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Abstract

This dissertation aimed to provide insight into continuity of care between care providers at the interface between primary and other care providers. More specifically, it explored the impact of continuity of care as a characteristic of strong primary care and its impact on hospital readmissions. For this purpose, three overarching themes were considered in more detail: The current state of communication and information flow between primary care and hospitals, the current state of provider connectedness between primary care physicians and other ambulatory physicians and the development, implementation and evaluation of a care programme (the VESPEERA programme) to improve communication and cooperation between general practices and hospitals. Four studies were conducted to explore the underlying research questions. This includes a qualitative interview study with staff from hospitals and general practices, a claims-based social network study in patients with chronic obstructive pulmonary disease, a quasi-experimental trial evaluating the effectiveness of the VESPEERA programme as well as a quantitative questionnaire survey. Overall, 49 persons from different groups participated in the qualitative interview study. The result of the qualitative analysis was 16 subthemes across five main themes, which were current cooperation, optimal cooperation, determinants of cooperation and personal emotional and social determinants. The participants described that communication is mostly written and synchronous communication via telephone is rather rare and takes place predominantly to obtain missing information. For the future, the participants wished for better communication and especially cooperation. This includes standardised and electronic information transfer between care providers. Personal emotional and social determinants, such as reciprocal appreciation and understanding of roles and responsibilities were described to impact information flow and communication. Furthermore, especially personal professional relationships, i.e. knowing each other, were mentioned to positively influence information flow. For the social network analysis, a network between 7,876 general practitioners, pneumologists and cardiologists with 121,750 connections was considered. In the final analysis, 7,294 patients who were nested in 3,673 general practitioners were included. Regarding the impact of network characteristics on continuity of care, closeness centrality and the EI-index showed a significant effect on the SECON in the year after discharge. Beyond that, degree centrality and the EI-index impacted readmission rates within 30 days after discharge from hospital. Additionally, density affected readmission rates within 90 days after discharge. No significant effect of network characteristics on readmission rates between 91 days and one year after discharge was found. In the VESPEERA trial, 371 patients fulfilled the eligibility criteria. Including the control group, which was matched from claims data, 742 patients were considered in the analysis. Regarding the primary Summary | 120 outcome, readmissions within 90 days after hospital discharge due to the same indication, the rate after the intervention period was almost the same in both groups. In the control group, the readmission rate increased, in the intervention group, a decrease was observed. Altogether, a difference of 6 % regarding readmission rates between the intervention and control groups was thus observed. The primary analysis did not show a significant effect, although the intervention patients showed a slightly better outcome. Therefore, no significance tests were performed for any secondary outcomes. The questionnaire survey, in which a total of 68 care providers participated, showed that the participants were rather indecisive when asked to rate the benefit over the expenses to use the intervention components with a tendency to a positive balance. The responses of the participants showed several factors affected the implementation of the VESPEERA programme. This includes insufficient resources such as financial compensation and the availability of staff and workplaces. Furthermore, legal regulations relevant at the time hindered implementation and participants saw the implementation as unwieldy, too comprehensive and too complex. However, as a result of working with the VESPEERA programme, almost half of the participants agreed that their awareness of the importance of cross-sectoral cooperation increased. Even in times of increasing use of modern information technology, social and emotional factors such as personally knowing each other were perceived to be crucially important for information flow and effective collaboration, allowing to improve informational and management continuity of care. A quantitative confirmation of this statement could not be achieved in the social network analysis as the effects of provider connectedness were small, did not improve the overall predictive power of explanatory and were not congruent across outcomes. Furthermore, due to several contextual factors, no statistically significant effect of the VESPEERA programme on patients’ hospital readmission rates was found. However, the results of the primary analysis as well as the analyses of secondary outcomes and the subgroups showed trends that patients might have benefitted from the intervention. For most outcomes, the odds ratios are in favour of the intervention group. The results of this dissertation raise the question of whether continuity of care is and will still be relevant in highly specialised and fragmented healthcare systems that take care of patients with complex health needs. Furthermore, it is unclear whether current measures of continuity of care do justice to the complexity of the matter. The overall results of this dissertation do, however, emphasise the relevance of having a single point of coordination. This is typically the general practitioner, in the future ideally in the form of a primary care team, who thus fulfils the pillars of primary care which include continuity and coordination of care.