Optimising personal continuity for older patients in general practice: a stepped wedge cluster randomised controlled trial

BACKGROUND Continuity of care denotes the connected and coherent care that is consistent with the health needs and personal circumstances of a patient. It is a widely accepted core principle of general practice. Continuity of care is a multidimensional concept, including personal continuity, team continuity, and cross-boundary continuity. This research project aims to optimise personal continuity for older patients in general practice. The benefits of personal continuity have been studied extensively and include a better patient-provider relationship, increased patient and doctor satisfaction, improved uptake of preventive care, higher medication adherence, less overuse of medical procedures, higher quality of patients’ life, fewer hospital admissions, and less healthcare costs. Several studies also found personal continuity to be associated with lower mortality. But society and healthcare have changed. Patients and doctors are increasingly mobile and solo practice is becoming rare. The number of patients with chronic diseases rises, and patients increasingly receive care from multiple professionals employed by different organisations. Most general practitioners work part-time and reorganize themselves into large group practices. Other healthcare workers such as the practice nurse have entered general practice. All these changes potentially fragment care and reduce personal continuity. Especially older patients suffer the consequences of fragmentation and discontinuity of care, as they are likely to have multiple chronic conditions and benefit the most from personal continuity. Therefore, strategies to improve continuity of care in older patients are highly warranted, especially because global demographic trends suggest that the number of older persons will double in the next 35 years. If proven effective, such strategies will lead to higher patient-doctor satisfaction, higher quality of patients’ life, less overuse of medical procedures, reduced hospitalisation, less healthcare costs, and – on the longer term – lower mortality. MAIN OBJECTIVE The overall aim of this project is to develop and evaluate a multi-component intervention (‘toolkit’) designed to optimise personal continuity for older patients in Dutch general practice. KEY OBJECTIVES I. To identify and assess the scientific evidence for a multi-component intervention to optimise personal continuity for older patients in general practice. II. To define and prioritise the separate components of the intervention. III. To test the feasibility and acceptability of the intervention and adapt the intervention if necessary. IV. To measure the effectiveness of the intervention on personal continuity for older patients in general practice. V. To investigate the level of implementation of the intervention, the barriers and facilitators to implementation, and the possible existence of adverse effects. METHODS For this research project, we adopted the UK Medical Research Council Complex Interventions framework. This framework provides an iterative phased approach to the development and evaluation of complex interventions, suggesting five phases: During phase 0 (preclinical phase), we will perform a literature study to create the theoretical basis for development and implementation of the intervention. During phase 1 (defining components of the intervention), we will perform surveys and focus groups to investigate patients’ and care providers’ views on personal continuity, and to define the components of the intervention. The intervention will consist of a toolkit to optimise personal continuity for older patients in general practice. During phase 2 (defining trial and intervention design), we will perform a pilot study and test the acceptability and feasibility of the constructed toolkit. The results will be used to construct the final version of the toolkit. During phase 3 (main trial), we will investigate the effectiveness of the constructed toolkit in a stepped wedge cluster randomised trial. During phase 4 (implementation), we will use database registrations, practice observations, surveys, and semi-structured interviews to investigate the level of implementation. COLLABORATION For the design and execution of this project, a unique collaboration has been initiated between researchers from the VU University Medical Center, the Radboud University Medical Centre, the Maastricht University, the University of Bristol, and the Netherlands Institute for Health Services Research. DELIVERABLES 1. A Continuity of Care Toolkit for Dutch general practice; 2. A PhD thesis, including at least five international peer-reviewed publications on personal continuity (survey, focus group study, design study, intervention study, and process evaluation study); 3. Patient information sheet on personal continuity, available on www.thuisarts.nl; 4. Position paper ‘Personal continuity’, which could be added to the ‘Toekomstvisie Huisartsenzorg 2022’ (‘Future Vision General Practice Care 2022’).