Exploring Continuity of Care in Primary Care Settings: Role of Physician Associates in Patient Outcomes

In this dissertation we will discuss about continuity of care in primary care and below are the summaries point:- Importance of Continuity of Care (CoC) in primary care settings for patient outcomes and the role of Physician Associates in a multi-disciplinary team. Challenges in ensuring CoC due to workforce shortage and increased workload, leading to the introduction of Physician Associates. Research findings highlight the benefits of CoC, including reduced mortality rates, improved patient satisfaction, and the crucial role of Physician Associates in achieving CoC.

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Running Head: DISSERTATION
“The importance and benefits of Continuity of Care in primary care settings in relation to patient
outcome, and the role the Physician Associate can play in a multi-disciplinary team.”
[Name of the Writer]
[Name of the Institute]

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Abstract
Aim: The study aims to explore the benefits and importance of CoC in primary care settings in
relation to patient outcomes and the role of the Physician Associate can play in a multi-
disciplinary team.
Background: Research suggests that CoC is vital because it ensures efficient and effective
healthcare and is an important constituent of high-quality care. However, the reported shortage
of workforce, scarce resources, and increased workload impedes a doctor’s ability to ensure
CoC. Hence, a new profession has been introduced in the UK known as “Physician Assistants”
(PA), who are educated to the national set standards and work as an independent practitioners in
a primary care setting
Rationale: Studies have suggested that CoC is declining in the primary care settings of England
due to increased workload and staff shortage. In addition, the physician associates are not getting
much recognition, and neither are there any guidelines and procedures to govern their role in the
hospitals. Hence, there is a need to pay a strong focus on the role of the PAs in MDT to reduce
the workload of doctors sparing time for more complex matters and ensuring CoC in the primary
care setting for improved healthcare outcomes.
Method: The qualitative method supported by an inductive approach, interpretivism philosophy,
and secondary is adopted in the projected study. A total of 25 articles are incorporated for the
systematic review. Thematic analysis was performed to identify relevant themes.
Results: The analysis of the identified studies resulted in four themes: (i) the importance of CoC
related to patient's outcome, (ii) the benefits of CoC related to patient's outcome, (iii) the role of
PAs in an MDT, and (iv) the role of PAs in MDT to ensure the delivery of CoC in the primary
care setting to improve patient's healthcare outcome.
Conclusion: CoC is important because it reduces mortality rate and chances of developing a
terminal or complex medical illness and enhances patient satisfaction. While the benefits of CoC
include enhanced utilisation of preventative health services, decreased chances of multi-
morbidity, effective and timely care, fewer hospitalisations and rehospitalisation etc. In addition,
PAs are an essential healthcare resource and must be included in the MDT to ensure CoC.

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Contents
Abstract................................................................................................................................2
Chapter 01: Introduction......................................................................................................5
1.0. Overview of Chapter 01.....................................................................................5
1.1. Introduction and Background.............................................................................5
1.2. Rationale.............................................................................................................7
1.3. Aims and Objectives..........................................................................................7
1.4. Research Question..............................................................................................8
1.4 Overview of the Methodology...................................................................................8
1.5 Layout of the Dissertation.........................................................................................9
Chapter 02: Methods and Literature Review....................................................................10
Methods.............................................................................................................................10
Research Design............................................................................................................10
Research Method...........................................................................................................11
Research Approach........................................................................................................12
Research Philosophy......................................................................................................13
Data Collection and Search Strategy.............................................................................14
Inclusion Criteria.......................................................................................................15
Exclusion Criteria......................................................................................................16
Data Analysis.................................................................................................................16
Ethical Considerations...................................................................................................17
Literature Review..............................................................................................................18
Introduction....................................................................................................................18
Literature Gap................................................................................................................18
The significance of care continuity in the primary care setting related to patient
outcome......................................................................................................................................18

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Advantages of COC in a primary care setting in relation to patient outcome...............20
Role of physician associate in a multidisciplinary team to ensure COC in the primary
care setting to improve patient outcomes..................................................................................24
Summary........................................................................................................................26
Chapter 03: Results............................................................................................................28
4.1. Search Results.........................................................................................................28
4.2. Overview of Articles...............................................................................................28
Chapter 04: Discussion......................................................................................................38
5.1. The Importance of CoC related to Patient's Outcome............................................38
Theme 2: The Benefits of CoC related to Patient's Outcome........................................42
Theme 3: The Role of PAs in an MDT..........................................................................45
Theme 4: The Role of PAs in MDT to Ensure the Delivery of CoC in the Primary Care
Settings to Improve Patient's Healthcare Outcome...................................................................49
Chapter 05: Conclusion and Recommendation.................................................................53
5.1. Conclusion..............................................................................................................53
5.2. Recommendations...................................................................................................56
References..........................................................................................................................58
Appendices........................................................................................................................83
Appendix 1: PRISMA Table.........................................................................................83
Appendix 2: CASP Table..............................................................................................84

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Chapter 01: Introduction
1.0. Overview of Chapter 01
The anticipated study is titled “The importance and benefits of Continuity of Care (CoC)
in primary care settings in relation to patient outcome, and the role the Physician Associate can
play in a multi-disciplinary team.” The prime goal of the study is to explore the benefits and
importance of CoC in primary care settings in relation to patient outcomes and the role of the
Physician Associate can play in a multi-disciplinary team. Thus, in the projected chapter,
vitalities such as aim, objectives, questions, rationale, and other aspects are discussed, which
helps the readers develop relevant insights and knowledge about the context of the study.
1.1. Introduction and Background
CoC is a method to ensure that the patient-centred care team cooperates and is
continuously involved in long-term healthcare management to achieve a mutual goal of high-
quality medical care (Nicaise et al., 2020). Providing good CoC is associated with high quality of
care and patient safety over time. As per Facchinetti et al. (2020), the main goal of CoC in the
primary care setting is to ensure that the healthcare professional team is responsive to the needs
of the patient and respect their values and preference. Hoyem (2019) regards CoC as the heart of
general practice and revealed that patients who receive CoC in primary care settings report
improved healthcare outcomes, cost-effective healthcare, and higher satisfaction rates. As per the
latest survey by NHS.uk (2021), approximate 52% of patients in England visit their preferred
GP. Although visiting a preferred GP is beneficial, patients living with a terminal illness and or
those with a mental health illness are found to receive more benefits from CoC.

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Research suggests that CoC is vital because it ensures efficient and effective healthcare
and is an important constituent of high-quality care (Guven-Kocak et al., 2020). CoC is also
found to increase patients’ willingness to follow medical advice and use preventative care
services, such as cancer screening or immunisation. The statistics revealed by Hetlevik, Holmas,
and Monstad (2021) suggested that 35.2% of the NHS patients are receiving good CoC;
however, the lack of physicians and funding for the primary care setting has made it difficult to
provide CoC in England. According to the British Medical Association (BMA, 2019), the NHS
currently has only one doctor for every 2200 patients because of a staff shortage. Although many
physicians report having a good ability to develop relationships with patients, the lack of time,
increased workload, and high workload impede their ability to provide CoC. 93% of the
physicians see heavy workloads as the primary factor of poor CoC, hence increasing mortality
(Chesak et al., 2020).
However, more recently, a new profession has been introduced in the UK known as
“Physician Assistants” (PA), who are educated to the national set standards and work as an
independent practitioners in a primary care setting (Straughton et al., 2022). As per BMA (2020),
there are 2500 qualified PAs employed by several medical institutions in the UK. They provide
better CoC and cost-effective services than many doctors because of their generic competence
across different clinical areas. Their presence in the workforce decreases the workload of junior
doctors and enhances CoC because they do not rotate, and increased provider continuity is linked
with positive medical care evaluation and improved patient outcomes (Taylor et al., 2020). They
are also considered valuable members of the Multidisciplinary Team (MDT) to provide safe
surgical/medical teams to patients. Keeping in view the state of CoC, the current study explores

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the importance and benefits of CoC in a primary setting related to patient health outcomes and
the role of PAs in a multi-disciplinary team providing CoC.
1.2. Rationale
Recent studies have suggested that CoC is declining in the primary care settings of
England due to increased workload and staff shortage (Park et al., 020). This declining state has
increased the mortality rates in elderlies, decreased quality of care, and reduced prescription
compliance. While this declining state can be attributed to increased changes in the patterns of
provisions such as the European Working Time Directive (EWTD), have decreased the hours of
education, and an increase in the ageing population of the community has increased the
healthcare burden on the healthcare institutions and professionals, hence impeding CoC (Gray et
al., 2018). Elderlies have complex medical needs, require more assistance and support, and have
increased expectation which requires attention from healthcare professionals. In addition, the
physician associates are not getting much recognition, and neither are there any guidelines and
procedures to govern their role in the hospitals (Levene et al., 2018). Hence, there is a need to
pay a strong focus on the role of the PAs in MDT to reduce the workload of doctors sparing time
for more complex matters and ensuring CoC in the primary care setting for improved healthcare
outcomes.
1.3. Aims and Objectives
The study aims to explore the benefits and importance of CoC in primary care settings in
relation to patient outcomes and the role of the Physician Associate can play in a multi-
disciplinary team.

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Pertaining to this, the proposed objectives of the study are:
 To explore the benefits of CoC in primary care settings in relation to patient outcomes.
 To explore the importance of CoC in primary care settings in relation to patient
outcomes.
 To identify the role of PAs in a Multi-disciplinary team.
 To highlight the role of PAs in a multi-disciplinary team to ensure CoC in the primary
care setting to improve patient outcomes.
1.4. Research Question
A PEO framework is used to develop an appropriate research question for the study. PEO
is abbreviated as Population, Exposure, and Outcome. Morgan et al. (2018) suggest that a PEO
framework is especially effective when exploring the benefits of intervention because it helps
identify searchable and discrete components of the study.
P Primary Care Setting, PAs
E CoC
O Improved patient outcome.
1.4 Overview of the Methodology
To achieve the aim and objectives and to answer the research question, the researcher of
the anticipated study keenly focused on setting up the best means and methods so that results can

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be accomplished with minimal likelihood of risks and issues. In this regard, the qualitative
method supported by an inductive approach, interpretivism philosophy, and secondary is adopted
in the projected study. Discussion with proper justification is conducted in Chapter 02.
1.5 Layout of the Dissertation
Figure 1. 1: Dissertation Layout - Source (Author Illustration)

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Chapter 02: Methods and Literature Review
The proposed chapter of the entitled study is segregated into two sections, i.e., methods
and literature review. Both chapters are referred to as fundamentals of the research work and
support the researcher to form a better connection with the readers by discussing the methods
used to complete the research and discussing previous studies and their contribution to the
entitled topic.
Methods
This section includes a detailed discussion of the methods employed by the researcher to
conduct the study. For this purpose, this section highlights the research design, method,
approach, philosophy, data analysis technique, ethical considerations etc.
Research Design
Dannels (2018) defines research design as the complete strategy a researcher chooses to
integrate and link several aspects of a study logically and coherently to ensure that the developed
research question is adequately answered. Often, it is referred to as a draft describing the
research techniques, methods and strategies used by the researcher. Therefore, Sileyew (2019)
suggests that research design is divided into four sections: research philosophy, research
approach, research method, and data collection technique. It is also considered one of the four
basic pillars of research methodology. Hence, the researcher has acted accordingly, and in this
regard, secondary data collection technique, inductive approach, interpretivism philosophy, and
qualitative research methodology is adopted. The justification for the chosen research design has
been discussed in the subsequent sections.

