الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Continuity of care (COC) should be an important element in the management of diabetic patients. Some research studies have found that greater COC is associated with earlier diagnosis of diabetes, better management of the condition, and more favorable intermediate outcomes, but other studies give contradictory results. There is lack of information regarding continuity of patient’s care among T2D patients in family health units in Alexandria. In addition, there is a great emphasis on the need to care for the fake of the patients and getting accreditation for family health units. So; this study will spotlight the status of COC for diabetes and its relation to quality measures which might positively impact the process of accreditation.
The present study assessed COC of T2D patients in Family Health units in Alexandria.
This study aimed to:
1. To measure continuity of care indices for diabetic patients.
2. To identify diabetic patients’ values and experiences with respect to continuity in diabetes care.
3. To assess physicians’ and nurses’ views of continuity of care.
4. To assess process and outcome measures for diabetes care quality.
5. To determine the relationship between continuity and quality of care for diabetic patients in terms of process and outcome of care.
6. To recommend strategies for improvement of continuity of care based on results.
The study had been conducted at Family Health Units and centers as a primary care level that representing the eight health districts at Alexandria Governorate and their two referral hospitals that provide health care for T2D patients as secondary and tertiary levels. The hospitals were Abo keer and Al-amrya hospitals. These family health units, centers and hospitals are following Alexandria Health Directorate and affiliated to the Ministry of Health and Population Egypt.
The study is descriptive cross sectional. The study has a retrospective part which is reviewing records of selected sample of T2D patients and assessment part to assess continuity of health care perceptions that include selected sample of patients interview questionnaire and structured self-administered questionnaire for physicians and nurses who provide health care for the T2D patients during their follow up visits at the family health facilities and at the referral hospitals.
Continuity of health care levels had been assessed by using the most common measures for continuity in reference studies, (UPC) Usual Provider of Care, (COCI) Continuity of Care index and (SECOC) Sequential Continuity Of Care. Each index has its mathematical equations that had been calculated for each patients records review.
Variables used to compute process and outcome quality measures for diabetes care quality as follow:
a- Process performance quality measures assessing services received by patients during 12 months prior to the date of medical record review as:
- Number of patients with one or more glycated hemoglobin (HbA1c).
- Patients with at least one micro albuminuria testing.
- Number of patients receiving at least one lipid profile (total cholesterol value).
- Number of patient with a dilated eye examination or evaluation of retinal photography by an ophthalmologist.
- Number of patients with a record of assessment of peripheral pulsation.
- Number of patients assessed for smoking cessation.
b- Intermediate outcome quality measures which include patients metabolic control indicators during the last 12 months prior to records review:
- Percentage of patients with last HbA1c less than 7%.
The relation between continuity indices scores and quality indicators had been discussed and studied at the present study.
The study revealed the following findings:
• The present study about T2D patients’ last care visits experience at different care level there were no statistical significance difference regarding changes in prescribed treatment, changes in instructions, adding or omission nor in dosage changes.
• About the waiting time for GP visit, specialist visit and hospital doctor visit, there were statistical significance difference (p<0.001) at the patients responses at “adequate “ as 61% of patients responded adequate waiting time for GP visits and 8.6% for specialist and 32.5%for hospital doctor while response” excessive” 10.8% for GP , 58.1% for specialists and 37.5% for hospital doctors and the difference was statistically significant.
Regarding continuity of care indices scores of patient sample and its relations to different patients demographic characteristics:
• The patients(n=336) usual provider continuity index UPC scores show the highest percentage of patients scores lied in 0.80-1 score (42.9%) with mean 0.61 ± 0.28, while at the COC index score was mean 0.59 ± 0.27 with highest percent (36.6%) lied in 0.80-1score category. The SECOC show the highest (35.4%) percentage of the score lied at 0.60- ≤ 0.80 category.
• The correlation between the UPC , COC , SECOC continuity indices mean score found to be a strong positive relation with statistical significance (p<0.0001).
