Introduction
The prevalence of NCDs is predicted to increase rapidly over the next decade [[
1]]. Like other low and middle-income countries (LMICs), Vietnam is facing the challenge of poor control of NCDs, especially hypertension and type 2 diabetes mellitus (T2DM) [
2]. More than 70% of people diagnosed with hypertension/diabetes had not achieved control of their diseases [
3,
4]. These issues pose a tremendous burden on already weakened health systems in LMICs, including Vietnam [
5].
Vietnamese healthcare delivery is decentralized into four levels: commune, district, provincial, and central. Despite efforts to better respond to the healthcare needs of hypertension and T2DM through several national strategies [
6], the delivery of NCD services is still hospital-and-specialist-centric, particularly for T2DM. A previous study showed that only 53% of commune health centers (CHCs) offered diabetes services, with only 3% having at least one type of diabetes medication (metformin, glibenclamide, or insulin), while 64% of CHCs offered treatment services for cardiovascular diseases [
7]. Bypassing primary care and overload of the upper-level health facilities, lack of investment of medication and equipment for NCDs at primary care, lack of intersectoral coordination and direction for NCDs management as well as evidence-based research have led to an inefficient and fragmented health system for NCDs services [
7,
8]. Moreover, since 2016, national law on health insurance schemes allowed insured individuals to seek care at any CHC or district-level health facility (DHC) within the same province, instead of being restricted to their registered facility [
9]. This law has improved the accessibility to quality healthcare services but has also led to a lack of follow-up and continuous care from a specific physician for people with NCDs.
Continuity of care (COC) is widely acknowledged as a benchmark for high-quality care services and an efficient healthcare system [
10]. Remarkably, the COVID-19 crisis revealed a weak COC system and disrupted care for people with NCDs who need long-term care [
11]. Initially introduced in the 1950s, the concept of COC referred to care provided by the same health professional (interpersonal continuity) [
12]. The World Health Organization (WHO) defined COC as the degree to which a series of discrete healthcare events is experienced by people as coherent and interconnected over time and consistent with their health needs and preferences [
13]. A multidisciplinary review summarized three major common themes within the different concepts of COC: (1) Interpersonal continuity - personal relationship between patient and care provider, (2) Informational continuity - communication of relevant patient information between providers, and (3) Management continuity - cooperation between providers [
10,
12,
14]. With the multi-dimensional construct of the COC concept, there is a broad spectrum for measuring COC in different aspects due to the differences in the healthcare system, medical conditions, and resource availability [
15]. Several reliable and valid instruments to measure COC were developed and available. However, using multiple tools is recommended to limit the disadvantages of a lack of perfect measurement tools and to ensure a comprehensive assessment of different aspects of the care continuum [
16,
17].
The advantages of COC have been documented in many countries [
16‐
25]. Previous studies demonstrated that a high level of continuity of care contributed to reducing mortality [
18], hospital and emergency admission, and healthcare costs [
19‐
21], improving treatment adherence and disease control [
22‐
24] as well as leveraging patient satisfaction and quality of life [
25]. Chronic care requires coordinated care among the multidisciplinary team and multi-care levels to ensure patients do not feel frustrated when they visit different healthcare providers in the referral process and do not receive
inconsistent advice and information from various providers [
26]. Studies on COC in primary care settings for NCDs in Vietnam have been limited to date. Given the healthcare system’s focus on hospitals and secondary care for NCDs, a robust and comprehensive approach to evaluating COC is strongly needed. This study aimed to determine the extent of COC for hypertension and T2DM within and across care levels and to investigate its associations with patients’ health outcomes and disease control.
Results
A total of 602 respondents were involved, resulting in an 88.3% response rate. Table
1 provides an overview of study population, indicating that 56.3% of participants were female. The average age of participants was 64.9 (SD = 12.1) years old. The majority of respondents were living in remote areas (71.1%), had personal health insurance (99.7%), and registered their first point of care at CHCs (93.2%). 42.2% of participants had a high rate of health-related quality of life. The average number of co-morbidities among participants was 1.4 (SD 0.8); the sample comprised a high proportion of mild CCI (88.7%). Nearly 70% of participants lived with NCDs for 5 years or less and were poorly controlled with their NCD conditions.