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Research Method
A study’s research method incorporates the interventions, processes, and techniques the
researcher uses to collect data and analyse them to understand a topic better and uncover new
information (Browne et al., 2019). These are often referred to as tools that are used to conduct
research. There are three broad categories of research methods adopted by a researcher to
complete a study such as mixed, qualitative, and quantitative methods.
Bloomfield and Fisher (2019) define quantitative research as accumulating and analysing
data gathered in numeric form by finding averages and patterns, testing relationships between
variables, formulating predictions, and generalising results to a broader population. This kind of
research approach helps researchers gain accuracy and objectivity in their research. In
comparison, qualitative research includes naturalistic inquiry to develop a deeper understanding
of the social phenomena in real world settings (Haven and Grootel, 2019). It focuses on the
“why” of the phenomenon rather than “what” and depends on the experiences that directly
involves human being as meaning-making agents in their daily lives. In contrast, mixed-method
research combines different quantitative and qualitative data elements within the same study to
answer a research question (Sahin and Ozturk, 2019). Such design allows for new
understandings related to the contexts and complexities of social experiences and enhances the
capacity for generalisation and explanation of a social phenomenon.
A qualitative research method is used for the current research because it allows the
researcher to develop an understanding of the topic in question profoundly and, at the same time,
is considered more cost-effective and economical (Mohajan, 2018). Also, it is beneficial because
it provides insight that is specific and relevant to the topic. The qualitative method supports the

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scholar to discuss all likely ins and outs of the work in a simple and steady yet critical and
argumentative way that is not possible in quantitative and mixed due to their numeric and
significant expertise requirement (Valtakoski 2020).
Research Approach
A research approach is a set of systematic plans and procedures that encompasses the
steps of broader assumptions to extended data analysis methods, interpretation, and collection
(Song, 2018). The research approach is highly dependent on the research question being studied.
Broadly, researchers utilise two research approaches: (i) the inductive approach and (ii) the
deductive approach. An inductive approach starts from collecting empirical observations, finding
patterns in those observations, and then developing a theory about these patterns (Walter and
Ophir, 2019). In contrast, a deductive approach starts with analysing a theory, developing an
appropriate hypothesis, and collecting enough data to test that hypothesis. A deductive approach
is advantageous because it increases the probability of a researcher explaining causal
relationships between variables and concepts (Pandey, 2019).
For the proposed study, the research adopted an inductive approach since it allows a
researcher to attend closely to the research context, offers flexibility, and supports the
development of a new theory (Crisp, Meir, and Onn, 2020). Moreover, it is beneficial for the
researcher because it provides information through actual observation and first-hand knowledge.
The rationale for not adopting deductively is discussed with Danaee Fard (2020) support where
the author has criticised the deductive approach that despite its effectiveness, it does not prove
anything due to its hypothesis formulation, which is based on assumptions, results may also vary
in such approaches, and hence, data may only fail to support or support or discredit a
generalisation.

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Research Philosophy
Hurlimann (2019) defines research philosophy as a researcher’s belief related to the way
they gather data of a phenomenon and analyses and use it to their advantage. It deals with the
nature, source, and development of knowledge. Researchers suggest that there are four pillars of
research philosophy: (i) knowledge, (ii) culture, (iii) truth, and (iv) critical thinking. For research,
philosophy is chosen based on the research method employed (Dougherty et al., 2019).
Commonly, research approaches are of four types employed to conduct a study: positivism,
pragmatism, interpretivism, and realism.
The view of positivism philosophy believes that only factual information gathered using
human senses is trustworthy (Marsonet, 2019). According to such an approach, the role of a
researcher is limited to collecting data and interpreting it objectively. The positivism philosophy
values freedom and is highly representative, generalisable, and objective (Ryan, 2018). In
comparison, pragmatism includes research designs that involve operational decisions relating to
“what steps will work best” in identifying answers to the proposed research question (Simpson,
2018). According to this approach, a research question is the essential determinant of research
philosophy.
Using a pragmatism approach allows the researcher to conduct research innovatively and
dynamically (Maarouf, 2019). Similarly, realism is based on the idea that reality exists
independently from the human mind (Westphal, 2018). This philosophy advocates for following
a scientific approach to knowledge development. According to Hwang (2019), realism attempts
to explain the observed phenomenon’s mechanism or “cause”. Lastly, the philosophy of

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interpretivism is based on the idea that researchers play a specific role in making sense of the
social world; hence this research approach is heavily based on the researcher’s interest.
The research approach selected for the proposed study is interpretivism because it offers
greater flexibility, and the responses are close to the truth and valid. Also, they provide a good
reflection of how people feel about a phenomenon and provide an accurate demonstration and
measure of what the researcher is set out to measure (Alharahsheh and Pius, 2020).
Data Collection and Search Strategy
Data for the proposed study was collected using an electronic database, such as PubMed,
Cochrane Library, CINAHL plus- EBSCO, Allied and Complementary Medicine Database
(AMED), Medline- EBSCO, PsycINFO- EBSCO, and Web of Science. These databases are
useful for the research since they include high quality journals on medicine and provide
researchers with the most relevant and modern data (Hopia and Heikkila, 2020). In addition,
these databases include peer-reviewed articles, hence contributing to the validity of the study.
Several keywords, wildcards, truncations, and phrases were used to facilitate the research
process further. The key terms used for the search include “benefits of continuity-of-care,” “the
importance of continuity of care,” “continuity-of-care in primary care settings,” and “the role of
PAs in the multidisciplinary team”. Moreover, Boolean operators “OR” and “AND” were used to
refine the research process further. About this, the keywords were improvised to “benefits AND
importance of continuity of care”, “the role of Physician Assistants OR PAs in the
multidisciplinary team,” and “physician assistants OR PA.” Using these keywords, 560 articles
were identified. By setting up the time range between 2015 and 2021, the hits were reduced to
315.

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Meanwhile, exclusion and inclusion criteria are also applied, including several limiting
variables such as the English Language and peer-reviewed articles. The application of these
limiters reduced the hits to 205. Among these 205 articles, 72 had to be discarded after scanning
and skimming the titles and abstract of the study since they did not fit the research criteria
developed by the reviewer. However, the leftover 133 articles were examined for their
robustness. While 30 were dropped because of inadequate information on data collection and
data analysis techniques. While 55 were discarded because they included incomplete information
required to answer a research question fully. After careful consideration, only 25 articles were
included in the review out of 48.
Furthermore, the researcher has adopted a systematic review strategy to deliver a clear
and comprehensive summary of the available scientific evidence and precisely answer the
proposed research question. In addition, inclusion and exclusion criteria are considered an
essential component of research because it hastens the identification of the articles most relevant
to the aims and objectives of the reviewer. Moreover, it helps discard the articles that are not
relevant to the topic, saving reviewers both cost and time and making the research process a lot
easier.
Inclusion Criteria
Data published between 2015 and 2022 has been included to gather the most relevant and
updated scientific evidence since medicine and healthcare are experiencing rapid development
due to advancements in technology and policies. Additionally, only articles published in the
English language were selected, and priority was given to the peer-reviewed articles compared to
websites and other mediums of attaining secondary data. Therefore, data with reliable and
authentic scientific evidence has been incorporated into the projected study.

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Exclusion Criteria
Any other sources, such as case studies, grey papers, news, websites, and editorial pieces,
were discarded. Moreover, articles published before 2015 were excluded. Also, articles that were
not peer-reviewed were removed from the study. Finally, articles published in any other
language were not considered. Articles which require some payment method and, at the same
time, are in the press or publishing phase are excluded.
Data Analysis
The researcher uses a thematic analysis technique to analyse the collected data.
According to Braun and Clarke (2019), the thematic analysis technique is advantageous for the
review because it offers greater flexibility to incorporate as many theories and factors as required
to examine the data. Also, it is one of the easiest and quickest methods, especially for new
researchers. The process of thematic analysis is completed in six steps: (1) familiarising oneself
with the data gathered, (ii) generating initial codes, (iii) searching for key themes, (iv) reviewing
themes, (v) defining themes, and (vi) write-up. In contrast, Pernnagari and Chakrabarti (2019)
argued that flexibility offered by thematic analysis could lead to greater inflexibility and lack of
coherence when developing appropriate themes. Moreover, the thematic analysis makes it
difficult for the reviewer to focus on a particular aspect, and distraction may result in data loss.
In addition, it offers limited imperativeness because researchers start ignoring the theoretical
framework and ignore the fact that when personal experiences align with the theoretical
framework, the study becomes more valuable.

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Ethical Considerations
Ethical consideration is defined as values and principles that must be followed while
dealing with human participants. The basic goal behind ethical considerations in research is to
ensure that no individual acts in a way that can harm an individual or the whole society and
refrains organisations and people from indulging in improper and vicious conduct (Arifin, 2018).
The main ethical considerations in research include confidentiality, results in communication,
anonymity, the potential for harm, and voluntary participation. Since systematic reviews do not
include human participants, they do not require ethical approval from the research committee or
ethics board. In addition, systematic reviews must acknowledge the ethical aspects of the study
because they consider the relevance and quality of reported evidence in primary research reports
(Suri, 2020). All the studies and information cited in the proposed research are properly cited and
referenced to acknowledge the ethical aspects. In addition, the analysis of the data is completed
professionally and ethically to ensure the validity and reliability of the findings. Therefore, the
researcher of the proposed study has also adopted the Data Protection Act of 2014 and best
practices like UKRIO professional practices to conduct qualitative research.