• There was a positive relation between UPC index and age groups of patients in the direction of young ages 20-30year and the difference is of statistical significance (p=0.013).
Regarding patients’ values and experiences with respect to continuity in diabetes care:
• Measures of patient experience regarding different continuity dimensions at the present study illustrate the following findings regarding informational continuity from T2D patients perceptions, the total mean scoring was 6.99±4.407 for the range score from 0- to12. While 43.2% of patients scores lied in the intermediate category and 15.2 % categorized as high level .
• The care coherence dimension total mean score 14.98 ±3.and the range score was from 0- to21 with the majority of patients(85.4%) scores categorized as intermediate level, accessibility of health care between levels show mean score 5.69± 3.175 and range score was from 0- to 12 and patients scores categorized as 46.7 % intermediate level and 11.9% as high level.
• Relational continuity with GP show mean dimension scores16.82 ± 4.421 .The score range was from 0- to 24 with 45.5% of patients lied in intermediate category compared to mean total scores of the relational continuity with specialist 15.89 ± 5.543 (score range 0-24) with 45.2% at intermediate category
• Correlation between the COC indices scores of study sample of patients and their perception scores of continuity of care dimensions show a strong positive relation between patients scores of informational continuity and COC(r=0.581 p=0.000) UPC (r=0.576 p= 0.000) SECOC(r=0.503 p=0.000) and difference were statistically significant
• Age groups of sampled T2D patients show a statistical significance relations with their mean managerial continuity in accessibility of health care between levels in the direction of 40 years with its highest to the age 60 -70 years (p=0.014) .Regarding relational continuity, patients mean score also show significant statistical relation to age groups with GP (p=0.016) and with specialist (0.013). The older the patient, the higher mean scores of relational continuity.
• Patients sex had a significant statistical relation only with informational continuity (p=0.021) with higher mean score with female sex.
• Marital status had statistical significant relation with accessibility between levels (p=0.024) and relational continuity with GP (p=0.023) and relational continuity with specialist (p=0.029) .The married patients had high mean continuity scores
Regarding assessment of process and outcome quality measures for diabetic care of T2D patients:
• In the last 12 month prior to records review to assess process quality measures , results showed that 48.5% of sampled patient did one or more HbA1c , 65.5% did one or more micro albuminuria test, 61.3% did one or more lipid profile , 56.2% did one or more dilated eye examination, 73.8% assessed for peripheral pulsation and 35.7% of patients assessed for smoking.
• The intermediate outcome quality measure , reviewing patients medical records showed that patients with last HbA1c level less 7% were 55.4% , patients with last cholesterol value 5mmol or less were 61.9% and patients with last blood pressure measure below 140/90 were 68.8%
• Quality score for the process and intermediate outcome measures show that 51.5% of sampled T2D patients’ scores category was Intermediate 3- ≤ 6 and 46.7% their score category was High 6- ≤ 9 while only 1.8 % of patients their quality score lied in Low category( 0- < 3) .
Relation between patients’ mean scores of continuity indices, process and intermediate outcome measures:
• There was a significant statistical relation between patient did dilated eye examination as a process measure and COC (p=0.012) UPC (p=0.001) SECOC (p=0.001).
• There was a significant statistical relation between patients assessment for peripheral pulsation as a process measure and COC (p= 0.001) UPC (p=0.019)
Physicians’ and nurses’ views of COC:
• Longitudinal continuity dimensions assessment for physicians and nurses responses scores revealed that the percent mean score of primary care level participants had higher mean percentage score (43.6 ±7.8) than hospital level participants (24.0 ± 20.2) and the difference was of statistical significance (p<0.001).
• Relational continuity dimension mean percentage score was 68.7±13.9 to the primary care level participants score which is higher than hospital level scores mean percentage score (36.8 ± 33.3) and the difference was statistically significant (p<0.001).