Table 1
Demographic and clinical characteristics of respondents (n = 602)
Gender: Female | 339 | 56.3 |
Age | | |
< 45 | 32 | 5.3 |
45–64 | 258 | 42.9 |
65–74 | 173 | 28.7 |
≥ 75 | 139 | 23.1 |
Area | | |
Urban | 174 | 28.9 |
Remotea | 428 | 71.1 |
Highest qualification | | |
Primary school and under | 252 | 41.9 |
Junior high school and higher | 350 | 58.1 |
Household income | | |
Poor | 77 | 12.8 |
Wealthy | 525 | 87.2 |
Health insurance ownership | | |
None | 2 | 0.3 |
Compulsory health insurance | 124 | 20.6 |
Government budget subsidy | 327 | 54.3 |
Voluntary health insurance | 149 | 24.8 |
First point of care | | |
Commune health centers | 561 | 93.2 |
District health centers | 41 | 6.8 |
Health-related quality of life | | |
Low | 348 | 57.8 |
High | 254 | 42.2 |
Diagnosis of NCDs | | |
Hypertension only | 352 | 58.5 |
Diabetes mellitus only | 115 | 19.1 |
Both hypertension and diabetes | 135 | 22.4 |
Charlson co-morbidity index | | |
Mild | 534 | 88.7 |
Moderate | 56 | 9.3 |
Severe | 12 | 2.0 |
Duration of disease | | |
≤ 5 | 386 | 67.0 |
6–10 | 120 | 20.8 |
> 10 | 70 | 12.2 |
Disease control | | |
Well control | 186 | 30.9 |
Poor control | 415 | 69.1 |
Tables
2 and
3 show the description of COC measured by COCI and NCQ scores among the study population. COCI had an overall mean value of 0.77 (SD = 0.25), with 52.7% achieving a high COCI score (> 0.75), while the mean NCQ score was 3.59 (SD = 0.7) with 31.2% achieving a high NCQ score (> 4.0). There was no statistically significant difference in COCI by gender, while males reported higher NCQ scores than females (
p < 0.05). People under 45 years old had the lowest COCI and NCQ scores. COCI score was lower (
p < 0.001), and the NCQ was higher (
p < 0.01) in remote areas compared to urban areas. There was a slight decrease in NCQ scores from low to high health-related quality of life (
p < 0.05). While both COCI and NCQ scores showed slight increases with adherence to healthy behaviors, only smoking behavior had a significant association with COCI (p < 0.05). People under the voluntary health insurance scheme had the highest COCI (
p < 0.001) and the lowest NCQ score (p < 0.001) among the study population.
Table 2
Distribution of COCI and NCQ scores by respondents’ characteristics
Sample size | | 285 (47.3) | 317 (52.7) | – | | 414 (68.8) | 188 (31.2) | – |
Average score (Mean (SD)) | 0.77 (0.25) | 0.55 (0.18) | 0.97 (0.07) | – | 3.59 (0.7) | 3.27 (0.6) | 4.29 (0.26) | – |
Gender | | | | | | | | |
Male | 0.79 (0.23) | 120 (45.6) | 143 (54.4) | 0.255 | 3.64 (0.68) | 171 (65.0) | 92 (35.0) | 0.049 |
Female | 0.75 (0.26) | 165 (48.7) | 174 (51.3) | 3.55 (0.72) | 243 (71.7) | 96 (28.3) |
Age | | | | | | | | |
< 45 | 0.66 (0.34) | 18 (56.3) | 14 (43.8) | 0.349 | 3.43 (0.78) | 23 (71.9) | 9 (28.1) | 0.213 |
45–64 | 0.76 (0.24) | 129 (50.0) | 129 (50.0) | 3.61 (0.73) | 169 (65.5) | 89 (34.5) |
65–74 | 0.79 (0.24) | 74 (42.8) | 99 (57.2) | 3.55 (0.74) | 117 (67.6) | 56 (32.4) |
≥ 75 | 0.78 (0.24) | 64 (46.0) | 75 (54.0) | 3.63 (0.57) | 105 (75.5) | 34 (24.5) |
