Why Have There Been No Great Women Artists? by Linda Nochlin "Why have there been no great women artists?" The question tolls reproachfully in the background of most discussions of the so-called woman problem. But like so many other so-called questions involved in the feminist "controversy," it falsifies the nature of the issue at the same time that it insidiously supplies its own answer: "There are no great women artists because women are incapable of greatness." The assumptions behind such a question are varied in range and sophistication, running anywhere from "scientifically proven" demonstrations of the inability of human beings with wombs rather than penises to create anything significant, to relatively open minded wonderment that women, despite so many years of near equality and after all, a lot of men have had their disadvantages too have still not achieved anything of exceptional significance in the visual arts. The feminist's first reaction is to swallow the bait, hook, line and sinker, and to attempt to answer the question as it is put: that is, to dig up examples of worthy or insufficiently appreciated women artists throughout history; to rehabilitate rather modest, if interesting and productive careers; to "rediscover" forgotten flower painters or David followers and make out a case for them; to demonstrate that Berthe Morisot was really less dependent upon Manet than one had been led to think-in other words, to engage in the normal activity of the specialist scholar who makes a case for the importance of his very own neglected or minor master. Such attempts, whether undertaken from a feminist point of view, like the ambitious article on women artists which appeared in the 1858 Westminster Review, or more recent scholarly studies on such artists as Angelica Kauffmann and Artemisia Gentileschi, are certainly worth the effort, both in adding to our knowledge of women's achievement and of art history generally. But they do nothing to question the assumptions lying behind the question "Why have there been no great women artists?" On the contrary, by attempting to answer it, they tacitly reinforce its negative implications. Another attempt to answer the question involves shifting the ground slightly and asserting, as some contemporary feminists do, that there is a different kind of "greatness" for women's art than for men's, thereby postulating the existence of a distinctive and recognizable feminine style, different both in its formal and its expressive qualities and based on the special character of women's situation and experience. This, on the surface of it, seems reasonable enough: in general, women's experience and situation in society, and hence as artists, is different from men's, and certainly the art produced by a group of consciously united and purposefully articulate women intent on bodying forth a group consciousness of feminine experience might indeed be stylistically identifiable as feminist, if not feminine, art..

1. Why Have There Been No Great Women Artists?
by
Linda Nochlin
"Why have there been no great women artists?" The question
tolls reproachfully in the background of most
discussions of the so-called woman problem. But like so many
other so-called questions involved in the
feminist "controversy," it falsifies the nature of the issue at the
same time that it insidiously supplies its
own answer: "There are no great women artists because women
are incapable of greatness."
The assumptions behind such a question are varied in range and
sophistication, running anywhere from
"scientifically proven" demonstrations of the inability of human
beings with wombs rather than penises to
create anything significant, to relatively open minded
wonderment that women, despite so many years of
near equality and after all, a lot of men have had their
disadvantages too have still not achieved anything of
exceptional significance in the visual arts.
The feminist's first reaction is to swallow the bait, hook, line
and sinker, and to attempt to answer the
question as it is put: that is, to dig up examples of worthy or
insufficiently appreciated women artists
throughout history; to rehabilitate rather modest, if interesting
and productive careers; to "rediscover"
forgotten flower painters or David followers and make out a
case for them; to demonstrate that Berthe

2. Morisot was really less dependent upon Manet than one had
been led to think-in other words, to engage in
the normal activity of the specialist scholar who makes a case
for the importance of his very own neglected
or minor master. Such attempts, whether undertaken from a
feminist point of view, like the ambitious
article on women artists which appeared in the 1858
Westminster Review, or more recent scholarly studies
on such artists as Angelica Kauffmann and Artemisia
Gentileschi, are certainly worth the effort, both in
adding to our knowledge of women's achievement and of art
history generally. But they do nothing to
question the assumptions lying behind the question "Why have
there been no great women artists?" On the
contrary, by attempting to answer it, they tacitly reinforce its
negative implications.
Another attempt to answer the question involves shifting the
ground slightly and asserting, as some
contemporary feminists do, that there is a different kind of
"greatness" for women's art than for men's,
thereby postulating the existence of a distinctive and
recognizable feminine style, different both in its
formal and its expressive qualities and based on the special
character of women's situation and experience.
This, on the surface of it, seems reasonable enough: in general,
women's experience and situation in
society, and hence as artists, is different from men's, and
certainly the art produced by a group of
consciously united and purposefully articulate women intent on
bodying forth a group consciousness of
feminine experience might indeed be stylistically identifiable as
feminist, if not feminine, art.
Unfortunately, though this remains within the realm of
possibility it has so far not occurred. While the

