Patient Complexity, Prescriber Continuity and Acute Care

To the Editors—Maciejewski et al.’s article on prescriber continuity is an important stepping stone in understanding the full impact of care continuity issues.¹ They showed that more prescribers lead to increased health care utilization, concluding that “the number of prescribers may be an appropriate target for reducing utilization.” This conclusion, however, may be too simplistic a view.

They report that patient-level factors including disease complexity and provider-level factors like extent of care coordination between providers were not analyzed. These elements are potentially more important factors. If the complexity of a patient’s care increases the need for multiple providers and patient care visits, then reducing utilization may lead to an overall decrease in quality of care. Similarly, provider-level factors, such as extent of care coordination, may be more important in the utilization of healthcare resources than simply the total number of providers. If the number of providers is merely a confounder or correlate, the simplistic conclusion to reduce the number of providers could lead to worsening quality of care.

The Lean Six Sigma provides a more complete model for understanding the impact of multiple providers. Initially developed to improve the efficiency of manufacturing cars, it has been applied most recently to healthcare. Applied to clinical care, any increase in the number of providers or any increase in utilization of health care resources would improve patient care quality as long as these additional resources added necessary value to patient care. Only when these added providers or added patient visits were redundant or wasteful would they reduce quality of care. If there is a need for an increasing number of patient visits due to any patient-level or provider-level factors, any increase in health care utilization would actually improve patient care and possibly even long-term costs, not reduce it as Maciejewski implies.

This model shifts our priorities from counting total number of providers and total number of patient visits to a more goal-directed question of utility: how does each provider or encounter enhance the care of a patient. Thought of another way, not all providers and not all patient visits are equal. Some provider involvement and acute care visits are valuable and necessary, while others are wasteful and redundant. In this model, it is about matching the right number of providers and the right number of visits to produce the best care possible.