Measuring fragmentation of ambulatory care in a tripartite healthcare system

Abstract

BackgroundHong Kong has a tripartite healthcare system, where western medicine provided in both public and private sectors coexist with Chinese medicine practice. The purpose of this study is to measure fragmentation of ambulatory care experienced by the non-institutionalized population aged 15 and over in such a tripartite system, thus shed light on the ongoing primary care reform.MethodsThis is a cross-sectional secondary data analysis using the Thematic Household Survey, which was conducted by the Hong Kong Census and Statistics Department during November 2009 to February 2010 to collect territory-wide health-related information. Among 18,226 individuals with two or more ambulatory visits during the past 12 months before interview, we grouped each visit into one of the three care segments—public western, private western and Chinese medicine. Two individual-level measures were used to quantify longitudinal fragmentation of care across segments over the one-year period: Most Frequent Provider Continuity Index (MFPC) and Fragmentation of Care Index (FCI). Both are analyzed for distribution and subgroup comparison. A Tobit model was used to further examine the determinants of fragmentation.ResultsMore than a quarter of individuals sought care in two or all three segments, with an average MFPC of 65% and FCI of 0.528. Being older, female, married, unemployed, uninsured, or born in mainland China, with lower education, lower income, higher number of chronic conditions or poorer health were found to have experienced higher fragmentation of care. We also found that, fragmentation of care increased with the total number of ambulatory care visits and it varied significantly depending on what segment the individual chose to visit most frequently—those chose private western clinics had lower FCI, compared with those chose public western or Chinese medicine as the most frequently visited segment.ConclusionsEven measured at healthcare segment level, people in Hong Kong experienced modest fragmentation of care. Individuals’ health beliefs—as a result of the persistent habitual tendency and latitude incentivized by the system—may be behind the fragmented care we saw. Efforts are needed to alter health beliefs, targeting subgroups of vulnerable population, and create environments that promote better coordinated primary care.

Prevalence of care fragmentation among outpatients attending specialist clinics in a regional hospital in Singapore: a cross-sectional study

“…Studies related to fragmentation of care delivery across multiple providers have shown that a mean FCI of 0.50 corresponds to moderate levels of care fragmentation and a mean FCI of 0.70 corresponds to moderately high levels of care fragmentation 20 22. While our study did not factor in care fragmentation associated with coordinating care across multiple healthcare entities and focused on multispecialty care fragmentation in a single institution, we found that moderately high (FCI ≥0.7) levels of care fragmentation persists in around 36% of the outpatient population.…”

“…The Fragmentation of Care Index (FCI) was developed from the Continuity of Care Index,20 22 introduced by Bice and Boxerman 25 28. It is a measure of dispersion of the patient care based on the number of patient visits, number of different providers visited and number of visits to each provider.…”

“…It is a measure of dispersion of the patient care based on the number of patient visits, number of different providers visited and number of visits to each provider. This measure was adopted from other studies20 22 which had used either clinics or type of clinics as their unit of measurement. The FCI was used in this study to measure the extent of care fragmentation for individual patients and was defined as:…”

“…Previous studies have looked at the extent of fragmented care in certain group of patients seeking care in both primary and specialist care settings 20 21. Other studies looked at care fragmentation with a broader scope, for instance, the extent of care fragmentation across tripartite care system in Hong Kong 22. These studies focused on measuring care fragmentation either from a broader perspective across entities within healthcare systems or only specific disease conditions across multiple healthcare settings.…”

Improving data sharing between acute hospitals in England: an overview of health record system distribution and retrospective observational analysis of inter-hospital transitions of care

“…Many patients experience a fragmented healthcare journey that involves transitions of care between multiple primary, secondary and tertiary care settings 1–4. To make informed and safe decisions for patients negotiating this complex system, clinicians need the right information about the right patient in the right place at the right time 5.…”