3. members of the Danube School, the followers of Caravaggio,
the painters gathered around Gauguin at
Pont-Aven, the Blue Rider, or the Cubists may be recognized by
certain clearly defined stylistic or
expressive qualities, no such common qualities of "femininity"
would seem to link the styles of women
artists generally, any more than such qualities can be said to
link women writers, a case brilliantly argued,
against the most devastating, and mutually contradictory,
masculine critical cliches, by Mary Ellmann in
her Thinking about Women. No subtle essence of femininity
would seem to link the work of Artemesia
Gentileschi, Mine Vigee-Lebrun, Angelica Kauffmann, Rosa
Bonheur, Berthe Morlsot, Suzanne Valadon,
Kathe Kollwitz, Barbara Hepworth, Georgia O'Keeffe, Sophie
Taeuber-Arp, Helen Frankenthaler, Bridget
Riley, Lee Bontecou, or Louise Nevelson, any more than that of
Sappho, Marie de France, Jane Austen,
Emily Bronte, George Sand, George Eliot, Virginia Woolf,
Gertrude Stein, Anais Nin, Emily Dickinson,
Sylvia Plath, and Susan Sontag. In every instance, women
artists and writers would seem to be closer to
other artists and writers of their own period and outlook than
they are to each other.
Women artists are more inward-looking, more delicate and
nuanced in their treatment of their medium, it
may be asserted. But which of the women artists cited above is
more inward-turning than Redon, more
subtle and nuanced in the handling of pigment than Corot? Is
Fragonard more or less feminine than Mme.
Vigee-Lebrun? Or is it not more a question of the whole Rococo
style of eighteenth-century France being
"feminine," if judged in terms of a binary scale of "masculinity"
versus "femininity"? Certainly, if
daintiness, delicacy, and preciousness are to be counted as

4. earmarks Of a feminine style, there is nothing
fragile about Rosa Bonheur's Horse Fair, nor dainty and
introverted about Helen Frankenthaler's giant
canvases. If women have turned to scenes of domestic life, or of
children, so did Jan Steen, Chardin, and
the Impressionists Renoir and Monet as well as Morisot and
Cassatt. In any case, the mere choice of a
certain realm of subject matter, or the restriction to certain
subjects, is not to be equated with a style, much
less with some sort of quintessentially feminine style.
The problem lies not so much with some feminists' concept of
what femininity is, but rather with their
misconception-shared with the public at large-of what art is:
with the naive idea that art is the direct,
personal expression of individual emotional experience, a
translation of personal life into visual terms. Art
is almost never that, great art never is. The making of art
involves a self-consistent language of form, more
or less dependent upon, or free from, given temporally defined
conventions, schemata, or systems of
notation, which have to be learned or worked out, either through
teaching, apprenticeship, or a long period
of individual experimentation. The language of art is, more
materially, embodied in paint and line on
canvas or paper, in stone or clay or plastic or metal it is neither
a sob story nor a confidential whisper.
The fact of the matter is that there have been no supremely
great women artists, as far as we know,
although there have been many interesting and very good ones
who remain insufficiently investigated or
appreciated; nor have there been any great Lithuanian jazz

5. pianists, nor Eskimo tennis players, no matter
how much we might wish there had been. That this should be
the case is regrettable, but no amount of
manipulating the historical or critical evidence will alter the
situation; nor will accusations of male-
chauvinist distortion of history. There are no women
equivalents for Michelangelo or Rembrandt,
Delacroix or Cezanne, Picasso or Matisse, or even, in very
recent times, for de Kooning or Warhol, any
more than there are black American equivalents for the same. If
there actually were large numbers of
"hidden" great women artists, or if there really, should be
different standards for women's art as opposed to
men's--and one can't have it both ways--then what are feminists
fighting for? If women have in fact
achieved the same status as men in the arts, then the status quo
is fine as it is.
But in actuality, as we all know, things as they are and as they
have been, in the arts as in a hundred other
areas, are stultifying, oppressive, and discouraging to all those,
women among them, who did not have the
good fortune to be born white, preferably middle class and,
above all, male. The fault lies not in our stars,
our hormones, our menstrual cycles, or our empty internal
spaces, but in our institutions and our education-
education understood to include everything that happens to us
from the moment we enter this world of
meaningful symbols, signs, and signals. The miracle is, in fact,
that given the overwhelming odds against
women, or blacks, that so many of both have managed to
achieve so much sheer excellence, in those
bailiwicks of white masculine prerogative like science, politics,
or the arts.
It is when one really starts thinking about the implications of