Area | | | | | | | | |
Urban | 0.82 (0.22) | 62 (35.6) | 112 (64.4) | < 0.001 | 3.47 (0.68) | 135 (77.6) | 39 (22.4) | 0.002 |
Remote | 0.74 (0.26) | 223 (52.1) | 205 (47.9) | 3.64 (0.71) | 279 (65.2) | 149 (34.8) |
Highest education | | | | | | | | |
Primary education and under | 0.76 (0.25) | 122 (48.4) | 130 (51.6) | 0.358 | 3.53 (0.75) | 179 (71.0) | 73 (29.0) | 0.177 |
Junior school and above | 0.77 (0.25) | 163 (46.6) | 187 (53.4) | 3.63 (0.66) | 235 (67.1) | 115 (32.9) |
Household income | | | | | | | | |
Poor | 3.47 (0.74) | 32 (41.6) | 45 (58.4) | 0.167 | 0.79 (0.24) | 54 (70.1) | 23 (29.9) | 0.448 |
Wealthy | 3.61 (0.69) | 253 (48.2) | 272 (51.8) | 0.76 (0.25) | 360 (68.6) | 165 (31.4) |
Health insurance ownership | | | | | | | | |
None | 0.68 (0.18) | 1 (50.0) | 1 (50.0) | < 0.001 | 4.52 (0.03) | 0 (0.0) | 2 (100.0) | < 0.001 |
Compulsory | 0.71 (0.18) | 92 (74.2) | 32 (25.8) | 3.94 (0.57) | 61 (49.2) | 63 (50.8) |
Government budget subsidy | 0.78 (0.25) | 140 (42.8) | 187 (57.2) | 3.55 (0.72) | 228 (69.7) | 99 (30.3) |
Voluntary | 0.79 (0.28) | 52 (34.9) | 97 (65.1) | 3.38 (0.64) | 125 (83.9) | 24 (16.1) |
QoL | | | | | | | | |
Low (< 0.91) | 0.76 (0.25) | 169 (48.6) | 179 (51.4) | 0.268 | 3.65 (0.71) | 226 (64.9) | 122 (35.1) | 0.011 |
High (≥ 0.91) | 0.78 (0.24) | 116 (45.7) | 138 (54.3) | 3.51 (0.69) | 188 (74.0) | 66 (26.0) |
Alcohol assumption | | | | | | | | |
Yes | 0.79 (0.25) | 54 (45.4) | 65 (54.6) | 0.354 | 3.63 (0.7) | 75 (63.0) | 44 (37.0) | 0.082 |
No | 0.76 (0.25) | 231 (47.8) | 252 (52.2) | 3.58 (0.7) | 339 (70.2) | 144 (29.8) |
Active smoking | | | | | | | | |
Yes | 0.78 (0.25) | 86 (42.2) | 118 (57.8) | 0.041 | 3.6 (0.71) | 136 (66.7) | 68 (33.3) | 0.24 |
No | 0.76 (0.25) | 199 (50.0) | 199 (50.0) | 3.6 (0.7) | 278 (69.8) | 120 (30.2) |
Physical activities | | | | | | | | |
Yes | 0.77 (0.25) | 214 (46.6) | 245 (53.4) | 0.295 | 3.58 (0.71) | 311 (67.8) | 148 (32.2) | 0.196 |
No | 0.76 (0.24) | 71 (49.7) | 72 (50.3) | 3.61 (0.67) | 103 (72.0) | 40 (28.0) |
Table 3
Continuity of care by clinical characteristics among study population
BMI | | | | | | | | |
Underweight | 0.77 (0.27) | 26 (45.6) | 31 (54.4) | 0.96 | 3.36 (0.76) | 46 (80.7) | 11 (19.3) | 0.074 |
Normal weight | 0.77 (0.24) | 200 (47.6) | 220 (52.4) | 3.64 (0.67) | 279 (66.4) | 141 (33.6) |
Overweight/ Obesity | 0.76 (0.27 | 59 (47.2) | 66 (52.8) | 3.59 (0.7) | 89 (71.2) | 36 (28.8) |
Waist circumference | | | | | | | | |
Normal | 0.82 (0.24) | 251 (51.0) | 241 (49.0) | < 0.001 | 3.43 (0.7) | 332 (67.5) | 160 (32.5) | 0.09 |
At risk | 0.76 (0.25) | 34 (30.9) | 76 (69.1) | 3.62 (0.7) | 82 (74.5) | 28 (25.5) |
Blood pressure | | | | | | | | |
Normal | 0.75 (0.27) | 104 (48.6) | 110 (51.4) | 0.135 | 3.58 (0.73) | 141 (65.9) | 73 (34.1) | 0.508 |
Elevated blood pressure | 0.8 (0.25) | 27 (36.5) | 47 (63.5) | 3.55 (0.63) | 53 (71.6) | 21 (28.4) |
High blood pressure | 0.77 (0.24) | 154 (49.0) | 160 (51.0) | 3.61 (0.7) | 220 (70.1) | 94 (29.9) |