• Informational continuity dimension responses scores of all physicians and nurses show that mean percentage score was 68.1±20.1 while primary care participants mean percentage score was 73.3±10.3 and 36.8±33.3 for hospital care level participants, the deference was of statistical significant (p<0.001).
• Staff communication have also a significant statistical difference between primary care level participants score (71.8 ±18.2)and hospital care level participants score (81.6 ± 13.1) and this was the only continuity dimension that the hospital care level scored higher than primary care level physicians and nurses the difference was of statistical significance (p=0.006).
• The mean of total scores of the four continuity dimension for the all physicians and nurses was 90.3 ± 15.5 and the mean percentage score was 64.5 ±11.0 .The primary care level participants mean scores was 93.1±10.7 and mean percentage score was 66.5 ± 7.7 which is higher than hospital care level perception scores 52.4±18.6 the difference was statistically significant (p<0.001).
Based on the study findings, the following recommendations were suggested:
Involving methods for assessing and promoting continuity in practice and developing some form of toolkit for practices that ensuring a better understanding of the importance of COC and the need to incentivize it alongside.
Patient’s experiences are important to be considered in designing services for patients with diabetes and in assessing the quality of care. Patients’ experiences of should be monitored and used routinely in a time manner by self-administered measures collected, scored and analyzed to reflect quality of health care service trend.
Assessment of professionals’ views of COC may be used to monitor service delivery and inform improvements in services.
Enhancing the patient experience of COC is especially important for hospital-based services.
We recommend computerization of medical records at the family health system. Computerization would enrich the informational continuity, staff communication and facilitation of patients’ medical records review for further researching.
Further research is required to develop and test interventions to enhance experiences of continuity through transitions in health and health care for different groups of patients as T2D patients who are vulnerable to experiences of loss of continuity when their health changes or when they move between different health care levels .
Conclusion
Regarding T2D patients experience regarding last health care visit at different health care levels:
• About T2D patients’ last care visits experience at different care level there were no statistical significance difference regarding changes in prescribed treatment. Waiting time for GP visit, specialist visit and hospital doctor visit, had statistical significance difference as about two thirds of the sample named the waiting time for GP as adequate compared to more than half of the sample named the waiting time for specialist as excessive .
Regarding COC indices scores of patients and its relations to their demographic characteristics:
• The patients’ UPC scores show the highest percentage, about half of the sampled of patients scores lied in 0.80-1 score, while at the COC score with its highest percent lied in 0.80-1score category. The SECOC show lesser scoring category where its highest percentage of the score lied at 0.60 ≤ 0.80 category.
• The correlation between the UPC, COC , SECOC continuity indices mean scores show a strong positive correlation with statistical significance .There was a positive relation between UPC index and age groups of patients in the direction of young ages 20-30 years
Regarding patients’ values and experiences with respect to continuity in diabetes care:
• About half of studied T2D Patients lied in the intermediate informational continuity perceptions scores category. the majority of them were categorized as intermediate level Care coherence dimension score, nearly half of patients were categorized as intermediate level accessibility of health care between levels scores and only one tenth of them were ranked as high level.
• About half of the studied patients belonged to intermediate category scores of relational continuity with GP and with specialist.
• Correlation between COC indices scores and T2D patients perceptions scores of COC show a moderate positive correlation between patients scores of informational continuity and COC ,UPC and SECOC
• Age groups of sampled T2D patients show a statistical significance relations with managerial continuity in accessibility of health care between levels, relational continuity with GP and relational continuity with specialist, as their mean scores were highest among the age group (60 -70 years).
