International Journal of Public Health

, Volume 60, Issue 4, pp 505–513 | Cite as

Continuity of care trajectories and emergency room use among patients with diabetes

  • Hui-Ying Tsai
  • Yiing-Jenq Chou
  • Christy Pu
Original Article



To analyze the pattern of continuity of care (COC) using trajectory analysis for a group of patients newly diagnosed with diabetes, and determine whether various trajectories lead to distinct patient outcomes.


We used the Taiwan National Health Insurance claims database. Newly diagnosed patients with diabetes in 2005 totaling 4367 were included in this study. All patients were followed up to 2011. We identified groups of COC trajectories using trajectory analysis. We subsequently determined whether various COC trajectories were associated with the frequency of total and diabetes-related emergency room (ER) use using negative binomial models.


We discovered five distinct COC trajectories for our newly diagnosed diabetes sample based on trajectory analysis. The early-seeker group had the lowest IRR for total ER visits (IRR = 0.56, P < 0.001), followed by the high-maintainer group (IRR = 0.67, P < 0.001). Similar results were obtained for diabetes-specific ER use.


We identified various COC trajectories for diabetes patients. Chronic disease patients may seek a suitable physician by compromising care continuity at the onset of disease progression and exhibit favorable outcome.


Continuity of care (COC) Group-based trajectory analysis Emergency room (ER) use Diabetes 



This study is funded by the Taiwan National Science Council, grant number: 101-2410-H-010-007.


