Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Jun;34(6):899-907.
doi: 10.1007/s11606-019-04859-1. Epub 2019 Feb 19.

Patients' and Providers' Views on Causes and Consequences of Healthcare Fragmentation in the Ambulatory Setting: a Qualitative Study

Lisa M Kern  1 , Monika M Safford  2 , Masha J Slavin  3 , Evguenia Makovkina  2 , Ahd Fudl  2 , J Emilio Carrillo  2 , Erika L Abramson  2
Affiliations

Patients' and Providers' Views on Causes and Consequences of Healthcare Fragmentation in the Ambulatory Setting: a Qualitative Study

Lisa M Kern et al. J Gen Intern Med. 2019 Jun.

Abstract

Background: Patients with chronic conditions routinely see multiple outpatient providers, who may or may not communicate with each other. Gaps in information across providers caring for the same patient can lead to harm for patients. However, the exact causes and consequences of healthcare fragmentation are not understood well enough to design interventions to address them.

Objective: We sought to elicit patients' and providers' views on the causes and consequences of healthcare fragmentation.

Design and participants: We conducted a qualitative study with focus groups of patients and, separately, of providers (attending physicians and nurse practitioners) at an academic hospital-based primary care practice in New York City in June-August 2017. Patient participants were English-speaking adults with ≥ 2 chronic conditions.

Approach: Each focus group lasted 1 h and asked the same two questions: "Why do you think some patients receive care from many different providers and others do not?" and "What do you think happens as a result of patients receiving care from many different providers?" Data collection continued until a point of data saturation was reached. Thematic analysis was used to identify themes and subthemes.

Key results: We conducted 6 focus groups with a total of 46 participants (25 patients and 21 providers). Study participants identified 41 unique causes of fragmentation, which originate from 4 different levels of the healthcare system (patient, provider, healthcare organization, and healthcare environment); most causes were not related to medical need. Participants also identified 24 unique consequences of fragmentation, of which 3 were desirable and 21 were undesirable.

Conclusions: The results of this study offer a granular roadmap for how to decrease healthcare fragmentation. The large number and severity of negative consequences (including medical errors, misdiagnosis, increased cost, and provider burnout) underscore the urgent need for interventions to address this problem directly.

Keywords: ambulatory care; healthcare delivery; healthcare organization.

PubMed Disclaimer

Conflict of interest statement

The authors declare that they do not have a conflict of interest.

Figures

Fig. 1
Fig. 1
Flow diagram describing patient recruitment.
See this image and copyright information in PMC

Comment in

References

    1. Elhauge E, ed. The fragmentation of U.S. health care: Oxford University Press; 2010.
    1. Pham HH, Schrag D, O'Malley AS, Wu B, Bach PB. Care patterns in Medicare and their implications for pay for performance. N Engl J Med. 2007;356:1130–9. doi: 10.1056/NEJMsa063979. - DOI - PubMed
    1. Pham HH, O'Malley AS, Bach PB, Saiontz-Martinez C, Schrag D. Primary care physicians’ links to other physicians through Medicare patients: the scope of care coordination. Ann Intern Med. 2009;150:236–42. doi: 10.7326/0003-4819-150-4-200902170-00004. - DOI - PMC - PubMed
    1. O'Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med. 2011;171:56–65. - PubMed
    1. Anderson G, for the Robert Wood Johnson Foundation. Chronic care: Making the case for ongoing care, 2010. (Accessed December 11, 2018, at https://www.rwjf.org/en/library/research/2010/01/chronic-care.html.)

Publication types

LinkOut - more resources