6. "Why have there been no great women
artists?" that one begins to realize to what extent our
consciousness of how things are in the world has been
conditioned-and often falsified-by the way the most important
questions are posed. We tend to take it for
granted that there really is an East Asian Problem, a Poverty
Problem, a Black Problem and a Woman
Problem. But first we must ask ourselves who is formulating
these "questions," and then, what purposes
such formulations may serve. (We may, of course, refresh our
memories with the connotations of the Nazis'
"Jewish Problem.") Indeed, in our time of instant
communication, "problems" are rapidly formulated to
rationalize the bad conscience of those with power: thus the
problem posed by Americans in Vietnam and
Cambodia is referred to by Americans as the "East Asian
Problem," whereas East Asians may view it, more
realistically, as the "American Problem"; the so-called Poverty
Problem might more directly be viewed as
the "Wealth Problem" by denizens of urban ghettos or rural
wastelands; the same irony twists the White
Problem into its opposite, a Black Problem; and the same
inverse logic turns up in the formulation of our
own present state of affairs as the "Woman Problem."
Now the "Woman Problem," like all human problems, so-called
(and the very idea of calling anything to do
with human beings a "problem" is, of course, a fairly recent
one) is not amenable to "solution" at all, since
what human problems involve is reinterpretation of the nature
of the situation, or a radical alteration of
stance or program on the part of the "problems " themselves.
Thus women and their situation in the arts, as
in other realms of endeavor, are not a "problem" to be viewed
through the eyes of the dominant male power
elite. Instead, women must conceive of themselves as

7. potentially, if not actually, equal subjects, and must
be willing to look the facts of their situation full in the face,
without self-pity, or cop-outs; at the same time
they must view their situation with that high degree of
emotional and intellectual commitment necessary to
create a world in which equal achievement will be not only
made possible but actively encouraged by
social institutions.
It is certainly not realistic to hope that a majority of men, in the
arts or in any other field, will soon see the
light and find that it is in their own self-interest to grant
complete equality to women, as some feminists
optimistically assert, or to maintain that men themselves will
soon realize that they are diminished by
denying themselves access to traditionally "feminine" realms
and emotional reactions. After all, there are
few areas that are really "denied" to men, if the level of
operations demanded be transcendent, responsible,
or rewarding enough: men who have a need for "feminine"
involvement with babies or children gain status
as pediatricians or child psychologists, with a nurse (female) to
do the more routine work; those who feel
the urge for kitchen creativity may gain fame as master chefs;
and, of course, men who yearn to fulfill
themselves through what are often termed "feminine" artistic
interests can find themselves as painters or
sculptors, rather than as volunteer museum aides or part-time
ceramists, as their female counterparts so
often end up doing; as far as scholarship is concerned, how
many men would be willing to change their
jobs as teachers and researchers for those of unpaid, part-time
research assistants and typists as well as full-

8. time nannies and domestic workers?
Those who have privileges inevitably hold on to them, and hold
tight, no matter how marginal the
advantage involved, until compelled to bow to superior power
of one sort or another.
Thus the question of women's equality--in art as in any other
realm--devolves not upon the relative
benevolence or ill-will of individual men, nor the self-
confidence or abjectness of individual women, but
rather on the very nature of our institutional structures
themselves and the view of reality which they
impose on the human beings who are part of them. As John
Stuart Mill pointed out more than a century
ago: "Everything which is usual appears natural. The subjection
of women to men being a universal
custom, any departure from it quite naturally appears
unnatural."' Most men, despite lip service to equality,
are reluctant to give up this "natural" order of things in which
their advantages are so great; for women, the
case is further complicated by the fact that, as Mill astutely
pointed out, unlike other oppressed groups or
castes, men demand of them not only submission but
unqualified affection as well; thus women are often
weakened by the internalized demands of the male-dominated
society itself, as well as by a plethora of
material goods and comforts: the middle-class woman has a
great deal more to lose than her chains.
The question "Why have there been no great women artists?" is
simply the top tenth of an iceberg of
misinterpretation and misconception; beneath lies a vast dark
bulk of shaky idees recues about the nature of
art and its situational concomitants, about the nature of human
abilities in general and of human excellence