Blood glucose | | | | | | | | |
Normal | 0.78 (0.28) | 56 (36.1) | 99 (63.9) | 0.002 | 3.5 (0.68) | 114 (73.5) | 41 (26.5) | 0.233 |
Impaired glucose tolerance | 0.75 (0.23) | 106 (55.2) | 86 (44.8) | 3.67 (0.7) | 125 (65.1) | 67 (34.9) |
High blood glucose | 0.77 (0.25) | 121 (48.8) | 127 (51.2) | 3.59 (0.71) | 168 (67.7) | 80 (32.3) |
Diagnosis of NCDs | | | | | | | | |
Hypertension only | 0.78 (0.26) | 156 (44.3) | 196 (55.7) | 0.032 | 3.6 (0.67) | 244 (69.3) | 108 (30.7) | 0.039 |
Diabetes only | 0.73 (0.24) | 67 (58.3) | 48 (41.7) | 3.67 (0.78) | 69 (60.0) | 46 (40.0) |
Both hypertension and diabetes | 0.77 (0.22) | 62 (45.9) | 73 (54.1) | 3.51 (0.69) | 101 (74.8) | 34 (25.2) |
Duration of disease | | | | | | | | |
≤ 5 | 0.76 (0.25) | 189 (49.0) | 197 (51.0) | 0.028 | 3.6 (0.71) | 257 (66.6) | 129 (33.4) | 0.316 |
6–10 | 0.78 (0.2) | 62 (51.7) | 58 (48.3) | 3.57 (0.68) | 86 (71.7) | 34 (28.3) |
> 10 | 0.81 (0.25) | 23 (32.9) | 47 (67.1) | 3.49 (0.74) | 52 (74.3) | 18 (25.7) |
Number of pills per day | | | | | | | | |
None | 0.62 (0.41) | 25 (51.0) | 24 (49.0) | 0.467 | 3.44 (0.73) | 40 (81.6) | 9 (18.4) | 0.036 |
1–2 | 0.78 (0.22) | 213 (48.3) | 228 (51.7) | 3.64 (0.69) | 290 (65.8) | 151 (34.2) |
≥ 3 | 0.78 (0.23) | 43 (42.2) | 59 (57.8) | 3.5 (0.73) | 75 (73.5) | 27 (26.5) |
Charlson co-morbidity index | | | | | | | | |
Mild | 0.77 (0.25) | 253 (47.4) | 281 (52.6) | 0.576 | 3.61 (0.69) | 361 (67.6) | 173 (32.4) | 0.118 |
Moderate | 0.75 (0.25) | 28 (50.0) | 28 (50.0) | 3.51 (0.68) | 42 (75.0) | 14 (25.0) |
Severe | 0.82 (0.25) | 4 (33.3) | 8 (66.7) | 3.13 (1.16) | 11 (91.7) | 1 (8.3) |
Disease control | | | | | | | | |
Well control | 0.81 (0.27) | 59 (31.7) | 127 (68.3) | < 0.001 | 3.48 (0.66) | 138 (74.2) | 48 (25.8) | 0.032 |
Poor control | 0.75 (0.24) | 225 (54.2) | 190 (45.8) | 3.64 (0.71) | 275 (66.3) | 140 (33.7) |
Usual health facility | | | | | | | | |
Commune health centers | 0.77 (0.25) | 223 (48.3) | 239 (51.7) | 0.71 | 3.68 (0.67) | 298 (64.5) | 164 (35.5) | < 0.001 |
District health centers | 0.76 (0.26) | 50 (44.2) | 63 (55.8) | 3.3 (0.71) | 96 (85.0) | 17 (15.0) |
Secondary/Tertiary care | 0.76 (0.24) | 12 (44.4) | 15 (55.6) | 3.23 (0.79) | 20 (74.1) | 7 (25.9) |
Number of emergency visits | | | | | | | | |
None | 0.77 (0.25) | 261 (47.1) | 293 (52.9) | 0.634 | 3.59 (0.7) | 383 (69.1) | 171 (30.9) | 0.803 |
1–2 times | 0.77 (0.23) | 20 (47.6) | 22 (52.4) | 3.6 (0.77) | 27 (64.3) | 15 (35.7) |
≥ 3 times | 0.65 (0.24) | 4 (66.7) | 2 (33.3) | 3.49 (0.7) | 4 (66.7) | 2 (33.3) |
Number of hospital admission | | | | | | | | |
None | 0.77 (0.25) | 236 (46.5) | 271 (53.5) | 0.356 | 3.6 (0.71) | 345 (68.0) | 162 (32.0) | 0.469 |
1–2 times | 0.74 (0.24) | 41 (49.4) | 42 (50.6) | 3.57 (0.69) | 59 (71.1) | 24 (28.9) |
≥ 3 times | 0.66 (0.25) | 8 (66.7) | 4 (33.3) | 3.45 (0.5) | 10 (83.3) | 2 (16.7) |
Table
3 showed no statistically significant difference in COCI and NCQ scores among people with different blood pressure levels, while a slight decrease in COCI was observed from normal to high blood glucose levels (
