Modifying continuity of care indices for adults with organ failure nearing the end of life: a retrospective population-based study in Ontario, Canada

Objectives — To develop and describe the performance of two modified relational continuity of care indices for adults with organ failure nearing the end of life, addressing limitations of existing indices that penalise multispecialty physician care.

Design — Population-based retrospective study.

Setting — Linked routinely collected health administrative databases in Ontario, Canada.

Participants — Adults aged ≥19 years who died between 1 January 2018 and 31 December 2022, with kidney failure on dialysis, advanced chronic obstructive pulmonary disease and/or heart failure.

Primary and secondary outcome measures — We adapted the Usual Provider of Care (UPC) and Bice-Boxerman Continuity of Care (BB) indices to avoid penalising multispecialty physician care, resulting in the UPC-Team and BB-Team indices. Indices were calculated for the last 2 years of life (truncating the last month) using outpatient physician visits. Correlation coefficients were produced between the unmodified indices, the modified indices and outpatient healthcare utilisation.

Results — The cohort included 199 035 individuals, with a median age of 79 years (P25, P75: 70, 86); 55.5% were male. The median modified continuity scores were higher than the unmodified scores (UPC=0.44 (0.32, 0.61), UPC-Team=0.79 (0.67, 0.89); BB=0.24 (0.15, 0.40), BB-Team=0.75 (0.52, 0.95)). The modified indices shared weaker correlations with outpatient healthcare use (ie, number of visits or specialists involved), compared with the unmodified indices.

Conclusions — The UPC-Team and BB-Team indices do not penalise patients for receiving multispecialty physician care, compared with the unmodified UPC and BB indices. The modified indices demonstrated more consistency in measuring continuity across patients with varying degrees of medical complexity and less correlation with outpatient healthcare use. Use of these indices is suggested to capture different aspects of relational continuity in the context of multispecialty care nearing the end of life.