9. in particular, and the role that the social order plays in all of
this. While the "woman problem" as such may
be a pseudo-issue, the misconceptions involved in the question
"Why have there been no great women
artists?" points to major areas of intellectual obfuscation
beyond the specific political and ideological issues
involved in the subjection of women. Basic to the question are
many naive, distorted, uncritical
assumptions about the making of art in general, as well as the
making of great art. These assumptions,
conscious or unconscious, link together such unlikely superstars
as Michelangelo and van Gogh, Raphael
and Jackson Pollock under the rubric of "Great"-an honorific
attested to by the number of scholarly
monographs devoted to the artist in question-and the Great
Artist is, of course, conceived of as one who has
"Genius"; Genius, in turn, is thought of as an atemporal and
mysterious power somehow embedded in the
person of the Great Artist.' Such ideas are related to
unquestioned, often unconscious, meta-historical
premises that make Hippolyte Taine's race-milieu-moment
formulation of the dimensions of historical
thought seem a model of sophistication. But these assumptions
are intrinsic to a great deal of art-historical
writing. It is no accident that the crucial question of the
conditions generally productive of great art has so
rarely been investigated, or that attempts to investigate such
general problems have, until fairly recently,
been dismissed as unscholarly, too broad, or the province of
some other discipline, like sociology. To
encourage a dispassionate, impersonal, sociological, and
institutionally oriented approach would reveal the
entire romantic, elitist, individual-glorifying, and monograph-
producing substructure upon which the
profession of art history is based, and which has only recently
been called into question by a group of

10. younger dissidents.
Underlying the question about woman as artist, then, we find
the myth of the Great Artist-subject of a
hundred monographs, unique, godlike-bearing within his person
since birth a mysterious essence, rather
like the golden nugget in Mrs. Grass's chicken soup, called
Genius or Talent, which, like murder, must
always out, no matter how unlikely or unpromising the
circumstances.
The magical aura surrounding the representational arts and their
creators has, of course, given birth to
myths since the earliest times. Interestingly enough, the same
magical abilities attributed by Pliny to the
Greek sculptor Lysippos in antiquity--the mysterious inner call
in early youth, the lack of any teacher but
Nature herself--is repeated as late as the nineteenth century by
Max Buchon in his biography of Courbet.
The supernatural powers of the artist as imitator, his control of
strong, possibly dangerous powers, have
functioned historically to set him off from others as a godlike
creator, one who creates Being out of
nothing. The fairy tale of the discovery by an older artist or
discerning patron of the Boy Wonder, usually
in the guise of a lowly shepherd boy, has been a stock-in-trade
of artistic mythology ever since Vasari
immortalized the young Giotto, discovered by the great
Cimabue while the lad was guarding his flocks,
drawing sheep on a stone; Cimabue, overcome with admiration
for the realism of the drawing, immediately
invited the humble youth to be his pupil. Through some
mysterious coincidence, later artists including
Beccafumi, Andrea Sansovino, Andrea del Castagno, Mantegna,

11. Zurbardn, and Goya were all discovered
in similar pastoral circumstances. Even when the young Great
Artist was not fortunate enough to come
equipped with a flock of sheep, his talent always seems to have
manifested itself very early, and
independent of any external encouragement: Filippo Lippi and
Poussin, Courbet and Monet are all reported
to have drawn caricatures in the margins of their schoolbooks
instead of studying the required subjects-we
never, of course, hear about the youths who neglected their
studies and scribbled in the margins of their
notebooks without ever becoming anything more elevated than
department-store clerks or shoe salesmen.
The great Michelangelo himself, according to his biographer
and pupil, Vasari, did more drawing than
studying as a child. So pronounced was his talent, reports
Vasari, that when his master, Ghirlandalo,
absented himself momentarily from his work in Santa Maria
Novella, and the young art student took the
opportunity to draw "the scaffolding, trestles, pots of paint,
brushes and the apprentices at their tasks" in
this brief absence, he did it so skillfully that upon his return the
master exclaimed: "This boy knows more
than I do."
As is so often the case, such stories, which probably have some
truth in them, tend both to reflect and
perpetuate the attitudes they subsume. Even when based on fact,
these myths about the early manifestations
of genius are misleading. It is no doubt true, for example, that
the young Picasso passed all the
examinations for entrance to the Barcelona, and later to the
Madrid, Academy of Art at the age of fifteen in
but a single day, a feat of such difficulty that most candidates
required a month of preparation. But one
would like to find out more about similar precocious qualifiers

