July 2008.indd SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL JULY 2008, VOLUME 8, ISSUE 2, P. 241-242 SULTAN QABOOS UNIVERSITY© RECEIVED - 21ST APRIL 2008 ACY Re: Continuity of Care - Literature Review and Implications To the Editor, We read the paper “Continuity of Care Literature review and implications” by Alazri M et al. with interest,1 and were gratified to find that it supported most of our personal biases regarding the benefits of continuity of care, in particular page 201, column 2, paragraph 3, lines 1-3, “In Type 2 diabetes, relational and longitudinal continuity could decrease diabetes related complications and improve the quality of life” [Reference 53]2 - exactly what we would expect from a strong, supportive, caring environment! It was only when we got to the follow-on, page 201, column 2 and paragraph 3, lines 3-5 that some disquiet set in when we read,“…however, another study showed that longitudinal continuity was associated with more diabetic complications” [Reference 52]3. Perhaps, we reflected, the primary health care team in this study might have de- layed appropriate referral for eye, renal or other complications, a problem that might be associated with the lack of proper secondary/tertiary diabetes support services. However, page 201, paragraph 6, lines 7-9, goes on to state “In diabetes, longitudinal continuity has been associ- ated with worsening diabetic control and increased risk of complications” [Reference 53]2. This appeared to be in direct conflict with the earlier citation of reference 531. On review of the references, it appears that Reference 522 is unrelated to diabetes; the paper by Love and col- leagues deals only with asthma in adults. Reference 532 by Hanninen et al. addresses the benefits of continuity of care in diabetes. Apart from its virtues, these authors also found that good continuity of care was associated with less satisfactory glucose control (Hb A(1c) 8.9 +/- 2.0 (+/- SD) vs. 8.3 +/- 2.0, P=0.04). Otherwise, we could not find any other evidence that continuity of care is bad for diabetic complications. It would be speculative to consider that a difference of Hb A(1c) of 0.6 percent, that was barely statistically significant in that study, is equivalent to “increased risk of complications.” In a recent comprehensive analysis of diabetic outcomes in Northern Europe, Wandell3 supports the concept that good continuity of care in diabetics was associated with better health related quality of life. We would be grateful if you shared our concerns with Dr. Alazri and his co-authors. Some clarification would be gratefully appreciated. George Carruthers and Hussain Saadi, Department of Internal Medicine and Office of the Dean, Faculty of Medicine & Health Sciences, UAE University, Al Ain, UAE R E FE R E N C E S 1. Continuity of Care - Literature Review and Implications. SQU Med J 2007 7:197-206. 2. [Reference 53] Hanninen J, Takala J, Keinanen-Kiukaanniemi S. Good continuity of care may improve quality of life in Type 2 diabetes. Diabetes Res Clin Pract 2001; 51:21-27. L E T T E R T O T H E E D I T O R G E O R G E C A R R U T H E R S A N D H U S S A I N S A A D I 242 2. [Reference 52] Love MM, Mainous AG, Talbert JC, Hager GL. Continuity of care and the physician-patient relationship: the importance of continuity for adult patients with asthma. J Fam Pract 2000; 49:998-1004. 3. Wandell PE. Quality of life of patients with diabetes mellitus. An overview of research in primary health care in the Nor- dic countries. Scand J Prim Health Care 2005; 23:68-74. A U T H O R ’ S R E S P O N S E Thank you for the comments of Prof. Carruthers, Dean of Medicine at UAE University, and his colleague about our paper published in the SQUMJ, Continuity of Care - Literature Review and Implications.1 Our response to his comments is as follows: • We agree with Dr. Carruthers regarding reference no. 52 which is not related to diabetes, but to asthma and it came to the reference list by mistake. The correct reference for the study, which showed that longitudinal continuity has been associated with worsening diabetic control and increased risk of complications, is: Over- land J, Yue DK, Mira M. Continuity of care in diabetes: to whom does it matter?2 However, this study used data derived from patients referred by general practitioners to a diabetic clinic in a teaching hospital in Australia, thus, there is a possibility of sampling bias, as patients who do not have longitudinal continuity may have less chances to be referred. Furthermore, some of those patients might have developed already diabetes-related complications, thus, they have been referred to the hospital. • Reference no. 52 has been corrected and now relates to diabetes.2 • Paragraph 6, lines 7-9, states “in diabetes, longitudinal continuity has been associated with worsening diabetic control and increased risk of complications.” The reference to this statement should be no. 52 (corrected) and not no. 53 in the article. • I agree with Dr Carruthers that in the Hanninen et al study3 good continuity of care was associated with less satisfactory glucose control (Hb A(1c) 8.9 +/- 2.0 (+/- SD) vs. 8.3 +/- 2.0, p = 0.04) which could have a signifi- cant effect on the long term outcomes. In fact, the explanation for the poor glycaemic control has not been explored in this study, but an assumption is made that patients would like to be treated for diabetes with their usual GP who accepts less strict glucose control and concentrates more on achieving better well-being. Overall, I would like to thank Dr. Carruthers for his valuable comments. Mohammed Alazri Department of Family Medicine and Public Health College of Medicine and Health Sciences Sultan Qaboos University R E FE R E N C E S 1. Continuity of Care - Literature Review and Implications. SQU Med J 2007 7:197-206. 2. Overland J, Yue DK, Mira M. Continuity of care in diabetes: to whom does it matter? Diabetes Res Clin Pract 2001; 52:55- 61. 3. Hanninen J, Takala J, Keinanen-Kiukaanniemi S. Good continuity of care may improve quality of life in Type 2 diabetes. Diabetes Res Clin Pract 2001; 51:21-27.