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Literature Review
Introduction
This section of the thesis aims to present an inclusive review of the literature regarding
the importance and advantages of Continuity of Care in primary care settings in relation to
patient outcomes and the role the Physician Associate can play in a multidisciplinary team. With
the help of this inclusive review, the research allows to develop the acquaintance with and
comprehend the present study in an explicit field before the analysis of the research.
Furthermore, following the review of literature must enable the researcher to explore what is
known and what has been carried out in previous studies. Besides, it helps in presenting the gap
in the knowledge regarding the continuity of care in primary care settings in relation to primary
care settings. Thus, identifying the gaps in literature and review from previous studies help
further explore the trends that are not identified in the literature. In addition, the subsections are
divided based on the individual the present study’s objectives to accomplish the research aim
adequately.
Literature Gap
There are gaps in the literature regarding how continuity adds to better health results and
cost-viability. The shortage of longitudinal examinations stays striking, yet very much planned
long haul studies are troublesome and costly. Meanwhile, much can be advanced generally
rapidly through straightforward and modest apparatuses and methods, such as patient experience
reviews, patient journals, and critical event analysis in practices. However, this study has filled
this literature gap by carrying out a qualitative review to contribute to the knowledge,
significance, and advantages of continuity of care in relation to patient outcomes in primary care
settings.

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The significance of care continuity in the primary care setting related to patient outcome
The meaning of continuity of care (COC) regarding the World Health Organization
(WHO) is how much individuals experience a progression of discrete medical incidents as sound
and interconnected over the long run and steady with their well-being needs and inclinations.
Moreover, both continuities of care and care coordination are associated with one another. On
the other hand, COC grants care coordination by developing the connections to help consistent
relations among various providers inside multidisciplinary teams or across care settings or
sectors (Alyafei and Al Marri, 2020).
Regarding the importance of COC in the primary care settings, it has been observed by
Pu et al. (2016) that COC has forever been at the core of general practice as it denotes the
associated and comprehensible care that is predictable with the wellbeing needs and individual
conditions of a patient. In contrast, as per Hoertel, Limosin, and Leleu (2014), it is vital to
guarantee successful and proficient medical services and is accepted to be fundamental for
excellent patient care. Patients who get continuity have better outcomes in healthcare and higher
rates of satisfaction, and the medical care they get is more cost-effective (Haggerty et al., 2013).
On the other hand, with regards to the significance of COC in primary care settings to
improve patients' health outcomes, Perdok et al. (2018) articulated that continuity of care is of
great significance as it is advantageous in medical services, particularly in primary care settings,
and is a significant piece of patient-driven care, the objective of which is to offer medical
services that are receptive to a patient's requirements and respectful of their inclinations and
values.
In addition, concerning the importance of continuity of care, the GP Patient Survey
demonstrates that 52% of patients in England had a desired GP (NHS, 2016). Seeing the desired

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GP, notwithstanding, is especially valuable for specific patient gatherings, and equilibrium
should be reached between patients who focus on admittance to any GP for transient sickness
and those who would prefer to stand by to see their desired GP for issues considered more
genuine. On the other hand, those living with multimorbidities, elderly individuals, those with
psychological well being troubles, and patients getting terminal care have all been displayed to
get specific advantages from getting continuity of care (Jeffers and Baker, 2016). However, as
per the “Royal College of General Practitioners” (RCGP, 2015) examination, the number of
individuals with a solitary long haul condition in England within primary health care settings is
supposed to ascend in 2008 by 2018 from 1.9 million to 2.9 million. Alongside an ageing
populace, the interest for continuity of care is more noteworthy than at any time in recent
memory in the 21st century, resulting in the augmented significance of continuity of care in
primary care settings.
In contrast, there are a few examinations within the literature, primarily in the domain of
primary health care settings and family medicine practice, that showed that continuity of care
brought about better fulfilment of patients and permitted the supplier of the medical service to
assemble information that saved time, exertion, impacted their utilisation examinations, taking
into consideration the management, and to a lesser level impacted the recommended drugs. As
well as invigorating the patients to esteem their link with their medical care providers, they have
more command over their ailment and wellbeing. Besides, the study of Norwood et al. (2021)
inferred that additional time is effectively utilised for examinations and expanded take-up of
wellbeing advancement. On the other hand, Gray et al. (2018) revealed decreased all-cause death
rate related to continuity of care through a review with a meta-examination directed in 2018.

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Albeit all the proof was observational, it takes a gander at the extraordinary significance of COC
in primary health care settings to improve patient outcomes (Gray et al., 2018).
Advantages of COC in a primary care setting in relation to patient outcome
According to Leleu and Minvielle (2013), congruity of care is a broadly acknowledged
fundamental principle of primary care. The expected advantages of continuity of care incorporate
a superior patient-provider relationship, expanded patient fulfilment, enhanced take-up of
preventive care, improved adherence to therapy, more open medical services, and decreased
medical care use and costs (Aaltonen et al., 2021; Bayliss et al., 2015). In contrast, as per Bayliss
et al. (2015), especially weak patients, like elderly patients, are assumed to profit from the COC,
as they will probably have different persistent conditions. As per Haggerty et al. (2013),
enhancing continuity of care has turned into a research need, as patients progressively get care
from numerous experts and associations.
Notwithstanding, according to Leleu and Minvielle (2013), the expected advantages of
COC, most examinations depend on patients' insight and have a restricted sample size because of
the load of data collection. Moreover, as per Baker et al. (2020), mortality might be the most
suitable rule to gauge the impact of COC, particularly in older individuals. Besides, various
examinations have researched the connection between COC in primary care and mortality. On
the other hand, Leleu and Minvielle (2013) carried out an observational study in light of
compensation claims from the "National Health Insurance System" and indicated higher
continuity of care related to a decreased probability of death.
On the contrary, Maarsingh et al. (2016) utilised information from the "Survey on Assets
and Health Dynamics Among the Oldest Old” (AHEAD) and inferred that congruity of care is
related to a significant decrease in long haul mortality. Nevertheless, in a retrospective cohort

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study in primary care settings, the group of elevated continuity had lower paces of death than the
group of lower continuity (Ha et al., 2019). Although these examinations found a valuable
impact of COC on mortality, the advantages of congruity of care might rely upon the setting of
national healthcare.
Moreover, Lautamatti et al. (2020) indicated that various benefits exude from the COC,
not the slightest of which is enhanced on outcomes of patients. However a study available in the
“Journal of Family Practice” noticed that maintaining continuity of care works on the quality of
care by enhancing receipt of preventive administrations and diminishing hospitalisations and
usage of emergency departments (Pahlavanyali et al., 2021). Contrarily, as per Chau et al.
(2021), continuity of care not in the least does it affect the care quality. However, it frequently
increments patient fulfilment, explicitly including those with chronic conditions. Besides, Gray
et al. (2018) demonstrated that COC improves patient outcomes as continuity of care improves
hypertension outcomes, appointment follow-through, prescription compliance among
preventative medicine and general health practitioners, and bacterial meningitis detection.
On the other hand, Bazemore et al. (2018) demonstrated that COC has a significant
positive influence on medical outcomes, such as the mitigation of physical, mental, and social
impairments, as well as lower overall healthcare spending. However, as per Kuo et al. (2019),
care provided continually improves the quality of care and outcomes across many disciplines. In
addition, various studies have indicated that patients who consistently receive care seem to be
more inclined to adhere to healthcare suggestions and get preventive administration integrating
vaccines or cancer screening.
Furthermore, Maarsingh et al. (2016) illustrated that lower mortality rates are linked to
escalated care of continuity by physicians. In Health care, bundled payment initiatives,

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accountable care organisations accountable for the expense and quality targets, and taking steps
to prevent hospital readmissions put a lot of emphasis on continuity of care. In addition, in
general practice, continuity of care resulted in increased medication adherence and decreased
hospital usage (Maarsingh et al., 2016). On the contrary, patients of full-time primary care
doctors have more continuity than patients of part-time general practitioners. However, patients
who perceive the same physician over time reduced the death rate.
Additionally, advantages for Patients regarding continuity of care, as documented by
Lautamatti et al. (2020), have improved patient satisfaction for both patients and healthcare
professionals. It includes not just the indulging physician However additionally nurses and other
healthcare team members. Additionally, continuity of care fosters loyalty and trust between
patients and healthcare providers (Walker et al., 2018; Lautamatti et al., 2020). In contrast,
Hainsworth, Dowse, Ebert, and Foureur (2021) viewed that patients value their medical
professionals, particularly the treating physician, by their willingness to stand in line for
consultations, follow treatment suggestions, and follow long-term preventative regimens, and
even pay higher costs if necessary. This was also validated by Wensing et al. (2021). However, it
appears to have far more for non-acute diseases, whereas many patients have no preference for
which medical physician they see if their situation is an emergency.
It simplifies the self-limiting symptomatology management by awaiting to see how the
disease progresses, in the count to increasing security and confidence among patients and
treating clinicians. However, Chan et al. (2021) illustrated that COC in primary care settings also
reduces the use of unnecessary laboratory, radiographic, and pharmaceutical tests. On the
contrary, Chen, Tseng, and Cheng (2013) found a significant increase in glycemic regulation and

24
adherence to overall medication in type II diabetic patients due to the continuity of care, which
helped prevent or delay long-term diabetes consequences.
However, numerous scholars identified that executing COC at the primary health care
level is varying and frequently experienced with numerous hurdles. The broad healthcare
networks complicated the continuity of care. However, as per Jung et al. (2018), barriers and
variables that affect the continuity of care can be divided into three categories. On the other
hand, factors relating to the experience of the patient in the healthcare system, factors relating to
healthcare professionals, namely treating physicians, and factors relating to the broader
healthcare system.
Role of physician associate in a multidisciplinary team to ensure COC in the primary care
setting to improve patient outcomes
According to Watkins, Straughton, and King (2019), physician associates (PAs) are a
somewhat new clinical professional group filling in as a feature of the multidisciplinary team to
convey patient care in primary health care settings. Nevertheless, there is a developing
accentuation on teamwork and the role played by physician associates in multidisciplinary teams
as in this consistently expanding, perplexing and changing medical care framework; compelling
cooperation is fundamental to both work on understanding patients' outcomes and experience and
to help the prosperity of the medical care labour force (Halter et al., 2017).
On the other hand, as per the medical care and social service experts in the study of Myc
et al. (2020), the role of physician associates in multidisciplinary groups was described by the
capacity to 'see the master plan'. However, Myc et al. (2020) distinguished five key exercises that
comprise a fruitful physician associate role, including organising, facilitating, group building,
incorporating care components, and showing initiative. However, Drennan et al. (2019) indicated

