Continuity in a fragmented healthcare system: - organizational and individual determinants

Continuity of care is key for high-quality primary care, associated with improved health outcomes, reduced mortality and more efficient use of resources. Achieving relational continuity is challenging in systems with high provider choice and fragmented care-seeking. Sweden exemplifies this tension, combining broad access to primary care and low GP continuity.

To examine how individual characteristics (age, morbidity, socioeconomic status and migration background) and primary care center (PCC) features (ownership, size, physician turnover, patient mix and location) are associated with relational continuity and to contrast within-PCC continuity with total continuity systemwide.

Retrospective cohort study using linked administrative register data covering all in-person physician contacts in primary care for 1.4 million residents in Region Skåne, Sweden.

Continuity of Care Index (CoCI) was measured using all primary care physician visits over 36-months. Linear regression models estimated associations between individual and PCC characteristics and continuity, adjusting for individual- and PCC-level covariates.

The characteristics most strongly associated with higher continuity were low physician turnover, older age, chronic conditions, smaller PCC size and private ownership. Individuals with higher education, higher income and foreign background had lower total continuity. Differences in continuity were more strongly associated with PCC characteristics than with patient characteristics.

Relational continuity in Swedish primary care is associated primarily with organizational factors, particularly physician turnover and practice size. Fragmented care-seeking among specific groups, especially individuals born outside the Nordic countries, contributes to lower total continuity but does not reflect weaker patient-provider relationships within PCCs.