We examined the relationship between physician connectedness and measures of physician performance by categorizing all patients seen in a large primary care network on the basis of their connectedness to a specific primary care physician. Our results indicate that many patients did not have a close continuous relationship with their designated primary care physician, the prevalence of physician-connected patients was variably distributed between practices, patients without a close relationship with a specific physician were less likely to complete recommended testing for preventive and chronic illness care, and differences in performance measures by race or ethnicity were smaller than differences in patient–physician connectedness within racial or ethnic groups. Controlling for patient–physician connectedness attenuated some differences among racial and ethnic groups in the receipt of guideline-recommended care.
Most definitions of primary care include reference to a continuous longitudinal relationship (5
). Although patients may have different preferences for continuous longitudinal relationships, with some patients preferring to avoid this type of arrangement altogether, primary care physicians can do much to promote greater connectedness with their patients (31
). Nonetheless, a close continuous relationship requires the active participation of both the patient and the physician. We developed a novel method to define how closely patients were connected to physicians. This method used a prediction model that was based on the physician’s assessment, regardless of whether patients having office visits with them actually belonged in their panel. Although similar to measures of continuity (15
), our measure differed because it was validated against physicians’ assessments of who they considered to be “my patient.” Our measure was also based on data obtained as part of usual care and can therefore be applied routinely to categorize all patients seen in a network. The validation did not ask the physician to identify their adherent patients but rather to identify all of the patients in their panel (21
). Although this method has some distinct and important limitations, the results suggest that physician connectedness may play an important role in understanding measures of physician performance.
Among the more striking findings of our study was the extent to which patients who were connected to a specific physician were more likely to receive guideline-recommended care than patients who were not connected to a specific physician. This finding is consistent with previous studies that demonstrated the benefit of a regular source of care on the likelihood of received guideline-recommended care (14
). However, studies comparing patients with and without a regular physician show better access to care (17
) but less consistent results on guideline-recommended care (38
). In addition, almost all studies examining continuity of care have used patient survey data for determining continuity of care. Thus, while useful for addressing health policy questions, such patient-derived measures would be difficult for health care systems to apply to their large patient populations for ongoing quality assessment and improvement programs.
Patients who were connected to a physician were more likely have insurance, speak English, and be non-Hispanic white. This strong relationship between patient–physician connectedness and race or ethnicity suggests that disparities in care may be mediated in part by the degree of connectedness to primary care physicians (42
). While some residual differences remained between groups, we found that connectedness was associated with larger disparities in screening rates than was race or ethnicity. The process of establishing a strong relationship with a specific physician may represent an important key to understanding disparities in care (13
). Greater insight into the role of patient-, provider-, or practice-level barriers to establishing a closely connected primary care relationship may lead to improved quality of care for vulnerable patients (44
The primary care physician is a key target of quality improvement efforts, such as pay-for-performance (45
). A key assumption in such programs is that patients who prefer not to (or cannot) follow a physician’s recommendations will be relatively equally distributed among physicians or practices. We found that the proportion of patients who were connected to physicians varied widely among practices. This variation may reflect differences in practice organization, physician practice styles, or patient characteristics. Because all our practices have a uniform management structure with integrated administrative and clinical information systems and nearly all our physicians have closed panels, variation in practice structure probably contributed little to the observed variation in patient connectedness. All physicians in our network receive reminders when patients are due and overdue for all of the measures used in this study. In addition, practice-based nurses call commercially insured patients and encourage them to complete these recommended tests. Despite all of these systems designed to decrease variation, we found the same association between physician connectedness and performance of guideline-recommended care in the subpopulation of commercially insured patients.
The association of connectedness with performance measures underscores the importance of accurately defining the eligible (or “denominator”) patient population for quality measurement. As demonstrated in our analysis, many patients receive episodic care from different providers without necessarily establishing a strong relationship with any 1 provider, even their listed primary care physician (48
). Pay-for-performance initiatives are based on the ability to accurately assign performance measures to practitioners who have some control over the outcome. Our results suggest that physicians with a relatively low percentage of connected patients are likely to receive lower scores on performance measures than physicians with a higher proportion of connected patients. If connectedness is determined in part by patient rather than just physician or practice characteristics, the disproportionate effect of connectedness on performance measurement may penalize physicians and practices caring for vulnerable populations with lower rates of physician connectedness. The potential result may be to direct resources away from those who care for populations with lower performance scores based on the patient’s ability or willingness to establish a long-term connection with a physician rather than the physician or practice’s efforts (7
Our results must be interpreted in the context of the study design. We did our study in 1 practice network, and our findings require confirmation in other settings. Although the concept of continuity of care is well established (5
), including continuity with a regular physician, the approach we used to measure patient–physician connectedness is relatively novel and is but 1 of several possible methods. For example, we based physician connectedness on a physician-derived standard, but other standards (for example, patient-derived) could also be used (50
). Simpler models to designate connectedness may also be possible, especially in more homogeneous care delivery settings. Nonetheless, the association of better performance with closer physician connection will probably remain robust by any valid measure of connectedness. Physician connectedness was strongly associated with visit frequency, and higher visit frequency is associated with better results on performance measures. However, when examined within strata of similar visit frequency, physician-connected patients continued to have improved outcomes. This argues that the concept of connectedness is more than simply a reflection of how often a patient is seen. Because we had limited access to tests obtained outside of our network, we may have underreported performance measures, particularly for patients with less physician connectedness. For this reason, we did not assess performance measures in unconnected patients. Nonetheless, we are informed of all tests, even those conducted outside our system, for our commercially insured patients. Finally, we did not collect data directly from patients and physicians and thus cannot report on the underlying reasons for the differences observed.
The concept of connectedness and its relationship to performance measures suggest strategies to efficiently organize quality-improvement interventions. Although one could simply hold physicians and practices accountable for assuring connectedness, this does not address relevant patient preferences. Alternatively, strategies could be implemented that take advantage of established connectedness patterns. For example, for patients closely connected to a single primary care physician, complex quality-improvement tasks, such as changing medications on the basis of laboratory test results, can be designed that rely on the physician as the “care catalyst” (51
). For patients who are not connected to a specific physician, organizational redesign that uses nonphysician case managers as an alternative to strong patient–physician connectedness may be an efficient model of care (15
In summary, many patients in a large adult primary care network were not closely connected to a specific primary care physician. The proportion of physician-connected patients varied considerably among practices and was strongly associated with the completion of recommended tests. In addition, patient characteristics, such as race or ethnicity, were associated with physician connectedness and with completion of recommended care.
Continuity of care is a basic tenet of high-quality primary care, but the relationship between quality of care and the connection between patient and physician has not been rigorously studied.
The researchers defined whether 155 590 adults in a primary care network received most of their care from a specific physician, practice, or neither. Patients who were connected to a particular physician were more likely to have received recommended care than patients who were connected to a practice but not a physician.
The study involved only 1 network, which is one of many potential definitions of continuity, and selected quality measures.