25
that work on setting and period of multidisciplinary group improvement impacted the manner by
which physician associates satisfied their roles. As per colleagues, physician associates were the
focal experts in care administrations for elderly individuals.
In contrast, concerning the role of physician associates in ensuring patient health
outcomes, Halter et al. (2020) showed that as give magnificent care to the patient and
administration delivery and are a talented and capable expansion to the multidisciplinary team. In
addition, they are brilliant people who have decided to become PAs, not specialists, and are
focused on their calling. On the contrary, Gershengorn et al. (2016) articulated that the PAs have
turned into a fundamental part of the multidisciplinary team both in medication and medical
procedures. Moreover, another role identified as physician associates has become familiar with
working in an MDT as they offer superb help to ward adjusts and the subsequent positions.
Furthermore, it is totally clear that while physician associates practice medication, they are not a
specialist, with no like-for-like equivalency and subsequently cannot supplant a specialist.
Nonetheless, working in a multidisciplinary team will intend that there is a cross-over of
information and abilities between proficient gatherings. Contrarily, affirmation and augmentation
of this cross-over can be worthwhile for the group in the rearrangement of the responsibility,
arrangement of preparing potential open doors for all staff and, eventually, benefit patients,
guaranteeing that the ideal individual, with the right abilities, sees the perfect patient brilliantly
(Myc et al., 2020).
In addition, Kleinpell et al. (2019) found a positive involvement of physician associates,
which was assembled into topics of giving congruity, helping patient stream, supporting patient
security and delivering specialist time for additional complicated patients and preparing. On the
contrary, Berkowitz et al. (2021) indicated that one of the most often revealed influences on the

26
association was that physician associate gave coherence to staffing in the multidisciplinary team,
that is to say, individual and group progression. They gave congruity in presence and coherence
in information and connections, which was accounted for as useful to patients, medical
caretakers and specialists. However, as depicted above, the continuity physician associates
provide was seen as significant in understanding well-being outcomes in primary health care
settings regarding congruity of care. Additionally, the role of physician associates is an important
expansion of the MDT (Everett et al., 2016). If an energetic expert upholds them, they
incorporate well with both the lesser clinical and nursing groups to further develop ward
effectiveness and progression of care for patients (Cawley and Hooker, 2018).
Moreover, regarding the role of physician associates in ensuring a multidisciplinary team
within the context of primary healthcare settings, they further develop continuity of care and
patient experience inside the primary clinic setting. However, Hustoft et al. (2018) propose that
physician associates give protected and identical consideration to characterised errands, save
time for specialists, and help with the patient stream. Notwithstanding, a few say that the genuine
and seen potential is being kept down by an absence of expert legal guidelines and the capacity
to recommend. It was found that physician associates were frequently credited with giving
soundness in the multidisciplinary group. This helped patients through coherence of presence on
the long-term wards, expanding the availability of clinical/careful groups for patients and
medical attendants. At the same time, frequently uninformed about the distinctions from
specialists, patients themselves were, by and large, a strength of the new job. In contrast, the
study of Horlait et al. (2022) indicated that physicians associates play an important part in giving
continuity of care all through the functioning week as they do not pull all-nighters or are ready to

27
come in case of an emergency moves that would somehow take them off the ward. They have
become specialists in ward decorum and are especially useful when the lesser specialists rotate.
Summary
In a nutshell, it can be inferred that coherence of care is a generally acknowledged fundamental
principle of primary care. The vital significance of coherence of care in primary health care is
certain. Moreover, legitimate execution and monitoring are under execution globally because of
the absence of comprehension of its significance and method of evaluation. There is an
extraordinary need to emphasise making COC a routine component of quality care, particularly
amid secondary and primary care. In addition, COC has forever been at the core of general
practice as it guarantees successful and proficient medical services and is accepted to be
fundamental for excellent patient care. Other than it has a few advantages; for example, patients
who get continuity have better medical service results and higher fulfilment rates, and the
medical care they get is more cost-effective. It likewise helps counter or decreases physical,
mental and social inabilities and diminishes total medical care spending.

28
Chapter 03: Results
The proposed chapter of the study provides a description of the number and types of
research articles used in the study. In addition, it discusses the results of the selected studies
included in the review.
4.1. Search Results
The literature search on electronic databases using appropriate keywords and search
terms yielded 560 articles which were reduced to 315 after applying the time range between
2015 and 2021. The hits were further reduced to 205 after applying other limiters. Proper
skinning and scanning of these articles lowered the article count to 55, among which 30 were
discarded due to insufficient information, and 25 were added to the study. Out of these 25
articles, 9 used a qualitative methodology, 13 used a quantitative methodology, and 3 used a
mixed methodology approach.
4.2. Overview of Articles
Chan et al. (2021) conducted a systematic review to explore how “Continuity of Care”
CoC impact healthcare outcome of patients with diabetes or hypertension. Munn et al. (2018)
suggested that a systematic review provides a comprehensive and clear overview of the scientific
evidence available on a specific topic ad reduces implicit researcher bias. However, Page et al.
(2021) argued that this approach is relatively more labour intensive and time consuming than
other reviews and restricts the inclusion of grey literature, often leading to a biased perspective.
The systematic review of 42 studies concluded that high CoC is linked with reduced
hospitalisation, mortality rates, emergency room attendance, healthcare expenses, body mass

29
index (BMI), and lipid outcome. In addition, 6 out of 12 studies included in the review suggested
that CoC is linked with improved haemoglobin A1c levels in diabetes.
Moreover, Gray et al. (2017) also conducted a systematic review of the association
between CoC and mortality rate among patients. An approximate figure of 726 articles was
identified for the review; however, only 22 met the eligibility criteria set by the reviewer. The
studies were from nine different countries with diverse cultural backgrounds. Eighteen studies
reported that providing CoC to patients significantly decreases mortality rate among patients,
while 3 others demonstrated no such relationship. Although, it was also observed that the
benefits of CoC were consistent for both specialist and generalist doctors. These findings are also
supported by Baker et al.’s (2020) systematic review to study the association of CoC in primary
care and lower patient mortality. 13 quantitative studies published in French and English
language were selected that included either retrospective cohorts or cross-sectional studies. Out
of these 13 studies, 12 measured the impact on all-cause mortality and found that CoC serves as
a protective factor against mortality, while the remaining 1 study demonstrated a protective role
of CoC in patients with coronary heart diseases. The study also suggests that improved physician
knowledge, patient trust, and clinical responsibility also serve as causative factors contributing to
CoC.
Similarly, a quantitative study was undertaken by Lautamatti et al. (2020) to assess the
association between CoC and satisfaction with local healthcare services. For this purpose, data
were collected using a questionnaire in a Finnish population sample. Borgobello et al. (2019)
proposed that questionnaires allow researchers to reach their target audience quickly and save
costs. In contrast, Gerpott et al. (2020) suggested that questionnaires can result in dishonest
responses, lack of personality, and unconscientious answers. In Lautamatti et al.’s (2020) study,

30
a named GP indicates CoC. The results suggested that service users who have a named general
practitioner (GP) in primary care reports to be more satisfied with the provided healthcare
satisfaction. Satisfaction was found to be higher in older male participants and those in a
relationship. The results are also supported by Maarsingh et al. (2016), who conducted a 17-year
prospective cohort study to examine the relationship between CoC in primary care and survival
in older patients. As per Teague et al. (2018), cohort studies enable researchers to study the
outcome of an intervention with a single or multiple exposures in one study. While Nohr and
Liew (2018) criticised, that cohort study might lead to attrition bias due to differential loss of
participants. The study sample comprised 1712 older patients aged above 60 years. Out of these,
43% of the participants (742) reported maximum CoC and 33.1% (251) participants had a
relationship with the same GP. Individuals in the lowest CoC category displayed a significantly
increased mortality rate as compared to those in the maximum CoC range. The findings of the
study implied that low CoC is linked to higher mortality, hence advocating for an increased need
for CoC.
Also supported by the retrospective cohort study between 2001 and 2015 conducted by
Chau et al. (2021) to check the association between CoC and diagnosis of multi-morbidity in
patients. Talari and Goyal (2020) suggest that a retrospective study enables comparison between
two groups: those with a condition and a similar group who does not have the condition or
disease. For this study, Chau et al. (2021) recruited 166,665 patients between the ages of 18 and
105 diagnosed with a minimum of one serious illness. The findings suggested that individuals
receiving high CoC and diagnosed with one illness were diagnosed with multi-morbidity at an
8% lesser rate than those receiving lower care continuity. Similarly, those with two diagnosed
conditions were diagnosed with a third condition at an 8% lesser rate than those with high

31
continuity of care. In a similar way, Aaltonen et al. (2021) conducted a retrospective population-
based study from 2001 to 2016 and studied how poor continuity of care in dementia leads to a
delay in hospital discharge for older patients. All participants (276,299) admitted into the
hospital were studied for delayed discharge post-admission and the number of hours delayed.
The obtained data were analysed using negative binomial regression analysis, generalised
estimating equations, and logistic regression analysis. The findings suggested that discharge
from the hospital was more delayed for patients who have dementia and significantly reduced for
other patients, while delays in discharge decreased for both. Dementia was the primary reason
behind these delayed discharges and a willingness to wait to be placed in long-term care.
However, CoC from a similar physician prior to being admitted was linked to timely discharge
for a patient struggling with dementia.
Wensing et al. (2021) also found through a cohort study to check the effect of CoC in
general practice settings and hospitalisation patterns of the patients. 1,037,075 were recruited and
provided with a general-practice care programme, while 723,127 were recruited but did not
receive the program. The findings suggest that the CoC is higher in the cohort that received the
care programme than in the other cohort. A good CoC is associated with less hospitalisation,
avoidable hospitalisation, and rehospitalisation. However, other factors such as increased age,
higher morbidities, home-dwelling status, and female gender increase an individual’s
vulnerability to a higher risk of hospitalisation.
At the same time, Jung et al. (2018) employed a cohort study technique to understand the
effect of CoC on the rate of hospital utilisation in patients with osteoarthritis by using insurance
claim data from 2014. The population of the study consisted of 131,566 patients where medical
costs and hospital admissions of the last three months were considered, and CoC was measured

32
using the frequently used CoC index. The collected data was analysed using negative binomial
regression analysis. The results indicate that CoC is greatly associated with the rate of
hospitalisation and medical costs. Patients who received CoC had a low relative risk of hospital
admission, and their medical cost was found to be lesser than those who did not receive CoC.
Similarly, Bazemore et al. (2018) also utilised a cohort study technique to examine the
association of care continuity with hospitalisations and healthcare costs. For this purpose,
Bazemore et al. (2018) utilised Medicare Claim Data from 1,448,952 beneficiaries receiving care
from 6,551 physicians working in primary care to calculate scores on CoC. The continuity
measures were found to be significantly correlated with decreased hospitalisation rates and
healthcare costs. Patients receiving care continuity were 16% less vulnerable to hospital
admissions than those who do not receive CoC and consequently have to spend less on
healthcare. Hence, CoC must be prioritised, considering the strength of association between CoC
and reduced health cost and utilisation.
Also, Kuo et al. (2019) studied the effect of CoC on the post-radiotherapy survival of oral
cavity cancer patients. 14,240 patients with buccal cavity cancer treated using radiotherapy
techniques were recruited for the study. The results were indicative of the fact that male gender,
low CoC, lower socioeconomic background, and no dental treatment pre-radiotherapy are
associated with increased mortality risk after radiotherapy. The chances of mortality were
comparatively higher for patients who lacked CoC as compared to those who received high CoC.
The findings imply that CoC is highly correlated with an increase in the survival rate of patients
who underwent complex therapy procedures.

