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Available tools to comprehensively assess continuity of care from the patients’ perspective

      To the Editor:
      Continuity of care (CC), nowadays considered a priority outcome of health care systems, has only been explored in a limited way from the patient’s perspective [
      • Reid R.
      • Haggerty J.
      • McKendry R.
      Defusing the confusion: concepts and measures of continuity of healthcare.
      ]. Studies generally assess one type of continuity, relational continuity [
      • Reid R.
      • Haggerty J.
      • McKendry R.
      Defusing the confusion: concepts and measures of continuity of healthcare.
      ], one care level, and primary care [
      • Jee S.H.
      • Cabana M.D.
      Indices for continuity of care: a systematic review of the literature.
      ] and generally focus on one type of pathology [
      • Gulliford M.
      • Naithani S.
      • Morgan M.
      Continuity of care in type 2 diabetes: patients’, professionals’ and carers’ experiences and health outcomes.
      ,
      • King D.
      • Jones L.
      • Nazareth I.
      Concern and continuity in the care of cancer patients and their carers: a multi-method approach to enlightened management.
      ]; only very few have approached CC in a comprehensive way [
      • Letelier M.J.
      • Aller M.B.
      • Henao D.
      • Sánchez-Pérez I.
      • Vargas I.
      • Coderch de Lassaletta J.
      • et al.
      Design and validation of a questionnaire to measure continuity between care levels from the user’s perspective.
      ]. Uijen et al. [
      • Uijen A.A.
      • Schellevis F.G.
      • van den Bosch W.J.
      • Mokkink H.G.
      • van W.C.
      • Schers H.J.
      Nijmegen Continuity Questionnaire: development and testing of a questionnaire that measures continuity of care.
      ] report the design and validation process of a new tool, the Nijmegen Continuity Questionnaire, aimed to assess continuity of care from the patients’ perspective. We would like to argue that contrary to the claims made by the authors, it is not the first tool to be developed that measures patients’ experienced continuity of care as a multidimensional concept regardless of morbidity and across multiple care settings: a questionnaire that measures continuity of care in a comprehensive way, regardless of morbidity and across multiple care settings has previously been developed: the CCAENA questionnaire (Continuity of Care Across Care Levels Questionnaire) [
      • Letelier M.J.
      • Aller M.B.
      • Henao D.
      • Sánchez-Pérez I.
      • Vargas I.
      • Coderch de Lassaletta J.
      • et al.
      Design and validation of a questionnaire to measure continuity between care levels from the user’s perspective.
      ,
      • Aller M.B.
      • Henao D.
      • Sánchez-Pérez I.
      • Vargas I.
      • Coderch J.
      • Llopart J.R.
      • et al.
      Design and validation of a questionnaire for the measurement of continuity between care levels from the users’ perspective.
      ].
      The CCAENA questionnaire was developed based on an extensive literature review and validated using an experts’ panel, two pretests, and a pilot test with a sample of 200 health care users [
      • Letelier M.J.
      • Aller M.B.
      • Henao D.
      • Sánchez-Pérez I.
      • Vargas I.
      • Coderch de Lassaletta J.
      • et al.
      Design and validation of a questionnaire to measure continuity between care levels from the user’s perspective.
      ]. The validation process indicated that the questionnaire designed was a valid and reliable instrument [
      • Letelier M.J.
      • Aller M.B.
      • Henao D.
      • Sánchez-Pérez I.
      • Vargas I.
      • Coderch de Lassaletta J.
      • et al.
      Design and validation of a questionnaire to measure continuity between care levels from the user’s perspective.
      ]. Subsequently, the tool was applied in 2010 to a large sample of 1,500 users (forthcoming results). Publications describing the questionnaire are easily found in the major bibliographic databases [
      • Letelier M.J.
      • Aller M.B.
      • Henao D.
      • Sánchez-Pérez I.
      • Vargas I.
      • Coderch de Lassaletta J.
      • et al.
      Design and validation of a questionnaire to measure continuity between care levels from the user’s perspective.
      ]; the tool was also presented in international meetings, including the European Public Health conference in Amsterdam in 2010 [
      • Aller M.B.
      • Henao D.
      • Sánchez-Pérez I.
      • Vargas I.
      • Coderch J.
      • Llopart J.R.
      • et al.
      Design and validation of a questionnaire for the measurement of continuity between care levels from the users’ perspective.
      ], and it is freely available on the Internet [
      • Vázquez M.L.
      • Aller M.B.
      • Coderch de Lassaletta J.
      • Pérez-Sánchez I.
      • Ferran M.
      • Colomés L.
      • et al.
      ]. This tool is one of the results emerging from research conducted over the last eight years [
      • Vázquez M.L.
      • Vargas I.
      • Unger J.P.
      • Mogollon A.
      • Silva M.R.
      • Paepe P.
      Integrated health care networks in Latin America: toward a conceptual framework for analysis.
      ,
      • Terraza-Núñez R.
      • Vargas I.
      • Vázquez M.L.
      Coordination among healthcare levels: systematization of tools and measures.
      ] and aimed at improving our understanding of the phenomenon of care coordination and continuity of care, analyzing the providers’ and patients’ points of view and using both qualitative and quantitative approaches.
      The CCAENA questionnaire, similar to the Nijmegen Continuity Questionnaire, encompasses the three types of continuity (relational, informational, and management continuity) [
      • Reid R.
      • Haggerty J.
      • McKendry R.
      Defusing the confusion: concepts and measures of continuity of healthcare.
      ] and measures the patients’ perceptions by means of five Likert scales. There are several differences between the two tools: (a) the items included to assess transitions between general practitioners and specialists are not identical, either in number or in formulation; (b) the Nijmegen Continuity Questionnaire also includes a scale to assess intralevel continuity of care, and (c) the CCAENA questionnaire incorporates an extra section that addresses the patient’s care trajectory across care levels for a given episode taking place in the last three months; this makes it possible to identify specific elements of (dis)continuity experienced by patients in transitions across the primary and secondary care levels (outpatient secondary care, emergencies, and hospitalization).
      To sum up, the questionnaire published by Uijen et al. [
      • Uijen A.A.
      • Schellevis F.G.
      • van den Bosch W.J.
      • Mokkink H.G.
      • van W.C.
      • Schers H.J.
      Nijmegen Continuity Questionnaire: development and testing of a questionnaire that measures continuity of care.
      ] seems to be a useful tool that will be helpful in providing new insights into the analysis of continuity of care across and within care levels; however, it is not the first tool to be developed. To benefit from previous efforts, and to better contribute to the advancement of knowledge, existing research tools and results should be taken into account.