p < 0.01). In the last 12 months, the average number of medical encounters was 14.8 (SD = 10.4), and people had low rates of emergency department encounters or hospital admissions. Among participants, people with only diabetes had the lowest COCI but the highest score of NCQ (
p < 0.05). Both COCI and NCQ increased gradually by increasing the number of daily pills. In contrast to NCQ, the better control of disease people achieved, the higher score of COCI they had (
p < 0.001).
The paired sample t-test was used to compare the NCQ score perceived by participants between general practitioners and specialists. Findings showed that general practitioners offered higher informational COC than specialists (p < 0.01), and the level of team/cross-boundary continuity was higher within the primary care team compared to between primary and specialist care (p < 0.001). We also compared the COC perceived by those with diabetes, hypertension, and both diseases within each subscale of the NCQ (Table
4). People with only T2DM had statistically significantly higher scores in Personal continuity - Specialist knows me, Personal continuity - Specialist shows commitment and Team/Cross-boundary within the specialist care subscales compared to those with hypertension and both diseases.
Table 4
Distribution of COC across care levels measured for people with hypertension, diabetes, and both diseases
Personal continuity/ Informational continuity |
GP knows me | 602 | 3.45 (0.75) | 115 | 3.38 (0.76) | 352 | 3.48 (0.76) | 135 | 3.44 (0.74) |
GP shows commitment | 602 | 3.1 (0.8) | 115 | 3.16 (0.8) | 352 | 3.11 (0.79) | 135 | 3.04 (0.8) |
Specialist knows me | 295 | 3.15 (0.79) | 63 | 3.42 (0.54) | 169 | 3.07 (0.83)** | 63 | 3.09 (0.81)* |
Specialist shows commitment | 295 | 3.02 (0.86) | 63 | 3.37 (0.7) | 169 | 2.92 (0.89)*** | 63 | 2.96 (0.82)** |
Team/Cross-boundary continuity |
Within primary care | 602 | 3.5 (0.73) | 115 | 3.48 (0.68) | 352 | 3.52 (0.74) | 135 | 3.47 (0.74) |
Within specialist care | 295 | 3.46 (0.84) | 63 | 3.72 (0.7) | 169 | 3.39 (0.89)** | 63 | 3.38 (0.78)* |
Within primary and specialist care | 295 | 3.08 (0.89) | 63 | 3.25 (0.81) | 169 | 3.07 (0.92) | 63 | 2.97 (0.89) |
Table
5 summarizes the results of the multivariable logistic regression model for the proportion of people who achieved a high level of COCI and NCQ. Participants in the urban area (OR: 1.75, CI: 1.17–2.63), having high blood pressure (OR: 3.83, CI: 2.2–6.8) and living with chronic diseases for more than 10 years had increased odds of having a higher COCI level. Moreover, COCI was consistently related to reduced odds of hospital admission, poor disease control, and impaired glucose tolerance. In terms of NCQ, people who reported higher scores on NCQ had no prior visit to the emergency department (OR: 3.75, CI: 1.25–10.22), more than 10 times of health encounters during the last 12 months (OR: 4.4, CI: 2.08–9.3), and poor control of disease (OR: 2.59, CI: 1.31–5.12).