33
In contrast, Ha et al. (2019) conducted an observational study to develop a time-duration
measure of care continuity to maximise the use of primary healthcare services. Pingault et al.
(2018) suggested that observational research allows researchers to study a variable in a realistic
setting to develop valuable insights about a particular topic. However, Schober and Vetter (2020)
argued that observational studies increase the chances of type 1 errors in research leading to
inaccurate statistical comparisons. The findings suggest that diabetic participants who visited
their GP within 9-13 months reported no complications, while people with 1-2 complications
visited their GP in 5-11 months and people with 3+ complications visited GP in 4-9 months.
Hence, it implies the need to develop a primary care continuity that adds to the time parameter of
capturing the impact of CoC on healthcare outcomes.
Furthermore, Pu et al. (2016) conducted quantitative data analysis to determine the
impact of CoC on the use of ER in a healthcare system. Data from National Health Insurance
was used for almost 23 million patients to examine whether CoC is related to a reduction in the
utilisation of emergency rooms by diabetic and hypertensive patients. An instrumental variable
approach was used to control the confounding factors linked with the CoC level of patients. The
findings revealed that the provision of CoC is associated with an effective reduction in ER use.
Pu et al. (2016) suggest that CoC is more effective than is assumed by the researchers since it
facilitates physician-patient communication, leading to enhances healthcare outcomes.
While Halter et al. (2017) undertook qualitative research to study the experience of
patients while consulting with PAs working in primary care hospitals. For this purpose, Halter et
al. (2017) used a semi-structured interview technique. As per Magaldi and Beler (2020), semi-
structured interviews encourage researcher and participant communication and allow the
interviewers to explore the answers to the questions and the reason behind them. Arguably,

34
Evans and Lewis (2018) presented that interview can be time consuming and requires extensive
resources. 30 patients were interviewed who consulted a PA on the same day. Most of the
participants reported having a positive experience and outcome after consultation with the PAs.
However, those reporting negative experiences identified that they faced issues when the
limitations of the role were reached, and they had to wait longer times to get support from a GP
or delays in prescription. Generally, PAs can be considered an appropriate substitute for General
Practitioners.
Similarly, Halter et al. (2020) conducted a mixed-method study to compare the
contribution and effectiveness of PAs and Foundation year two doctors-in-training (FY2 doctors)
in emergency settings. Sahin and Ozturk (2019) suggest that mixed-method research provides a
better chance of understanding complex clinical situations from multiple perspectives. In
comparison, Walshe (2019) presented that mixed-method research can be complex to carry out
and require expertise. The quantitative data was collected using anonymised clinical records of
all the patients seen by the doctor-in-training and PAs.
Additionally, qualitative data was collected from patients and staff using semi-structured
interviews. The results demonstrate that re-visitation after seven days was the same for PAs and
FY2 doctors. Although patients who received care from a PA received an X-ray investigation,
almost all patients had a clinically adequate patient chart. Also, patients were satisfied with PA’s
care, but they had a limited understanding of the role. Hence, PAs provide the same quality of
care as doctors-in-training and can be proved to be a valuable resource to reduce the burden on
doctors working in emergency and primary care settings.

35
Additionally, another retrospective cohort study conducted by Gershengorn et al. (2016)
assesses whether adding a PA to a critical care outreach team (CCOT) enhances the process and
clinical outcomes. The intervention group had a PA integrated into the CCOT team and the
control group with no changes in the team, while the facilities for both groups were kept the
same to reduce any bias. Tamblyn et al. (2018) added that any bias in research could affect the
robustness of the research findings. It was also found that the time-to-transfer patients in ICU
significantly decreased in the intervention group. Although, the length of stay and hospital
mortality rates were found to be similar for both groups.
Furthermore, Kleinpell et al. (2019) systematically reviewed the literature to study the
effectiveness of adding PAs in acute critical care. After a review of 44 relevant studies assessing
the effectiveness of PAs using different measures, such as mortality, quality of care, and length-
of-stay, it was found that PAs can contribute positively to patient care outcomes. All the studies
identified that adding PA to the critical care team enhances CoC, staff and patient satisfaction,
patient care management, and safety and quality metrics.
Everett et al. (2016) conducted a cross-sectional survey to determine the relationship
between PA role and patient healthcare outcomes. According to Spector (2019), a cross-sectional
study is relatively cheaper and consumes less time than any other research. However, Asiamah et
al. (2021) opposed that cross-sectional studies are not effective in determining the relationship
between two variables because both are measured simultaneously. The data obtained were
analysed using multinomial logistic regression and multivariate logistics. It was found that as
compared to patients receiving care from physicians, patients with PAs as their supplement or
usual providers had increased chances of having 5 or more hospital visits. In addition, patients
having PA as their supplement provider used the emergency department more than other

36
patients. The findings thus suggest a need to consider various healthcare factors and outcomes
when identifying the roles of PA in primary care teams.
In comparison, Drennan et al. (2020) conducted a mixed-method longitudinal study to
determine the efficiency, contribution, and effectiveness of PAs added in the staffing of
surgical/medical teams in acute care settings. Qualitative data for the research was collected from
36 consultants, nurses, managers, and junior doctors and quantitative data was collected by
analysing 198 documents. The results suggested that PAs are seen as a valued addition to the
surgical and medical team and benefit patients, surgical/medical team, nurses and improved
efficiency. However, individuals see the legislative restriction of medicine prescribing as a
hindrance to the employment and deployment of PA in acute wards. Also, Watkins (2019)
conducted a literary analysis to analyse how PAs can effectively work in healthcare teams and
provide benefits to healthcare institutions. Watkins (2019) suggested that PAs are trained to
provide general services and serve as an effective resource for healthcare professionals,
especially in the face of the chronic staff shortage experienced by the NHS. PAs can add to the
quality of the care provided to the patients, decrease patient waiting times, and improve
coordination in the healthcare organisation.
Myc et al. (2020) conducted a retrospective analysis in an acute care setting to evaluate
the effectiveness of multi-disciplinary functioning in increasing positive patient-centred
outcomes. For this purpose, data were obtained from 554 patients. The study’s findings
suggested that utilising a multi-disciplinary team (MDT) and adopting a multi-disciplinary
intervention decreased the chances of mortality for patients suffering from acute pulmonary
embolism. Also, MDT is linked with lower hospital costs. Hence, adopting an MDT approach
can be beneficial for many healthcare issues.

37
Similarly, Hustoft et al. (2018) conducted a prospective cohort study to assess the
relationship between high functioning MDT and CoC and patient-reported benefits in
rehabilitation centres. The association was assessed using a linear mixed-effect model. The
analysis revealed that the patients who received care from a team with good relationships
experienced better continuity of care than those who received care from MDT without good
collaboration. Communication was an effective measure in recognising the relationship between
MDT.
At the same time, Horlait et al. (2022) undertook a literature review to study the role of
PAs in MDT meetings regarding cancer care. It was found that the integration of PAs in MDT is
associated with improved healthcare delivery and outcome for cancer patients. PAs work as an
advocate for cancer patients providing support and providing patients with necessary information
regarding diagnosis and treatment. However, several barriers limit PA’s efficiency in MDT,
including team-related issues, health care policy and management etc. Cawley and Hooker
(2018) also conducted mixed-method research to understand the factors related to the concept of
PA in the global health system. A systematic review and interview technique was used to obtain
the necessary data for the research. Findings suggest that PAs are a remarkable addition to the
healthcare institutions for enhancing the quality of care delivered to the patient, facilitating
patients’ access to healthcare services, being cost-beneficial, and providing a care quality
equivalent to a physician.
Lastly, Berkowitz et al. (2021) conducted a survey to determine if the patients were
willing to be treated by a physician assistant using quantitative surveys consisting of hypothetical
scenarios. Responses were collected from over 7000 citizens. Over 90% of the respondents were
willing to choose the PA for their healthcare needs if the waiting time for the doctor was 4 hours;

38
however, the willingness decreased as the time gap decreased to 2 hours. Hence, this suggests a
strong association between a perceived seriousness of the condition and selecting to visit a PA.
Chapter 04: Discussion
The analysis of the identified studies resulted in four themes: (i) the importance of CoC
related to patient's outcome, (ii) the benefits of CoC related to patient's outcome, (iii) the role of
PAs in an MDT, and (iv) the role of PAs in MDT to ensure the delivery of CoC in the primary
care setting to improve patient's healthcare outcome. This projected chapter of the study critically
discusses these themes in detail.
5.1. The Importance of CoC related to Patient's Outcome
CoC is generally concerned with the quality-of-care provided to the patient over time
(Jackson and Ball, 2018). Medves et al. (2022) suggest that CoC has two general perspectives:
traditional and contemporary. The traditional perspective viewed CoC as a "continuous caring
relationship" between patients and their identified healthcare professionals. This view is also
supported by the Royal College of General Physicians (RCGP, 2021) definition of CoC, which
suggests that CoC can be defined as the degree to which a patient experiences continuing
relationship with a healthcare professional or a member of a health care team and the
collaborative clinical care they receive as they move smoothly through different levels of the
healthcare service. In contrast, the contemporary view is that CoC is the delivery of seamless
service to the patient through collaboration, coordination, and information sharing between
providers. Also supported by Alison (2020) that the longevity of lifespan and developments in
the domain of medicines and technology has allowed the mitigation of several conditions;
however, it has also resulted in patients with complex needs that a single professional can rarely