  1. Anscombe FJ (1948) The transformation of Poisson, binomial and negative-binomial data. Biometrika 35:246–254CrossRefGoogle Scholar
  2. Bice TW, Boxerman SB (1977) A quantitative measure of continuity of care. Med Care 15(4):347–349CrossRefPubMedGoogle Scholar
  3. Chen CC, Chen SH (2011) Better continuity of care reduces costs for diabetic patients. Am J Manag Care 17(6):420–427PubMedGoogle Scholar
  4. Chen CC, Tseng CH, Cheng SH (2013) Continuity of care, medication adherence, and health care outcomes among patients with newly diagnosed type 2 diabetes: a longitudinal analysis. Med Care 51(3):231–237CrossRefPubMedGoogle Scholar
  5. Cheng SH, Chen CC, Hou YF (2010) A longitudinal examination of continuity of care and avoidable hospitalization: evidence from a universal coverage health care system. Arch Intern Med 170(18):1671–1677CrossRefPubMedGoogle Scholar
  6. Cheng SH, Hou YF, Chen CC (2011) Does continuity of care matter in a health care system that lacks referral arrangements? Health Policy Plan 26(2):157–162CrossRefPubMedGoogle Scholar
  7. Christakis DA, Mell L, Koepsell TD, Zimmerman FJ, Connell FA (2001) Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics 107(3):524–529CrossRefPubMedGoogle Scholar
  8. Chu HY, Chen CC, Cheng SH (2012) Continuity of care, potentially inappropriate medication, and health care outcomes among the elderly: evidence from a longitudinal analysis in Taiwan. Med Care 50(11):1002–1009CrossRefPubMedGoogle Scholar
  9. De Maeseneer JM, De Prins L, Gosset C, Heyerick J (2003) Provider continuity in family medicine: does it make a difference for total health care costs? Ann Fam Med 1(3):144–148CrossRefPubMedCentralPubMedGoogle Scholar
  10. D’Hoore W, Bouckaert A, Tilquin C (1996) Practical considerations on the use of the Charlson comorbidity index with administrative data bases. J Clin Epidemiol 49(12):1429–1433CrossRefPubMedGoogle Scholar
  11. Doescher MP, Saver BG, Fiscella K, Franks P (2001) Racial/ethnic inequities in continuity and site of care: location, location, location.”. Health Serv Res 36(6 Pt 2):78–89PubMedCentralPubMedGoogle Scholar
  12. Guthrie B, Wyke S (2000) Does continuity in general practice really matter? BMJ 321(7263):734–736CrossRefPubMedCentralPubMedGoogle Scholar
  13. Gyrd-Hansen D, Olsen KR, Sorensen TH (2012) Socio-demographic patient profiles and hospital efficiency: does patient mix affect a hospital’s ability to perform? Health Policy 104(2):136–145CrossRefPubMedGoogle Scholar
  14. Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R (2003) Continuity of care: a multidisciplinary review.”. BMJ 327(7425):1219–1221CrossRefPubMedCentralPubMedGoogle Scholar
  15. Harris KM (2003) How do patients choose physicians? Evidence from a national survey of enrollees in employment-related health plans. Health Serv Res 38(2):711–732CrossRefPubMedCentralPubMedGoogle Scholar
  16. Hennen BK (1975) Continuity of care in family practice. Part 1: dimensions of continuity. J Fam Pract 2(5):371–372PubMedGoogle Scholar
  17. Ionescu-Ittu RJ, McCusker A, Ciampi AM, Vadeboncoeur D, Roberge D, Larouche J, Verdon Pineault R (2007) Continuity of primary care and emergency department utilization among elderly people. CMAJ 177(11):1362–1368CrossRefPubMedCentralPubMedGoogle Scholar
  18. Kasteler J, Kane RL, Olsen DM, Thetford C (1976) Issues underlying prevalence of “doctor-shopping” behavior. J Health Soc Behav 17(4):329–339CrossRefPubMedGoogle Scholar
  19. Lafferty J, Rankin F, Duffy C, Kearney P, Doherty E, McMenamin M, Coates V (2011) Continuity of care for women with breast cancer: a survey of the views and experiences of patients, carers and health care professionals. Eur J Oncol Nurs 15(5):419–427CrossRefPubMedGoogle Scholar
  20. Levesque JF, Mukherjee S, Grimard D, Boivin A, Mishra S (2013) Measuring the prevalence of chronic diseases using population surveys by pooling self-reported symptoms, diagnosis and treatments: results from the World Health Survey of 2003 for South Asia. Int J Public Health 58(3):435–447CrossRefPubMedGoogle Scholar
  21. Lin W, Huang IC, Wang SL, Yang MC, Yaung CL (2010) Continuity of diabetes care is associated with avoidable hospitalizations: evidence from Taiwan’s National Health Insurance scheme. Int J Qual Health Care 22(1):3–8CrossRefPubMedGoogle Scholar
  22. Maziak W, Critchley J, Zaman S, Unwin N, Capewell S, Bennett K, Unal B, Husseini A, Romdhane HB, Phillimore P (2013) Mediterranean studies of cardiovascular disease and hyperglycemia: analytical modeling of population socio-economic transitions (MedCHAMPS)—rationale and methods. Int J Public Health 58(4):547–553CrossRefPubMedGoogle Scholar
  23. McWhinney IR (1975) Continuity of care in family practice. Part 2: implications of continuity. J Fam Pract 2(5):373–374PubMedGoogle Scholar
  24. Menec VH, Sirski M, Attawar D (2005) Does continuity of care matter in a universally insured population? Health Serv Res 40(2):389–400CrossRefPubMedCentralPubMedGoogle Scholar
  25. Menec VH, Sirski M, Attawar D, Katz A (2006) Does continuity of care with a family physician reduce hospitalizations among older adults? J Health Serv Res Policy 11(4):196–201CrossRefPubMedGoogle Scholar
  26. Nyweide DJ, Anthony DL, Bynum JP, Strawderman RL, Weeks WB, Casalino LP, Fisher ES (2013) Continuity of care and the risk of preventable hospitalization in older adults. JAMA Intern Med 173(20):1879–1885CrossRefPubMedGoogle Scholar
  27. Singer JD, Willett JB (2003) Applied longitudinal data analysis: modeling change and event occurrence, Oxford university press, OxfordGoogle Scholar
  28. Tu HT, Lauer JR (2008) Word of mouth and physician referrals still drive health care provider choice. Res Brief 9:1–8Google Scholar
  29. Worrall G, Knight J (2011) Continuity of care is good for elderly people with diabetes: retrospective cohort study of mortality and hospitalization. Can Fam Physician 57(1):e16–e20PubMedCentralPubMedGoogle Scholar
  30. Young BA, Lin E, Von Korff M, Simon G, Ciechanowski P, Ludman EJ, Everson-Stewart S, Kinder L, Oliver M, Boyko EJ, Katon WJ (2008) Diabetes complications severity index and risk of mortality, hospitalization, and healthcare utilization. Am J Manag Care 14(1):15–23PubMedCentralPubMedGoogle Scholar

Copyright information

© Swiss School of Public Health 2015

Authors and Affiliations

  1. 1.Institute of Hospital and Healthcare AdministrationNational Yang-Ming UniversityTaipeiTaiwan
  2. 2.Department of Public HealthNational Yang-Ming UniversityTaipeiTaiwan

Personalised recommendations