12. for art academies who then went on to
achieve nothing but mediocrity or failure--in whom, of course,
art historians are uninterested--or to study in
greater detail the role played by Picasso's art-professor father in
the pictorial precocity of his son. What if
Picasso had been born a girl? Would Senor Ruiz have paid as
much attention or stimulated as much
ambition for achievement in a little Pablita?
What is stressed in all these stories is the apparently
miraculous, nondetermined, and asocial nature of
artistic achievement; this semireligious conception of the
artist's role is elevated to hagiography in the
nineteenth century, when art historians, critics, and, not least,
some of the artists themselves tended to
elevate the making of art into a substitute religion, the last
bulwark of higher values in a materialistic
world. The artist, in the nineteenth-century Saints' Legend,
struggles against the most determined parental
and social opposition, suffering the slings and arrows of social
opprobrium like any Christian martyr, and
ultimately succeeds against all odds generally, alas, after his
death-because from deep within himself
radiates that mysterious, holy effulgence: Genius. Here we have
the mad van Gogh, spinning out
sunflowers despite epileptic seizures and near-starvation;
Cezanne, braving paternal rejection and public
scorn in order to revolutionize painting; Gauguin throwing away
respectability and financial security with a
single existential gesture to pursue his calling in the tropics; or
Toulouse-Lautrec, dwarfed, crippled, and
alcoholic, sacrificing his aristocratic birthright in favor of the
squalid surroundings that provided him with
inspiration.
Now no serious contemporary art historian takes such obvious

13. fairy tales at their face value. Yet it is this
sort of mythology about artistic achievement and its
concomitants which forms the unconscious or
unquestioned assumptions of scholars, no matter how many
crumbs are thrown to social influences, ideas
of the times, economic crises, and so on. Behind the most
sophisticated investigations of great artists-more
specifically, the art-historical monograph, which accepts the
notion of the great artist as primary, and the
social and institutional structures within which he lived and
worked as mere secondary "influences" or
"background"-lurks the golden-nugget theory of genius and the
free-enterprise conception of individual
achievement. On this basis, women's lack of major achievement
in art may be formulated as a syllogism: If
women had the golden nugget of artistic genius then it would
reveal itself. But it has never revealed itself.
O.E.D. Women do not have the golden nugget theory of artistic
genius. If Giotto, the obscure shepherd boy,
and van Gogh with his fits could make it, why not women?
Yet as soon as one leaves behind the world of fairy tale and
self-fulfilling prophecy and, instead, casts a
dispassionate eye on the actual situations in which important art
production has existed, in the total range of
its social and institutional structures throughout history, one
finds that t he very questions which are fruitful
or relevant for the historian to ask shape up rather differently.
One would like to ask, for instance, from
what social classes artists were most likely to come at different
periods of art history, from what castes and
subgroup. What proportion of painters and sculptors, or more
specifically, of major painters and sculptors,

14. came from families in which their fathers or other close
relatives were painters and sculptors or engaged in
related professions? As Nikolaus Pevsner points out in his
discussion of the French Academy in the
seventeenth and eighteenth centuries, the transmission of the
artistic profession from father to son was
considered a matter of course (as it was with the Coypels, the
Coustous, the Van Loos, etc.); indeed, sons
of academicians were exempted from the customary fees for
lessons. Despite the noteworthy and
dramatically satisfying cases of the great father-rejecting
revoltes~s of the nineteenth century, one might be
forced to admit that a large proportion of artists, great and not-
so-great, in the days when it was normal for
sons to follow in their fathers' footsteps, had artist fathers. In
the rank of major artists, the names of Holbein
and Durer, Raphael and Bernim, immediately spring to mind;
even in our own times, one can cite the
names of Picasso, Calder, Giacometti, and Wyeth as members of
artist-families.
As far as the relationship of artistic occupation and social class
is concerned, an interesting paradigm for
the question "Why have there been no great women artists?"
might well be provided by trying to answer the
question "Why have there been no great artists from the
aristocracy?" One can scarcely think, before the
anti traditional nineteenth century at least, of any artist who
sprang from the ranks of any more elevated
class than the upper bourgeoisie; even in the nineteenth century,
Degas came from the lower nobility more
like the haute bourgeoisie, in fact-and only Toulouse-Lautrec,
metamorphosed into the ranks of the
marginal by accidental deformity, could be said to have come
from the loftier reaches of the upper classes.
While the aristocracy has always provided the lion's share of the