Table 5
Factors related to the high level of continuity of care
Gender | | | | | | |
Male | | 1 | 0.663 | | 1 | 0.032 |
Female | −0.08 | 0.92 (0.64–1.33) | −0.43 | 0.65 (0.44–0.96) |
Area | | | | | | |
Remote | | 1 | 0.007 | | 1 | 0.005 |
Urban | 0.56 | 1.75 (1.17–2.63) | −0.65 | 0.52(0.33–0.83) |
Blood glucose level | | | | | | |
Normal | | 1 | | | 1 | |
Impaired glucose tolerance | −0.69 | 0.5 (0.31–0.82) | 0.006 | 0.4 | 1.49 (0.87–2.56) | 0.145 |
High blood glucose | 0.2 | 1.22 (0.72–2.08) | 0.462 | −0.11 | 0.9 (0.5–1.63) | 0.725 |
Blood pressure level | | | | | | |
Normal | | 1 | < 0.001 | | 1 | 0.001 |
High blood pressure | 1.34 | 3.83 (2.2–6.8) | −1.0 | 0.37 (0.2–0.67) |
Usual healthcare facility | | | | | | |
Commune health centers | | 1 | | | 1 | |
District health centers | 0.14 | 1.16 (0.72–1.85) | 0.549 | −1.11 | 0.35 (0.18–0.61) | < 0.001 |
Secondary/Tertiary care | 0.22 | 1.25 (0.52–3.0) | 0.623 | −0.45 | 0.64 (0.25–1.66) | 0.358 |
Number of hospitalization | | | | | | |
None | | 1 | | | 1 | |
1–2 times | −0.24 | 0.79 (0.4–1.54) | 0.786 | −0.74 | 0.48 (0.2–1.12) | 0.09 |
≥ 3 times | −1.66 | 0.2 (0.04–0.93) | 0.04 | −1.58 | 0.21 (0.03–1.25) | 0.086 |
Emergency encounter | | | | | | |
Yes | | 1 | 0.79 | | 1 | 0.018 |
No | −0.12 | 0.89 (0.36–2.18) | 1.27 | 3.57 (1.25–10.22) |
Number of total medical encounters |
≤ 5 | | 1 | | | 1 | |
6–10 | −0.39 | 0.67 (0.31–1.45) | 0.313 | 0.66 | 1.94 (0.71–5.3) | 0.194 |
> 10 | 0.11 | 1.12 (0.65–1.91) | 0.687 | 1.48 | 4.4 (2.08–9.3) | < 0.001 |
Duration of disease | | | | | | |
≤ 5 | | 1 | | | 1 | |
6–10 | −0.12 | 0.88 (0.56–1.39) | 0.594 | −0.25 | 0.78 (0.47–1.28) | 0.32 |
> 10 | 0.72 | 2.06 (1.15–3.67) | 0.015 | − 0.44 | 0.65 (0.35–1.21) | 0.172 |
Charlson co-morbidity index |
Mild | | 1 | 0.102 | | 1 | 0.074 |
Moderate, Severe | 1.08 | 2.95 (0.81–10.8) | −1.98 | 0.14 (0.02–1.21) |
Disease control | | | | | | |
Well control | | 1 | < 0.001 | | 1 | 0.006 |
Poor control | −1.98 | 0.14 (0.07–0.27) | 0.95 | 2.59 (1.31–5.12) |
Health-related quality of life |
Low | | 1 | 0.733 | | 1 | 0.054 |
High | −0.07 | 0.94 (0.64–1.37) | − 0.41 | 0.67 (0.44–1.01) |
Table
6 presents the pair-wise correlation of COC measurements. Overall, the COCI was weakly correlated with NCQ and the
Personal continuity - Primary care provider knows me subscale (p < 0.01). It also showed that the correlation coefficients between the NCQ subscales and the total NCQ score were high, ranging from 0.68–0.79 (
p < 0.01). Other positive correlations were found between different subscales of NCQ (p < 0.01), except for correlations between the
Personal continuity- Primary care provider knows me subscale and other subscales regarding specialist care.