39
manage; hence CoC provides a multidimensional approach to achieve both "continuous
relationship" and "seamless service" to the patient.
CoC can be of three types: relational continuity, management continuity, and
informational continuity. Relational continuity involves visiting the same doctor or team again,
while management continuity includes coordination and management of care. Finally,
information continuity is the continuity of patients' information and records (RCGP, 2018). The
findings of Baker et al. (2020) study suggested that CoC is associated with lower mortality rates
in the primary care settings and serves as a protective factor against mortality and coronary heart
diseases. Also backed by the study conducted by Olsen, Falun, and Keilegavlen (2021), which
revealed that continuity of care is attributed to a lower risk of developing cardiovascular issues in
patients due to increased focus on the factors that contribute to the worsening of the problem,
such as lipid level and high blood pressure. In contrast, Cosin-Sales et al. (2019) argued that
relational continuity has no significant relationship with cardiovascular risk management;
however, informational continuity governs the relationship even if relationship continuity cannot
be maintained. At the same time, Khera et al. (2020) added that the complexities associated with
coronary heart diseases are accelerating due to improved treatment, specialised care, and ageing;
hence CoC significantly decreases their chances of readmission through access to information
about follow-up care, medications, and lifestyle changes.
In comparison, Lautammati et al.'s (2020) study revealed that CoC is important to
enhance patients' satisfaction with healthcare services being provided to them. Results of the
Lautammati et al. (2020) study stressed that patients who consulted and received care from the
same GP were found to be more satisfied with healthcare services. Salim et al. (2019) also
supported that CoC with a primary care physician leads to decreased use of ER services and

40
increased physician and patient satisfaction. This satisfaction can be attributed to the
development of a trusting relationship and the ability of the GP to cater to the patient's needs
successfully. Moreover, ward (2018) also suggested that a well-established relationship between
patients and their GP is linked with greater patient engagement, better healthcare outcomes, and
increased rates of follow-up by the patient. However, the findings were argued by Desborough et
al. (2018), who emphasised that the association of CoC and patient satisfaction is determined by
other factors, including waiting times, communication behaviour of the GP, age, gender, number
of visits, patient's trust, and interpersonal skills of the GP. At the same time, Orte et al. (2020)
employed a different perspective and suggested that increasing patient satisfaction is an
important determinant of the quality of healthcare. In addition, patient satisfaction with
healthcare services affects patient retention, clinical outcomes, and medical and insurance claims
made.
Not only this, but CoC is also important for increasing the survival of the patients post-
surgeries and complex ailments. Maarsingh et al. (2016) examined through their cohort study of
17 years that older patients who remained in contact with their named GP survived for 17 years
as compared to those who did not receive CoC. Cohen-Mekelburg et al. (2020) also support
Maarsingh et al. (2016) findings and claim that this survival is linked to greater consumption of
health promotion, increased satisfaction, and better adherence to medicine and lifestyle changes
in the GP because of a trusting relationship developed between them. In comparison, Vincent
(2019) presented that maintaining CoC is essential in readmission cases to promote the survival
of patients because it guarantees patients' safety. A similar phenomenon was observed by Kuo et
al. (2019): mortality was significantly higher for patients with oral-cavity cancer who did not
receive CoC after radiotherapy than those who received good CoC. Grewal et al. (2019) also

41
support that CoC after cancer treatment is positively correlated with supportive care and
symptoms palliation. As per WHO (2018), patient safety is at the heart of healthcare services and
aims to reduce and prevent errors, harms, and risks to the patient that might occur during
healthcare provision. While, Liukka et al. (2020) argued that adverse events in healthcare
practice are the 10th leading cause of mortality, morbidity, and disability worldwide. CoC ensures
patient safety by protecting patient information, providing quality treatment for a specified
illness, developing a relationship that promotes the wellbeing of the patient, and providing
necessary information about the medical condition and its treatment. However, Jones and
Johnston (2019) suggested that to promote patient safety through CoC, it is essential to share
concise and thorough patient information among team members and build trust between the
healthcare team and the patient. In addition, Ohta et al. (2020) added that information sharing is
an important aspect of CoC because it helps avoid medication errors and reduce the chances of
duplicate testing, hence reducing additional healthcare costs, doctor visits, hospital admission,
and ER visits. Although, the ethical principles require healthcare professionals to only share
information that is important for patients' survival and does not breach their privacy.
Similarly, the findings of Chau et al. (2021) revealed that CoC is important to decrease
the chances of multi-morbidity in patients through follow-ups and monitoring factors leading to
multi-morbidity. For instance, patients with type 2 diabetes have a high prevalence of multi-
morbidities, specifically obesity. Also supported by a study conducted by Nicolet et al. (2022)
that the risk of developing and managing multi-morbidity significantly improved in patients who
received CoC. Arguably, Wan et al. (2021) presented that CoC is associated with improved
healthcare outcomes for patients with diabetes irrespective of multi-morbidity. Chan et al.'s
(2021) findings also support the claim of Wan et al. (2021) and suggest that CoC is associated

42
with reduced lipid outcomes, BMI, healthcare expenses, ER attendance, and hospitalisation and
mortality rate in diabetic patients.
Theme 2: The Benefits of CoC related to Patient's Outcome
The concept of CoC heavily relies on the provision of quality-of-care to the patient over
time in order to provide cost-effective and efficient medical care (Jackson and Ball, 2018). Also
supported by Wright and Mainous (2018), patients who receive continuity in care enjoy several
benefits, such as cost-effective healthcare services, higher satisfaction, and better healthcare
outcomes. Thus, CoC is a valuable resource for both patients and healthcare professionals.
The first benefit reported by Gray et al. (2017) is that CoC is associated with a decreased
mortality rate among patients. Similar findings were reported by Kim et al. (2018), who
examined that CoC decreases mortality rate among patients by enhancing quality-of-care,
increasing patients' adherence to medication, motivating patients for a follow-up, and enhancing
utilisation of preventative healthcare services. However, Sandvik et al. (2022) argued that CoC
must also integrate appropriate physician knowledge, clinical responsibility, and support to
decrease the mortality rate among patients. Comparatively, Goodacre, Campbell, and Carter
(2015) proposed that the hospital mortality rate tells about the type of care being provided at a
hospital. The mortality rate reflects the effectiveness, safety, and timeliness of care provided to a
patient. Hence, a high mortality rate indicates that the patient is not being offered quality care
and their needs are not being met effectively, leading to increased death. At the same time,
Lingsma et al. (2018) suggest that a high mortality rate might also indicate that the number of
sick patients in a hospital is increasing, probably due to the hospital's negligence or the
government. An increased mortality rate thus draws attention and calls for investigations. CoC

43
communicates that patient-centred, effective, equitable, and efficient care is being provided to
the patients by decreasing mortality rates.
Another study conducted by Wensing et al. (2021) highlighted that CoC leads to fewer
hospitalisations, rehospitalisation, and avoidable hospitalisations. Dyer et al. (2021) also backed
that high CoC with a family physician is associated with a reduced risk of utilising care-sensitive
hospitalisation and avoidable hospitalisations. In comparison, Ma (2019) took a different route
and focused on the primary factors leading to rehospitalisation in patients and suggested that
worsening of symptoms, development of a comorbidity, dietary and medication non-adherence,
and absence of motivation and social support are all responsible for increased cases of
hospitalisation and rehospitalisation. Similarly, Wengsing et al. (2021) proved that CoC deals
with all these elements. A growing body of evidence supports that CoC increases medication and
dietary adherence, decreasing the chances of symptoms worsening or reappearing (Schoenthaler
et al., 2018). While Wyngaerden et al. (2019) found that good CoC provides patients with the
necessary social support from their physician and healthcare team, enhancing their self-esteem
and motivating their recovery efforts. In healthcare, social support provided to the patient
alleviates their emotional stress, enhances self-esteem, and promotes good mental health. Similar
findings were reported in the study of Jung et al. (2018), who employed a cohort study technique
and found that CoC is found to be linked with decreased hospitalisation and medical costs.
Medical costs for patients who received CoC were significantly lesser than for other patients.
Also supported by Hollander and Kadlec (2015) that CoC decreases healthcare costs by directly
targeting the cost-related variables, such as hospitalisations, but does not directly impact
healthcare costs.

44
In contrast, Nicolet et al. (2022) presented that a decrease in healthcare costs is associated
with relational CoC; patients who have a strong attachment to practice have to incur lower
healthcare costs. This inverse relationship between both variables persists irrespective of the
patients' number of complex illnesses and age or gender. Prip et al. (2018) suggested that a
relationship developed between the healthcare professional and patient enables the physician to
understand the patient's life circumstances and needs to provide the exact intervention the patient
requires hence reducing time and cost for both patient and physician.
Moreover, through their retrospective study, Aaltonen et al. (2021) found that poor CoC
in dementia is associated with a delayed discharge after admission and increased length of stay
for patients. The findings of Aaltonen et al. (2021) study also suggest that CoC from a named GP
before a hospital admission enhances the probability of timely discharge for dementia patients.
Similarly, Landeiro et al. (2019) also added that delays in hospital discharge are usually due to
difficulties in providing post-hospital discharge care, such as inadequate recording of patient
information, staff shortage, and increased pressure on the nurses. These delays in the discharge
of patients increased the cost for healthcare organisations because of inappropriate utilisation of
hospital beds, consequently increasing the number of seriously-ill patients dependent on
outpatient care since most of the beds are occupied by the patients that should have been allotted
to more chronically ill patients (Rojas-Garcia et al., 2018). Thus, CoC decreases the unfair
utilisation of beds due to negligence on the part of the hospital by providing timely care and
discharge because of information and relational continuity. In a similar way, Bazemore et al.
(2018) observed that the patients who received CoC were 16% less likely to be hospitalised,
hence decreasing the healthcare cost.

