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Original Investigation |

Continuity and the Costs of Care for Chronic Disease

Peter S. Hussey, PhD1; Eric C. Schneider, MD1,2; Robert S. Rudin, PhD1; D. Steven Fox, MD1; Julie Lai, MPH1; Craig Evan Pollack, MD3
[+] Author Affiliations
1RAND Corporation, Santa Monica, California
2Division of General Medicine and Primary Care, Brigham and Women’s Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts
3Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA Intern Med. 2014;174(5):742-748. doi:10.1001/jamainternmed.2014.245.
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Importance  Better continuity of care is expected to improve patient outcomes and reduce health care costs, but patterns of use, costs, and clinical complications associated with the current patterns of care continuity have not been quantified.

Objective  To measure the association between care continuity, costs, and rates of hospitalizations, emergency department visits, and complications for Medicare beneficiaries with chronic disease.

Design, Setting, and Participants  Retrospective cohort study of insurance claims data for a 5% sample of Medicare beneficiaries experiencing a 12-month episode of care for congestive heart failure (CHF, n = 53 488), chronic obstructive pulmonary disease (COPD, n = 76 520), or type 2 diabetes mellitus (DM, n = 166 654) in 2008 and 2009.

Main Outcomes and Measures  Hospitalizations, emergency department visits, complications, and costs of care associated with the Bice-Boxerman continuity of care (COC) index, a measure of the outpatient COC related to conditions of interest.

Results  The mean (SD) COC index was 0.55 (0.31) for CHF, 0.60 (0.34) for COPD, and 0.50 (0.32) for DM. After multivariable adjustment, higher levels of continuity were associated with lower odds of inpatient hospitalization (odds ratios for a 0.1-unit increase in COC were 0.94 [95% CI, 0.93-0.95] for CHF, 0.95 [0.94-0.96] for COPD, and 0.95 [0.95-0.96] for DM), lower odds of emergency department visits (0.92 [0.91-0.92] for CHF, 0.93 [0.92-0.93] for COPD, and 0.94 [0.93-0.94] for DM), and lower odds of complications (odds ratio range, 0.92-0.96 across the 3 complication types and 3 conditions; all P < .001). For every 0.1-unit increase in the COC index, episode costs of care were 4.7% lower for CHF (95% CI, 4.4%-5.0%), 6.3% lower for COPD (6.0%-6.5%), and 5.1% lower for DM (5.0%-5.2%) in adjusted analyses.

Conclusions and Relevance  Modest differences in care continuity for Medicare beneficiaries are associated with sizable differences in costs, use, and complications.

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Figure.
Odds of Incidence of Hospitalizations, ED Visits, and Complications (A) and Percentage Change in Costs (B) Associated With a 0.1-Unit Increase in the Bice-Boxerman COC Index

Medicare beneficiaries with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus (DM) for 12-month episodes of care in 2008 and 2009. Incidence reflects the odds ratio using logistic regression models. Cost models show the change in the continuity of care (COC) index change from 0.4 and 0.5. Error bars represent 95% CIs. ED indicates emergency department.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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