Table 6
Pearson correlation coefficients between Continuity of care Index and domains of Nijmegen continuity of care
COCI | 1 | | | | | | | | |
NCQ | −0.12** | 1 | | | | | | | |
Subscale 1_GP | 0.09** | 0.68** | 1 | | | | | | |
Subscale 2_GP | −0.06 | 0.74** | 0.56** | 1 | | | | | |
Subscale 3_GP | 0.04 | 0.71** | 0.51** | 0.56** | 1 | | | | |
Subscale 1_SP | −0.05 | 0.77** | 0.06 | 0.35** | 0.22** | 1 | | | |
Subscale 2_SP | −0.05 | 0.72** | 0.02 | 0.34** | 0.19** | 0.74** | 1 | | |
Subscale 3_SP | −0.01 | 0.75** | 0.11 | 0.36** | 0.38** | 0.6** | 0.54** | 1 | |
Subscale 3_GP&SP | 0.001 | 0.79** | 0.23** | 0.36** | 0.34** | 0.57** | 0.60** | 0.54** | 1 |
Discussion
COC plays a crucial role in ensuring the quality, safety, and efficiency of chronic care. Our study indicated that the COC was not sufficiently achieved by most people with diabetes and hypertension, as documented in the existing literature. Using NCQ to measure COC across care levels, similar to our results, a study in the Netherlands found a mean COC value for their population of 3.38 (SD = 0.72) [
41]. The COCI results in our study were consistent with a previous study in Korea (2013) (COCI for four-year follow-up in T2DM: 0.75) [
42], lower than another study in Korea (2019) (COCI among diabetic people: 0.83) [
21], and higher than a study in Italy (2016) (COCI for multiple chronic conditions: 0.44) [
43], in China (2017–2019) (COCI for hypertension and T2DM: 0.58) [
20] and in Norway (2021) (COCI for T2DM: 0.67 and COCI for heart failure: 0.77) [
44]. Compared to studies using the same cutoff point of COCI, our study had a lower proportion of high COCI than others [
29,
37]. Differences in sample size and health conditions of the study population may explain the variations in COC results. Previous studies predominantly utilized claims data or national health insurance databases with a high proportion of people with co-morbidity requiring long-term and continuous care, unlike our study population with a low proportion of co-morbidity. Additionally, these studies were conducted in hospital settings, while our research focused on primary care. The insufficient COC observed in our study and previous studies raises concerns about fragmented care for people with chronic diseases. It emphasizes the need for increased efforts to promote continuity in chronic care and implement integrated care programs in primary care.
An interesting result of our study is that remote areas exhibited lower levels of COCI and higher NCQ scores compared to urban areas. The lower COCI is consistent with the lack of health workforces and poor accessibility to health care providers, acknowledged in available evidence [
45,
46]. Otherwise, considering patients’ perceived COC, people in remote areas could have closer relationships with their primary care providers, resulting in higher perceived informational and management continuity. In contrast, in urban areas, people may have more options for healthcare providers and facilities, potentially resulting in fragmented care. The discrepancies observed in COC results between the Bice - Boxerman continuity of care index and the Nijmegen continuity of care questionnaire might be due to the extent of the COC concept measured in our study. Apparently, COC should be seen within the context of healthcare service organization and delivery systems. Thus, simply analyzing sequential visits to the same provider is insufficient; it is crucial to additionally assess patients’ perspectives on the healthcare process they received. Our study employed both instruments to capture various aspects of COC; COCI provided better insight into healthcare utilization fragmentation among individuals with NCDs, while NCQ highlighted how well patients received COC across primary care and hospital care. While this issue needs further investigation, our study approach can be applicable to other countries and settings with similar healthcare delivery systems.