45
Likewise, Pu et al. (2016) found that good CoC is linked to reducing the use of ER
services. As identified by Pu et al. (2016), one essential aspect of the CoC was effective
communication. In healthcare, effective communication is the timely, discrete, and clear
exchange of information between a healthcare professional and patient. Effective communication
is important because it decreases healthcare costs, protects a patient against harm, promotes
independence and autonomy, and increases the efficiency of the interventions (Ratna, 2019).
Also, effective communication leads to the development of an interpersonal relationship, which
helps the doctor to effectively share information among the team so they can provide effective
and efficient care. Therefore, CoC enhances patient wellbeing by establishing clear
communication between both parties related to the disease and its management and treatment.
Comparatively, Ha et al. (2019) suggested that the time duration between care continuity
also influences the benefits of CoC. Patients who visited their named GPs and received follow-
ups reported fewer complications than those who did not visit their GPs. Anderzen et al. (2018)
suggested that time has always been an important factor in healthcare provision. Receiving the
right service or care at the right time by the right professional is considered a successful formula
for optimal health and wellbeing. In comparison, Ohden (2019) suggested that visiting a GP on
time increases the chances of timely detection and management of healthcare issues to mitigate
them effectively.
Theme 3: The Role of PAs in an MDT
PAs is a newly introduced profession in healthcare of the UK that works alongside
physicians in Hospitals and GPs in surgeries. They offer their support to doctors by diagnosing
and managing patients and formulating their diagnoses; however, the statutory framework
restricts their ability to prescribe medication to the patients (Hooker et al., 2019). Despite this,

46
they are a valuable addition to the MDT working in hospitals. . According to an estimate by the
RCP (), there are approximately 2,850 PAs working in the healthcare organisations of the UK,
and the numbers are expected to grow.
A study conducted by Halter et al. (2020) revealed that PAs are as effective in healthcare
organisations as FY2 doctors; they are able to accurately diagnose healthcare conditions and
order laboratory tests that support the presence of a disease or ailment. Patients in Halter et al.
(2020) study also reported being satisfied with the care provided to them by the PA. However, a
systematic review of studies evaluating the satisfaction of patients after consulting a PA revealed
that the patient satisfaction after receiving care from a PA was similar to the patients cared for by
a physician. These findings suggest that PAs play an essential role in the MDT due to their
generalised training in all aspects of care and ability to form appropriate relationships with the
service user (Malone, 2021). In contrast, doctors reported that the legal restriction impedes the
ability of the healthcare organisations to deploy PAs as an effective resource in England
effectively.
Moreover, Gershengorn et al. (2016) also found that adding PA to the CCOT enhances
clinical outcomes for patients admitted to the emergency ward. Gershengorn et al. (2016)
elaborated that the presence of PA in a CCOT team facilitated the transfer time to ICU for
patients and decreased delay in admissions. Joyce et al. (2019) suggest that PA facilitates the
transfer of patients by conducting appropriate physical exams, ordering and interpreting tests,
counselling patients on their diagnoses and treatment, and obtaining informed consent hence
decreasing the load in the healthcare team and decreasing time in hospital admissions. However,

47
the findings were argued by Rimmer (2018), who suggested that physician assistants, although
quite effective, can only work under the supervision of physicians, according to the regulatory
requirements. In the face of the chronic staff shortage faced by the NHS today and the increased
number of patients with equally complex needs, PAs can increase the care quality provided to the
patients. Ghadiri (2020) also supported that integrating a PA into the team leads to a reduction in
medical errors, improves mortality rates in patients, and increases patient safety.
Similar results were reported by Kleinpell et al. (2019) that the addition of PA to an MDT
enhances continuity of care, decreases hospital mortality rate and length-of-stay in hospitals,
enhances patient care management and improves quality metrics and safety procedures. In MDT,
PAs ensure comprehensive, robust, and continuous services (Meehan et al., 2019). According to
Wallenburg et al. (2019), the care quality being provided to the patients is directly associated
with an increased survival rate in vulnerable patients by building patient satisfaction and
reducing infection rates in hospital settings. Similarly, Guest et al. (2022) added that PAs have
the clinical competence to treat central-line infections and reduce sepsis and ICU pneumonia.
They are also efficient in setting up protocols and dealing with high-risk patients.
In contrast, Ruggeri et al. (2018) presented that PAs increase patient satisfaction by
reducing wait times, providing them information related to their condition, and managing and
treating those conditions. Research suggests that increased waiting times serves as a primary
source of patient dissatisfaction and leads to prolonged suffering and deteriorating health
condition (Aburayya et al., 2020). The availability of PAs thus reduces the physician's load and
allows them the room to accommodate patients requiring same-day appointments, reducing the
anxiety patients face in the waiting rooms.

48
Horlait et al. (2022) also found out that the inclusion of PAs in MDT enhances healthcare
outcomes and delivery for cancer patients. They play an essential role by advocating for patients'
rights and providing support and information regarding treatment and diagnosis in their care
journey. Although, a number of barriers were also recognised by Horlait et al. (2022), which
include issues within the team, issues related to healthcare management and policies, and role
restrictions imposed by the organisations. Ferrante et al. (2018), through their research, also
highlighted barriers that impeded the introduction of PAs in the primary care setting of the UK
and recognised that GPs had concerns regarding the role of PAs around supervision burden,
managing medical complexities, and medicolegal implications, and non-prescriber status in
general practice. Faraz (2019) also supported that although PAs are highly efficient, they might
not have the necessary knowledge and expertise to deal with complex situations. In contrast,
Hawkins, Laird, and Goreczny (2018) presented that this should not be the prime concern since
they can still help the physicians by taking up the simple cases and providing room for
physicians to cater to more complex issues that are beyond the capabilities of a PA. In the same
research, Morgan et al. (2019) found that patients were unconcerned about the specific
competencies of the PA as long as they were effectively supervised. At the same time, Morgan et
al. (2019) added that the findings of these studies imply the need for support to mitigate the
prejudicial and stereotypical attitude of the healthcare professionals toward the role of PAs.
Drennan et al. (2020) studied the effectiveness, contribution, and efficiency of PAs when
integrated into the medical/surgical team in acute care settings. The findings indicated the same
that PAs are viewed as a valuable addition to the surgical/medical team and found to enhance
team performance significantly, maximise benefits to the patients, and improve the efficiency of
the team. As a healthcare professional, it is one's ethical duty to practice the principle of

49
beneficence- defined as providing maximum benefit to the patient, and non-maleficence-
avoiding any intentional or unintentional harm to the patient (Stone, 2018). The addition of PAs
in MDT maximises benefits to the patient by reducing waiting times, timely catering to the needs
of the patient, and advocating for their rights. At the same time, the non-prescribing status of the
PAs hinders their deployment by the surgical team in acute wards. Comparatively, the RCP
(2018) presents that although the PAs cannot prescribe medication due to the absence of
necessary prescribing legislation and statutory regulation, they must have enough pharmacology
knowledge to manage the patients safely. Even in the absence of prescribing role, they can
support the MDT because of their competencies in providing generalised services, such as
examination, diagnosis, management, care provision, and education of patients.
Theme 4: The Role of PAs in MDT to Ensure the Delivery of CoC in the Primary Care Settings
to Improve Patient's Healthcare Outcome
As discussed in theme 3, PAs play an important role in MDT and enhance their
performance and efficiency through their competence in providing generalised and effective
services to the patients in a timely manner and providing physicians with the space to
accommodate and attend to more complex cases. Not only this, but they also have an essential
role in ensuring CoC in the primary care setting to improve patients' health-related outcomes.
The findings from the Hix, Fernandes and Joyce (2019) study suggested that PAs ensure CoC
and enhance patients' experience in a hospital setting. They ensure CoC by helping with the
patient flow and freeing up time for doctors to cater to their patients. However, the findings of
Hix, Fernandes and Joyce (2019) were argued by Rimmer (2018) and added that there seems to
be a gap between the actual and perceived potential of the PAs because their competence is being
affected by the absence of proper professional statutory regulations and standards.

50
Halter et al. (2017) found that patients reported positive experiences and healthcare
outcomes after consulting a PA through their research. They reported that the PA was attentive,
accurately understood their issues, formulated a diagnosis, and provided education regarding
their diagnosis and possible treatment. Although, in Halter et al. (2017) study, some of the
participants also reported negative experiences mainly associated with the limitations of the PA's
role, such as delays in prescription and longer waiting times to get support from a GP. The
findings of Halter et al. (2017) were also supported by Brown et al. (2020) that PAs help ease
staff pressure and allow doctors to attend to more complex cases. In contrast, Meehan et al.
(2019) argued that despite the proven potential of the PAs in primary care settings, there is not
enough scientific evidence on the advantages and disadvantages of PAs to make them a general
practitioner in healthcare settings. Ghadiri (2020) contradicted Meehan et al. (2019) findings and
added that a growing number of hospitals are now using PAs as an additional source to deal with
the increasing workload on the healthcare professionals, leading to burnout and distress.
However, Agarwal and Hoskin (2021) also added that the profession is being held back by a lack
of autonomy.
Comparatively, Everett et al. (2016) examined that patients having PA as their care
provider visited the hospital more often than patients consulting a GP. Moreover, patients being
cared for by a PA are more likely to use the emergency department than other patients. The
findings are supported by Szeto, Till, and McKimm (2019) that the lack of statutory guidance
might impede a PAs ability to provide efficient care; hence the patients have to revisit the
hospital multiple times to get their prescriptions written, or tests ordered. In comparison,
Abraham (2019) negated that it is not the statutory guidance that leads to patient revisit but their
inefficiencies in providing appropriate care, leading to increased ER use and hospital visits.

51
However, Nelson et al. (2019) argued that PAs in the UK are found to have significantly reduced
the chronic skill shortage in the NHS and provide care that meets the standards of care set by the
regulatory authorities. Although, in order to increase their efficiencies, a number of training
courses are being developed to strengthen their role in the hospital settings further.
In contrast, Watkins (2019) also criticised the findings of Everett et al. (2016) and proved
through his literary analysis that PAs enhances healthcare outcomes for the patients by providing
generalised services, decreasing waiting times, and improving coordination among healthcare
teams and organisations. Giles (2022) further added that the generalised services provided by the
PAs include taking histories, formulating a diagnosis, conducting a physical examination,
ordering and interpreting test results, suturing, applying casts, educating patients, carrying out
research, becoming secondary operators in operation theatres, and conducting round in the
nursing homes and hospitals. By performing these small tasks on behalf of the physicians, PAs
enhances efficient use of healthcare resources, decrease waiting room anxieties, and ensure CoC
(Marshall et al., 2020). They provide informational continuity to the physicians so that they can
offer CoC to their patients. Research further supports that PAs are competent in performing all
these tasks because they pass a certifying board examination and complete their experience of 45
months in a healthcare organisation before they are awarded their certificates.
Myc et al. (2020) further supported the findings of Watkins (2019) and added that the
inclusion of PAs in MDT enhances healthcare outcomes by decreasing the rate of mortality,
lowering healthcare costs, and providing equitable services under one roof. It was also revealed
that PAs in MDT enhances team collaboration, resulting in better CoC for patients. Research
conducted by Hooker and Berkowitz (2020) supports that PAs enhances team collaboration
through their effective communication skills, which helps in building quality relationships. Also

52
backed by Laughey et al. (2020) that non-medical practitioners, such as PAs and ANPs, have
higher empathy and low avoidance towards patients from different backgrounds and illnesses,
hence providing equality in the care. While Roberts et al. (2019) also added that PAs could help
reduce barriers for patients accessing healthcare services, especially in underdeveloped areas.
Similar findings were reported by Hustoft et al. (2018), who examined that patients receiving
care from MDT having PAs as their members experienced better CoC as compared to MDT
without PA. Hsu et al. (2019) also supported that PAs enhance patient satisfaction by taking
more time to understand their issues and explaining them to patients. Studies suggest that
patients who are well aware of their diagnosis are more likely to adhere to their medications
(Raynor, 2020).
Cawley and Hooker (2018) also found that PAs enhances quality-of-care, facilitate
patient's access to healthcare services, provide better education and time than physicians, and are
cost-effective. Hui et al. (2018) also found that PAs are productive members of any
surgical/medical team and cost-effective in their approach to care. They relieve physicians from
their daily duties, saving a cost of almost one-third of a doctor. Keeping in view the effectiveness
of PA reported by Cawley and Hooker (2018), Berkowitz et al. (2021) also surveyed if patients
had the same view of PAs. Berkowitz et al. (2021) found that patients were happy to be treated
by a PA if they did not have to wait four hours for a physician. Hence, it could be deduced from
the mentioned studies that PAs in MDT play an essential role in enhancing CoC and improving
healthcare outcomes for patients.

