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Gulshan Sharma, MD, MPH; Kathlyn E. Fletcher, MD, MA; Dong Zhang, PhD; Yong-Fang Kuo, PhD; Jean L. Freeman, PhD; James S. Goodwin, MD

JAMA. 2009;301(16):1671-1680.

Context  Little is known about the extent of continuity of care across the transition from outpatient care to hospitalization.

Objectives  To describe continuity of care in older hospitalized patients, change in continuity over time, and factors associated with discontinuity.

Design, Setting, and Participants  A retrospective cohort study of 3 020 770 hospital admissions between 1996 and 2006 using enrollment and claims data for a 5% national sample of Medicare beneficiaries older than 66 years. Data files were constructed to include the patients’ demographic and enrollment information (denominator file) and claims for hospital stays (MEDPAR file) and physician services (carrier claims file). Characteristics of the hospitals were included in annual provider of services files. Being seen by a physician was defined as when a physician had submitted a bill for evaluation and management services for that patient.

Main Outcome Measures  Percentage of patients who during hospitalization were seen by any outpatient physician they had visited in the year before hospitalization (continuity with any outpatient physician) or by their primary care physician (PCP) (continuity with a PCP).

Results  In 1996, 50.5% (95% confidence interval [CI], 50.3%-50.7%) of hospitalized patients were seen by at least 1 physician that they had visited in an outpatient setting in the prior year, and 44.3% (95% CI, 44.1%-44.6%) of patients with an identifiable PCP were seen by that physician while hospitalized. These percentages decreased to 39.8% (95% CI, 39.6%-40.0%) and 31.9% (95% CI, 31.6%-32.1%), respectively, in 2006. Greater absolute decreases in continuity with any outpatient physician between 1996 and 2006 occurred in patients admitted on weekends (13.9%; 95% CI, 12.9%-14.7%) and those living in large metropolitan areas (11.7%; 95% CI, 11.1%-12.3%) and in New England (16.2%; 95% CI, 14.4%-18.0%). In multivariable multilevel models, increasing involvement of hospitalists was associated with approximately one-third of the decrease in continuity of care between 1996 and 2006.

Conclusion  Between 1996 and 2006, physician continuity from outpatient to inpatient settings decreased in the Medicare population.

Author Affiliations: Department of Internal Medicine (Drs Sharma, Kuo, Freeman, and Goodwin) and Sealy Center of Aging (Drs Sharma, Zhang, Kuo, Freeman, and Goodwin), University of Texas Medical Branch, Galveston; and Clement J. Zablocki Veterans Affairs Medical Center and Department of General Internal Medicine, Medical College of Wisconsin, Milwaukee (Dr Fletcher).

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