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Continuity of Service Provision for Repeat Customers: Empirical Investigations of Continuity of Care in Primary Care Practices


Type

Thesis

Change log

Authors

Kajaria Montag, Harshita 

Abstract

Many service processes are sequences of independent transactions between customers and servers. In such contexts it is well known that pooling server time and offering an arriving customer the next available server, independently of whether they had seen the customer before, is most efficient. However, when customer episodes depend on one-another, then this is not necessarily the case. Ensuring customers have a dedicated server may offer efficiency advantages. This thesis is an empirical investigation of the productivity advantages of dedicated servers in the context of primary care. In this context, server dedication equates with the notion of continuity of care, which is the extent to which a patient has her consultations with the same doctor. The thesis is composed of two in-depth empirical studies. The first study provides evidence of the productivity implications of relational continuity of care (RC), while the second study addresses the question how practice managers can increase continuity of care. Both studies use a detailed clinical dataset from the Clinical Practice Research Datalink that collects patient-consultation level electronic health records and is representative of the UK population. From its overall database of over 11 million patients spanning 674 practices, our data consists of the entire medical record of 5 million patients who have had contact with primary care between 2007 and 2018 across different providers of care (secondary care etc.). In the first study, I show that continuity of care has a significant productivity benefit. Specifically, due to the trust-based relationship, accumulated knowledge over time and stronger accountability for the patient, the average time to next visit for a patient is longer when patients see their regular provider than after they see another doctor. The data shows that the productivity benefit of care continuity is larger for older patients, patients with multiple chronic conditions, and patients with mental health conditions. I discuss operational and strategic implications of these findings for primary care practices in capitation environments and for third-party payers of their services. This first study suggests that prioritizing continuity of care is an effective strategy to reduce demand for consultations. The second study, entitled “The Operational Determinants of Relational Continuity of Care" builds on the first part and identifies the levers and strategies that primary care practice managers can implement to promote continuity within the constraint of a diminishing workforce. We find that a sustained increase in workload - caused by demand growth - and increasing fragmentation of the workforce - due to a shift to part-time and agency work - induces significant heterogeneity between practices in their ability to provide care continuity. Specifically, these two factors alone explain more than 50% of the decline in care continuity over the ten-year window of the study, with workforce fragmentation having the greater impact. We discuss the implications for workforce management in primary care practices that wish to promote continuity of care.

Description

Date

2021-09-01

Advisors

Scholtes, Stefan

Keywords

healthcare, operations, service management, continuity

Qualification

Doctor of Philosophy (PhD)

Awarding Institution

University of Cambridge