Keywords: Continuity of care, Relational continuity, General Practice, Primary care

Background:

Continuity of care is a core attribute of high-quality primary care and is associated with improved health outcomes, reduced mortality, and more efficient use of healthcare resources. In healthcare systems characterized by high provider choice and fragmented care-seeking patterns, achieving relational continuity is challenging. Sweden exemplifies this tension, with broad access to primary care but relatively low GP continuity.

Research questions:

How are individual characteristics and primary care center (PCC) features associated with relational continuity measured by the Continuity of Care Index (CoCI)?
How is continuity within PCCs related to total continuity across the primary care system?

Method:

Retrospective cohort study using linked administrative register data covering in-person physician visits in primary care among residents in Region Skåne, Sweden. CoCI was based on all primary care physician visits 2017-2019. Associations between individual- and PCC-level characteristics and continuity were estimated with linear regression models.

Results:

349,661 individuals and 172 PCCs were included. Mean CoCI was 0.24 for total continuity and 0.28 within PCCs. Physician turnover was the strongest determinant of continuity, with CoCI difference of 0.11 between the lowest and highest quartile, followed by patient age, having chronic conditions, PCC size, and private ownership. Individuals with higher socioeconomic status and non-Western background had lower total continuity, largely explained by more fragmented care-seeking. PCC features were more strongly associated with continuity than patient characteristics.

Conclusions:

The results suggest that relational continuity in Swedish primary care is mainly shaped by organizational factors, particularly physician turnover and practice size. Fragmented care-seeking patterns among specific patient groups—especially individuals born outside the Nordic countries—contribute to lower total continuity but do not reflect weaker patient–provider relationships within PCCs. Policies that improve workforce stability, strengthen structural support for continuity, and target PCCs serving socioeconomically deprived populations are likely necessary to enhance continuity of care.

Points for discussion:

How do the results compare to evidence and experience from other countries?

How is continuity of care in primary care prioritized in the political debate in other countries?

Are high levels of continuity of care always something to aim for? Downsides of prioritizing continuity of care in primary care?