LOS. Using standard performance ratings, we find that a positive correlation exists between high performing hospitals and lower diseconomies of cost with respect to LOS (lower cost elasticity of LOS). These results can help managers identify the root causes of high cost variability in their hospital and by reducing high cost events it can improve the reliability of the hospital`s financial plans}
Papers in progress
Pushing Past Patient Ratios: How a Recalculation of Workload Alters the Perception of Workload in Nursing (with RJ Niewohner)
Optimizing maternity pathways (with Agni Orfanadouki and Yueyang Zhong)
Access and Adherence: Evaluating Botswana's Pharmacy Expansion Initiative on Chronic Patient Health Outcomes (with Chris Chen)
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