Title: Continuity and team approaches to care
Description: Team approaches to care are increasingly being considered critical to improving quality for patients with complex chronic conditions and for primary care practices in general. However, many studies demonstrate some benefit to structuring care so that individual provider visit continuity is a priority. The dissertation aims to better understand how various conditions influence team performance and the quality care delivered to patients. Section 1 explores the effect of multidisciplinary primary care teams on patients' experiences with care. Higher physician continuity was associated with more favorable patients' experiences. An exception was patients' assessments of teams, which were better when on- vs. off-team visits occurred. For other measures, the decrements associated with discontinuity were the same irrespective of whether discontinuities involved on- or off-team visits. The findings highlight the challenges of incorporating teams into primary care in ways that patients experience as value-added rather than disruptive to primary care relationships.

Section 2 clarifies whether visit continuity influences patients' experiences equally in various clinical situations. Physician-patient interaction quality and organizational access were more strongly influenced by visit continuity among respondents in early stages of a physician-patient relationship and with worse self-rated health. Visit continuity during early stages of a physician-patient relationship may ultimately increase the acceptability of approaches that leverage physician time. Section 3 assesses which patient, physician, and organizational factors are related to voluntary physician switching among HIV-infected patients. Lower voluntary switching was predicted by patient trust, physician anti-retroviral knowledge, moderate (rather than low or high) HIV patient volume at a care site, and Ryan White Care Act funding. Patients with chronic illnesses may use several markers of specialization and technical quality to make decisions about their care.

Section 4 assesses the effect of care team composition on the quality of HIV care. In adjusted analyses, having a care team composed of three or more clinicians was associated with more consistent prescribing of Pneumocystis carinii (PCP) prophylaxis when medically-indicated. However, patients with multiple physicians generally reported worse care coordination and exhibited less appropriate use of emergency services. These findings highlight that team approaches offer a mix of advantages and disadvantages to patients.