53
Chapter 05: Conclusion and Recommendation
5.1. Conclusion
To conclude, the study conducted was titled as “The importance and benefits of
Continuity of Care (CoC) in primary care settings in relation to patient outcome, and the role the
Physician Associate can play in a multi-disciplinary team.” CoC is generally defined as an
approach to ensure that patient-centred care is available to the patient at all times and the
healthcare team provide consistent long-term care. The primary aim of CoC is to ensure that
patients’ needs and preferences are respected and valued at all times. It is found specifically
beneficial for patients suffering from mental health issues or a terminal illness requiring long-
term care. CoC increases the willingness of the patient to adhere to the medical treatment and use
preventative care measures. However, increased workload, lack of time, and high stress impede
their ability to provide quality care and CoC to patients, hence increasing the rate of mortality.
To deal with these issues, a new profession was recently introduced known as PAs, who have the
necessary expertise and knowledge to provide care according to the set standards. These PAs
hence decrease the workload of the junior doctor and ensure CoC because they do not rotate, and
their increased availability is linked with improved patient healthcare outcomes and positive
medical care evaluation.
Studies conducted more recently examined that CoC provision is decreasing in the UK
because of increased staff shortage and workload, consequently affecting the quality-of-care,
mortality rates, and decreased compliance of prescriptions provided by the Physicians. In
addition, the lack of recognition for the PA’s role and insufficient statutory procedures and
guidelines impedes their successful deployment in healthcare institutes. Hence, the study
particularly focused on the role of PAs in MDT in decreasing workload for physicians and

54
ensuring CoC promotes improved healthcare outcomes. Hence, the basic aim of the study was to
explore the benefits and importance of CoC in primary care settings in relation to patient
outcomes and the role of the Physician Associate can play in a multi-disciplinary team.
Moreover, a PEO framework is used to develop a research question for the topic in question
since it is found to be effective in identifying discrete and searchable components of the study.
Hence, the developed research question for the study was “What are the benefits and importance
of CoC in Primary Care Settings in relation to patient outcome and the role of PAs in MDT?”
To conduct the study, a qualitative research methodology is employed for the study since
it provides the researcher with a chance to develop a deep understanding of the phenomenon and
is more economical and cost-effective. Similarly, an inductive approach is used because it offers
greater flexibility and provides data based on first-hand knowledge and actual observations. In
addition, an interpretivism research philosophy was integrated because the responses obtained
using such an approach are valid and close to the truth. Moreover, data for the proposed study
was collected using electronic databases such as PubMed, Cochrane Library, CINAHL plus-
EBSCO, Allied and Complementary Medicine Database (AMED), Medline- EBSCO,
PsycINFO- EBSCO, and Web of Science. Several keywords, wildcards, truncations, and phrases
were used to facilitate the research process further. The key terms used for the search include
“benefits of continuity-of-care,” “the importance of continuity of care,” “continuity-of-care in
primary care settings,” and “the role of PAs in the multidisciplinary team”.
Moreover, Boolean operators were also used. These keywords yielded 560 articles which
were reduced to 25 after applying several limiters, including time range between 2015 and 2021,
articles published in the English Language, and peer-reviewed articles. Out of these 25 articles, 9

55
used a qualitative methodology, 13 used a quantitative methodology, and 3 used a mixed
methodology approach.
Additionally, the research adopted a systematic review strategy to present a
comprehensive and clear summary of the findings. The obtained data were analysed using the
thematic analysis technique, and all ethical considerations were taken into account while
conducting the research to ensure the robustness of the study.
The thematic analysis of the identified literature resulted in four themes: (i) the
importance of CoC related to patient's outcome, (ii) the benefits of CoC related to patient's
outcome, (iii) the role of PAs in an MDT, and (iv) the role of PAs in MDT to ensure the delivery
of CoC in the primary care setting to improve patient's healthcare outcome. The findings suggest
that CoC is important because it reduces mortality rate and chances of developing a terminal or
complex medical illness and enhances patient satisfaction. Also, it is linked with greater
satisfaction, health promotion, and better medication adherence. In addition, it was found that
CoC is positively associated with enhanced patient safety and correlated with symptoms
palliation and supportive care for long-treatments.
While the benefits of CoC, as reported by several researchers, include enhanced
utilisation of preventative health services, decreased chances of multi-morbidity, effective and
timely care, fewer hospitalisations and rehospitalisation, decreased chances of symptoms
worsening or reappearing, necessary social support for patients, and decreased medical costs.
Furthermore, CoC also decreases the chances of delayed discharge, increases the length of
hospital stays, reduces unfair utilisation of hospital beds, and reduces the use of ER services. At
the same time, studies also suggest that PAs play an effective role in MDT. They offer better
support to the patients, accurately diagnose and manage healthcare conditions, and enhance

56
patient satisfaction. PAs are competent in providing generalised care to the patients and able to
form an appropriate relationship with the patients. the generalised services provided by the PAs
include taking histories, formulating a diagnosis, conducting a physical examination, ordering
and interpreting test results, suturing, applying casts, educating patients, carrying out research,
becoming secondary operators in operation theatres, and conducting round in the nursing homes
and hospitals. In contrast, the legal restrictions and non-prescribing status of the PA affect their
ability to utilise their competence in the healthcare system fully. Also, a growing body of
evidence suggests that the inclusion of PA in MDT is linked with better healthcare performance,
timely care provision, patient flow, and free up space for physicians. Additionally, PAs in the
UK has significantly reduced the chronic skill shortage and provided care that meets the standard
of the regulatory authorities.
5.2. Recommendations
Although the study appropriately addressed the formulated objectives and answered the
developed research question, few recommendations can improve the validity and reliability of
the research in the future. The first recommendation is to conduct primary research on the
proposed topic because it would enable the researcher to develop a deeper insight into the views
and thoughts of the patients and healthcare staff regarding the benefits and importance of CoC
and the role of Pas in the provision of CoC. As Bailey et al. (2018) supported that primary
research provides reliable and accurate data. It was due to the pandemic that primary research
could not be conducted because it restricted our access to different healthcare institutions. Also,
it is recommended that a more extensive and comprehensive literature be reviewed and analysed
to identify more relevant themes related to CoC's importance and benefits and PA's role since the
current research could only identify a few themes and articles due to the time restrictions.

57
Additionally, it is recommended that proper statutory guidelines and strategies are
developed for PAs working in the hospital settings since they are proved to be a valuable
resource for medical/surgical teams. Also, the statutory guidance developed must keep in mind
the generalised role of the PAs and provide them with necessary guidance and training, so they
can prescribe medication, too, hence mitigating the barriers restricting their effective deployment
in the healthcare institutions (Levene et al., 2018). Also, it is recommended that healthcare
professionals, such as senior nurses and general physicians, provide PAs with the necessary
guidance and support during their professional careers to practice their roles more competently.
In addition, educational institutions providing training to these PAs must develop a course
content that ensures maximum development of the attributes and skills required to provide care
in a healthcare institution (Chen et al., 2013). There is also a need to deal with the negative
attitudes and prejudices attached to the non-medical practitioners to motivate the patients to visit
a PA instead of a GP for minor issues.
In addition, more focused steps are essential to ensure CoC for patients. Moreover, PAs
must be integrated into the sessions while developing legislations, guidelines, and policies so
they can provide regarding the issues they face at work and recommend interventions which can
be utilised to deal with those issues more competently (Orte et al., 2020). Furthermore, it is
recommended that healthcare institutions must develop a rule for employing PAs and making
them a part of the MDT to free up space for the physicians to attend to more complex cases and
decreases waiting times for the patients.

58
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Appendices
Appendix 1: PRISMA Table

84
Articles Are
the
results
valid?
Is it
worth
continui
ng?
Was the
research
design
appropriate to
address the
aims of the
research?
Was the
recruitmen
t strategy
appropriat
e to the
aims of
the
research?
Was the
data
collected
in a way
that
addresse
d the
research
issue?
Has the
relationship
between
researcher
and
participants
been
adequately
considered
?
Have ethical
issues been
taken into
consideration
?
Was the
data
analysis
sufficiently
rigorous?
Is there a
clear
statemen
t of
findings?
How
valuable
is the
research
?
Chan et al.
(2021) Yes Yes Yes Yes Yes Yes Yes No Yes Yes
Gray et al.
(2017) Yes No Yes Yes No Yes Yes No Yes Yes
Baker et al.
(2020) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Lautamatti
et al. (2020) Yes Yes Yes Yes Yes Yes No Yes Yes Yes
Maarsingh
et al. (2016) Yes Yes Yes No Yes Yes Yes Yes Yes No
Chau et al.
(2021)
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Aaltonen et
al. (2021) Yes Yes Yes Yes Yes Yes Yes No Yes Yes
Wensing et
al. (2021) Yes No Yes Yes No Yes Yes No Yes Yes
Jung et al.
(2018) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Bazemore et
al. (2018) Yes Yes Yes Yes Yes Yes No Yes Yes Yes

85
Kuo et al.
(2019) Yes Yes Yes No Yes Yes Yes Yes Yes No
Ha et al.
(2019)
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Pu et al.
(2016) Yes Yes Yes Yes Yes Yes Yes No Yes Yes
Halter et al.
(2017) Yes No Yes Yes No Yes Yes No Yes Yes
Halter et al.
(2020) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Gershengor
n et al.
(2016)
Yes Yes Yes Yes Yes Yes No Yes Yes Yes
Kleinpell et
al. (2019) Yes Yes Yes No Yes Yes Yes Yes Yes No
Everett et
al. (206)
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Drennan et
al. (2020) Yes Yes Yes Yes Yes Yes Yes No Yes Yes
Watkins
(2019) Yes No Yes Yes No Yes Yes No Yes Yes
Myc et al.
(2020) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Hustoft et
al. (2018) Yes Yes Yes Yes Yes Yes No Yes Yes Yes
Horlait et al.
(2022) Yes Yes Yes No Yes Yes Yes Yes Yes No
Cawley and
Hooker
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

86
(2018)
Berkowitz
et al. (2021)
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Appendix 2: CASP Table