Continuity of Care Impacts Health Care Costs, Hospitalizations in Dementia

Fragmented care led to an additional $567 million to $1.1 billion in health care spending.

Patients with dementia and lower continuity of care have higher health care spending, hospitalizations, emergency department (ED) visits, and testing, according to data analysis of fee-for-service Medicare patients.

Although most care for patients with dementia is in the ambulatory setting, the care can be fragmented and complicated by poor communication and coordination.

To better understand the impact of continuity of care on outcomes and health care costs for patients with dementia, Halima Amjad, MD, MPH, of Johns Hopkins University School of Medicine in Baltimore, MD and colleagues conducted an observational retrospective analysis of data from a large fee-for-service Medicare cohort.

The study included over 1.4 million Medicare beneficiaries with a dementia diagnosis who were 65 years of age or older and who had 4 or more ambulatory care visits. Continuity was scored on a scale of 0 to 1 based on patterns that demonstrated that total visits were with fewer clinicians. The outcomes assessed included health care spending, hospitalization, ED visits, laboratory testing, and radiology.

Patients with higher continuity of care had a mean of 10.5 visits with 2.5 clinicians compared to 15.6 visits with 7.1 clinicians in the low-continuity groups. Those with low continuity of care tended to have more chronic diseases such as coronary artery disease, chronic obstructive pulmonary disease, and congestive heart failure.

The investigators found that as continuity decreased, health care utilization increased. For example, the annual rate of hospitalization was 0.83 in the highest continuity group and 0.88 in the lowest continuity group. Similarly, Medicare beneficiaries with lower continuity had higher annual rates of emergency department visits (0.99 vs 0.84), urinalysis (1.09 vs 0.72), CT scans of the head (0.83 vs 0.71), and total healthcare spending ($24,371 vs $22,004) than participants with the highest continuity even after factoring in comorbidities and sociodemographic variables (P<.001 for all).

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“When considering differences in health care spending per beneficiary, individuals with the most fragmented care are associated with an additional $567 million to $1.1 billion in health care spending compared with those with medium or high continuity,” the authors wrote.

They hypothesized that improvements in continuity of care in patients with dementia may lead to fewer ED and hospital visits and a decrease in overtreatment and unnecessary testing. Familiarity with a patient’s cognition, functional abilities, support systems, comorbidities, and goals of care are potential mechanisms of this association.

The authors noted that the study was limited by using claims-based diagnosis which potentially misses some patients with dementia. Also, the study did not account for disease severity and the clinician-patient relationship.

“Even within new models of care, emphasis on COC with clinicians may be necessary to improve quality and cost of care for this growing, complex patient population,” the authors concluded.

The study was funded by the John A. Hartford Foundation and the National Institute of Aging.


Amjad H, Carmichael D, Austin AM, Chang C, Bynum JW. Continuity of Care and Health Care Utilization in Older Adults With Dementia in Fee-for-Service Medicare.JAMA Intern Med. 2016; doi:10.1001/jamainternmed.2016.3553.