Continuity and the costs of care for chronic disease

JAMA Intern Med. 2014 May;174(5):742-8. doi: 10.1001/jamainternmed.2014.245.


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.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Chronic Disease / economics*
  • Chronic Disease / therapy
  • Continuity of Patient Care / economics*
  • Diabetes Complications / economics
  • Diabetes Mellitus / economics
  • Emergency Service, Hospital / economics
  • Emergency Service, Hospital / statistics & numerical data*
  • Female
  • Heart Failure / complications
  • Heart Failure / economics
  • Hospitalization / economics*
  • Hospitalization / statistics & numerical data
  • Humans
  • Linear Models
  • Logistic Models
  • Male
  • Medicare / economics*
  • Pulmonary Disease, Chronic Obstructive / complications
  • Pulmonary Disease, Chronic Obstructive / economics
  • United States