Relevant to our study, Hopstaken JS et al. [
41], Hetlevik Ø et al. [
44], and Arnold C [
47] also described the higher COC of primary care compared to hospital/specialist care. The advantage of a broad network and the critical role of primary care in providing essential and longitudinal care for hypertension, diabetes, and other NCDs are indisputable. The widespread availability of CHCs throughout Vietnam facilitates easier access to primary care services, fostering stronger patient-provider relationships and mutual trust. In contrast, a broader range of services provided by DHCs or upper-level facilities may lead to patients receiving care from multiple providers, resulting in disjointed care and weak continuity. A study across three provinces in Central Vietnam with 1662 residents found that CHCs provided better ongoing and coordinated care, although with lower accessibility and readability of services compared to higher-level public and private health facilities [
48]. Therefore, strengthening robust primary care through improving service availability and readiness for chronic care and increasing the number of well-trained primary care providers, particularly in rural areas, have been recommended as top-priority solutions in our own and other studies [
7,
45,
48]. We also propose that the health authority and care providers should implement telemedicine and virtual chronic care services with a financially supported mechanism to enhance equitable access to health services and boost the COC for people with chronic diseases.
Another concept of COC for people with complex care needs is management continuity which relates to the interconnectedness of care providers along the chronic care pathway. Our results align with previous studies in which patients reported limited continuity between primary and specialist care [[
24], 41, 47]. De Witt A et al. conducted a study in Australia that also emphasized insufficient partnership, communication and timely information exchange between primary and hospital cancer services from the health professionals’ perspectives [
49]. In Thua Thien province, a qualitative study showed a lack of perception and practice toward interprofessional collaboration in chronic care among primary care professionals, hindering a shared decision-making approach in people-centered care [
50]. To foster holistic, people-centered care and enhance continuity, we strongly advocate for implementing team-based and multidisciplinary care and comprehensive training programs in interprofessional collaboration toward chronic diseases. Upgrading electronic medical record and personal health record systems and installing an interactive referral system for primary-specialist care coordination are other promising interventions to improve care coordination between providers and ensure patients receive appropriate follow-up care.
In this study, we highlighted a high proportion of poor control of T2DM and hypertension, approximately two-thirds of the study population. Our findings support existing literature, indicating an association between COC and disease control. Whereas higher COCI was found among people with better disease control [
21,
51], higher NCQ was observed among people with poor management [
24,
47]. This suggests that better disease control may be linked to improved self-efficacy and seeking care from specific providers when needed, resulting in higher COCI levels and lower disjointed care. Otherwise, people with poor disease control often require more attention and coordination between primary and specialist care. Consequently, they could have more visits for follow-up care and shorter periods between visits to the healthcare provider compared to those with better disease control. These aspects could contribute to higher NCQ scores and better perceived COC.
Our findings align with the literature, illustrating that high COC was associated with reduced hospital and emergency department admissions [
19,
21,
24] and better-controlled blood pressure and blood glucose levels [
21,
51]. COC has been acknowledged to facilitate higher patient self-care behaviors and adherence to physicians’ recommendations and treatment regimes, which could improve disease control and reduce preventable hospital hospitalizations and complications [
19,
52]. Studies by Ludt et al. [
53] and Arnold et al. [
47] indicated that people receiving lifestyle counselling and involved in the shared decision-making process had higher odds of better COC. Additional services such as behavior change counselling, self-care consultation, and patient empowerment could strengthen patient-provider relationship, enhance treatment adherence, and improve care provider commitment to patient health conditions.
The findings of this study hold significant relevance for advocating policies in the reform of healthcare systems for NCDs, not only in Vietnam but also in other countries that encounter similar circumstances. Our study used a precise approach that examined the multi-dimensions of the COC concept in primary care settings, however, we did not include an analytical hierarchy to weight and aggregate the composite COC indicators/subscales. Moreover, our study has a limitation as a cross-sectional descriptive study based on self-reported questionnaires. While we examined various T2DM and hypertension-related outcomes to identify predictors of higher COC, the possibility of recall bias restricts our ability to evaluate a cause-effect relationship between COC and health outcomes and health services utilization. Further studies using medical records or national health insurance data could derive better insight into the association of COC with health service utilization and the cost-effectiveness of chronic care.
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