Continuity in a Changing Health Care Environment
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Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
J Gen Intern Med 28(4):493–4 DOI: 10.1007/s11606-012-2294-z © Society of General Internal Medicine 2012
It’s Saturday morning, and an otherwise healthy 35year-old patient with a sore throat, cough and fever is concerned that she may have strep. She knows she will be unable to see her primary care provider (PCP) until at least Monday. With a busy week at work ahead, she decides instead to go to her local retail clinic, where she is seen by a nurse practitioner and preliminary results are negative for strep. Feeling relieved by the results, she does not bother calling her PCP. In this issue of JGIM, Reid and colleagues address the impact of visiting a retail clinic on continuity with primary care.1 Their study finds that patients who visit retail clinics once are more likely to return to retail clinics for subsequent care. Though patients experience decreased continuity with their PCP, they do not experience measurable changes in rates of preventive care or chronic disease management. The findings remind us that for many of the patients served by retail clinics and the conditions they treat, continuity may not be clinically necessary. As more patients receive care through medical homes and as retail clinics expand their scope of practice, continuity will likely take on renewed importance. To assess the impact of retail clinics on continuity, it is necessary to disentangle the different dimensions of continuity—longitudinal, interpersonal, and informational —that may be disrupted when patients visit retail clinics.2 Longitudinal continuity reflects the underlying principle of having a medical home where patients can receive the majority of their care over time. Interpersonal continuity encompasses the traditional model of a stable and personal physician–patient relationship. Informational continuity refers to whether all reports and communications regarding a patient are available to a physician at the point of care. Longitudinal and interpersonal continuity may be compromised when a visit to a retail clinic replaces a visit to a primary care provider.3 The resultant discontinuity is compounded by the tendency of those who seek acute care at a retail clinic once to do so moving forward. And for those without a PCP, visiting a retail clinic may decrease the Published online January 4, 2013
impetus to establish care with a primary care provider, though it is currently unknown how often this happens in practice. Retail clinic visits, however, do not invariably replace visits to primary care.4 Some patients would have chosen to receive acute care in an urgent care center or emergency room instead of visiting a retail clinic. Others may have forgone care or chosen to ‘wait it out’. The potential for induced demand in retail clinics—due in large part to their increased convenience—may be an important contributor to apparent changes in continuity. To the extent that retail clinics increase
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