      References

        • Reid R.
        • Haggerty J.
        • McKendry R.
        Defusing the confusion: concepts and measures of continuity of healthcare.
        Canadian Health Services Research Foundation, Ottawa, Canada2002 (Available at) (Accessed July 11, 2011)
        • Jee S.H.
        • Cabana M.D.
        Indices for continuity of care: a systematic review of the literature.
        Med Care Res Rev. 2006; 63: 158-188
        • Gulliford M.
        • Naithani S.
        • Morgan M.
        Continuity of care in type 2 diabetes: patients’, professionals’ and carers’ experiences and health outcomes.
        National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO), London, UK2007 (Available at) (Accessed July 11, 2011)
        • King D.
        • Jones L.
        • Nazareth I.
        Concern and continuity in the care of cancer patients and their carers: a multi-method approach to enlightened management.
        National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO), London, UK2006 (Available at) (Accessed July 11, 2011)
        • Letelier M.J.
        • Aller M.B.
        • Henao D.
        • Sánchez-Pérez I.
        • Vargas I.
        • Coderch de Lassaletta J.
        • et al.
        Design and validation of a questionnaire to measure continuity between care levels from the user’s perspective.
        Gac Sanit. 2010; 24: 339-346
        • Uijen A.A.
        • Schellevis F.G.
        • van den Bosch W.J.
        • Mokkink H.G.
        • van W.C.
        • Schers H.J.
        Nijmegen Continuity Questionnaire: development and testing of a questionnaire that measures continuity of care.
        J Clin Epidemiol. 2011; 64: 1391-1399
        • Aller M.B.
        • Henao D.
        • Sánchez-Pérez I.
        • Vargas I.
        • Coderch J.
        • Llopart J.R.
        • et al.
        Design and validation of a questionnaire for the measurement of continuity between care levels from the users’ perspective.
        Eur J Public Health. 2010; 20: 14
        • Vázquez M.L.
        • Aller M.B.
        • Coderch de Lassaletta J.
        • Pérez-Sánchez I.
        • Ferran M.
        • Colomés L.
        • et al.
        CCAENA questionnaire.
        (Available at) (Accessed July 15, 2011)
        • Vázquez M.L.
        • Vargas I.
        • Unger J.P.
        • Mogollon A.
        • Silva M.R.
        • Paepe P.
        Integrated health care networks in Latin America: toward a conceptual framework for analysis.
        Rev Panam Salud Publica. 2009; 26: 360-367
        • Terraza-Núñez R.
        • Vargas I.
        • Vázquez M.L.
        Coordination among healthcare levels: systematization of tools and measures.
        Gac Sanit. 2006; 20: 485-495

      Linked Article

      • Which questionnaire to use when measuring continuity of care
        Journal of Clinical EpidemiologyVol. 65Issue 5
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          The Nijmegen Continuity Questionnaire (NCQ) measures patients’ experienced personal, team, and cross-boundary continuity of care regardless of morbidity and across multiple care settings [1]. We agree with Aller et al. [2] that existing measurement instruments should be taken into account when developing a new instrument. That is why we performed a systematic literature review to assess all existing instruments measuring continuity of care or related concepts, such as coordination or integration of care.
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