• Patients sex had a significant statistical relation only with informational continuity with higher mean score among female sex. Marital status had statistical significant relation with accessibility between levels and relational continuity with GP and relational continuity with specialist with the married patients had the higher mean continuity scores
Regarding assessment of process and outcome quality measures for diabetic care of patients:
• Assessment of peripheral pulsation had the highest percentage among T2D records followed by doing micro albuminuria tests , then lipid profile test then dilated eye examination then HbA1c tests and the least percentage was to smoking assessment. The intermediate outcome quality measures revealed that nearly half number of the patients had controlled last HbA1c level less 7%, and patients with controlled last blood pressure measure get the highest percentage among the three assessed intermediate outcome measures. Quality score for the process and intermediate outcome measures show that nearly half of the studied T2D patients were at intermediate level and less than half of them were at high level .
Relation between patients mean scores of COC and quality indicators:
• There was a significant statistical relation between patient assessment regarding dilated eye examination as a process measure and the three used continuity indices (COC, UPC and SECOC). Patients assessment for peripheral pulsation had a significant positive relation only with two continuity indices (COC& UPC).
Physicians’ and nurses’ views of continuity of care:
• Longitudinal, Relational and Informational continuity dimensions scores of physicians and nurses for primary care level were significantly statistically higher than that for hospital care level participants. However, staff communication was the only continuity dimension that the hospital care level scored significantly statistically higher than primary care level. The primary care level total mean scores for COC perception is significantly statistically higher than hospital care level perception scores.
Recommendations
Based on the study findings and conclusions the following can be recommended:
1- Involving methods for assessing and promoting continuity in practice as continuity indices measures UPC/ COC / SECOC
2- Developing some form of toolkit for practices that ensuring a better understanding of the importance of continuity .
3- Assessing the quality of care by developing quality score (include process and outcome measures) for each diabetic patient should be monitored routinely in a time manner collected, scored and analyzed to reflect quality of health care service trend.
4- This research is in line with those of the previous validation process(18) and suggests that the CCAENA questionnaire is an adequate tool for measuring patients’ perceptions of continuity of care. Providers and researchers interested in improving continuity of care across care levels could apply the CCAENA questionnaire to identify areas for improvement
5- Assessment tools of professionals’ views of continuity of care is of importance to be included in health policy cycle to monitor service delivery and inform improvements in services. Organizing care through professionals may enhance patients’ experience of continuity of care.
6- Improving patient perception and experience about health service by primary care policies through two ways, firstly recognize the contribution of continuity to quality of care in general practice, Secondly by practices being incentivized and rewarded for achieving and maintaining this aspect of care.
7- Involving the whole practice team for initiatives is a must to reach high level of care coherence in health care service
8- There has been little attention to measuring patient perspectives of continuity. Relatively little is known about how patients perceive different aspects of the ‘smoothness’ of their care and the stability of those perceptions and preferences over time.
9- To enhance relationship continuity, it is recommended to give the patients an opportunity to see the same clinician (longitudinal continuity), if they wish to do so. Longitudinal continuity is a pre-condition for on-going therapeutic relationships, and should be encouraged.
10- Studying the effects and causes of discontinuities of clinician in their work places specially at primary care levels and investigating ways of measuring UPC that can be used in setting service standards reference index to improve quality.
11- There is a need for redesigning and increasing size of medical records follow up sheets at the family health filling system at its different care levels to enrich the patient’s medical informational continuity, empower staff communication and facilitate patients’ medical records review for further researching.
12- Further researches are needed to:
- Develop and test interventions to enhance experiences of continuity through transitions in health care for T2D experiences of loss of continuity when their health changes or move between different health care levels (primary, secondary or tertiary) .
- Methods are needed to evaluate information transfer and consistency of care among hospitals and primary-care providers, that go beyond simply measuring availability and flow of information to measuring how it’s taken up and used to improve health outcomes.
- There are gaps in the knowledge about how different types of continuity contribute to health outcomes, and about cost-effectiveness. The need for longitudinal researches increased. There has been little attention to measuring patient perspectives of continuity. Relatively little is known about how patients perceive different aspects of the ‘smoothness’ of their care and the stability of those perceptions and preferences over time.