15. patronage and the audience for art-as,
indeed, the aristocracy of wealth does even in our more
democratic days-it has contributed little beyond
amateurish efforts to the creation of art itself, despite the fact
that aristocrats (like many women) have had
more than their share of educational advantages, plenty of
leisure and, indeed, like women, were often
encouraged to dabble in the arts and even develop into
respectable amateurs, like Napoleon III's cousin, the
Princess Mathilde, who exhibited at the official Salons, or
Queen Victoria, who, with Prince Albert, studied
art with no less a figure than Landseer himself. Could it be that
the little golden nugget-genius-is missing
from the aristocratic makeup in the same way that it is from the
feminine psyche? Or rather, is it not that
the kinds of demands and expectations placed before both
aristocrats and women-the amount of time
necessarily devoted to social functions, the very kinds of
activities demanded-simply made total devotion to
professional art production out of the question, indeed
unthinkable, both for upper-class males and for
women generally, rather than its being a question of genius and
talent?
When the right questions are asked about the conditions for
producing art, of which the production of great
art is a subtopic, there will no doubt have to be some discussion
of the situational concomitants of
intelligence and talent generally, not merely of artistic genius.
Piaget and others have stressed in their
genetic epistemology that in the development of reason and in
the unfolding of imagination in young
children, intelligence or, by implication, what we choose to call
genius-is a dynamic activity rather than a
static essence, and an activity of a subject in a situation. As
further investigations in the field of child

16. development imply, these abilities, or this intelligence, are built
up minutely, step by step, from infancy
onward, and the patterns of adaptation-accommodation may be
established so early within the subject-in-
an-environment that they may indeed appear to be innate to the
unsophisticated observer. Such
investigations imply that, even aside from meta-historical
reasons, scholars will have to abandon the notion,
consciously articulated or not, of individual genius as innate,
and as primary to the creation of art.'
The question "Why have there been no great women artists?"
has led us to the conclusion, so far, that art is
not a free, autonomous activity of a super-endowed individual,
"Influenced" by previous artists, and, more
vaguely and superficially, by "social forces," but rather, that the
total situation of art making, both in terms
of the development of the art maker and in the nature and
quality of the work of art itself, occur in a social
situation, are integral elements of this social structure, and are
mediated and determined by specific and
definable social institutions, be they art academies, systems of
patronage, mythologies of the divine creator,
artist as he-man or social outcast.
Extract from Women, Art and Power and Other Essays,
Westview Press, 1988 by Linda Nochlin, pp.147-
158
Journal of Clinical Epidemiology 63 (2010) 1000e1010

17. A prospective cohort study found that provider and information
continuity
was low after patient discharge from hospital
Carl van Walraven
a,b,*, Monica Taljaard
a
, Chaim M. Bell
b,c,d,e
, Edward Etchells
c
, Ian G. Stiell
f
,
Kelly Zarnkeg, Alan J. Forstera
aOttawa Hospital Research Institute, Ottawa, Ontario, Canada
b
Institute for Clinical Evaluative Sciences, Toronto, Ontario,
Canada
c
Department of Medicine, University of Toronto, Toronto,
Ontario, Canada
dKeenan Research Centre of the Li Ka Shing Knowledge
Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
eDepartment of Health Policy Management and Evaluation,
University of Toronto, Toronto, Ontario, Canada
f

18. Department of Emergency Medicine, University of Ottawa,
Ottawa, Ontario, Canada
g
University of Calgary, Alberta, Canada
Accepted 25 January 2010
Abstract
Objective: Continuity of care is composed of provider and
information continuity and can change value over time. Most
studies that
have quantitatively associated continuity of care and outcomes
have ignored these characteristics. This study is a detailed
examination of
continuity of care in patients discharged from hospital that
simultaneously measured separate components of continuity
over time or
determined the factors with which they are associated.
Design Setting: Multicenter, prospective cohort study of
patients discharged to the community after elective or emergent
hospitaliza-
tion. For all physician visits during 6 months after discharge,
we identified the physician and the availability of particular
information (in-
cluding hospital discharge summary and any information from
previous physician visits). Four physician continuity scores
(preadmission;
hospital admitting; hospital consultant; and postdischarge) and
two information continuity scores (discharge summary and
postdischarge
visit information) were calculated for all patients (range: 0e1,
where 0 is perfect discontinuity and 1 is perfect continuity).
Results: Four thousand five hundred fifty-three people were
followed for a median of 175 days. Both provider (range of

19. median values:
0e0.410) and information (range: 0.220e0.427) continuity scores
were low and varied extensively over time. With a few
exceptions, con-
tinuity measures were independent of each other. The influence
of patient factors on continuity varied extensively between the
continuity
measures with the most influential factors being admission
urgency, admitting service, and the number of physicians who
regularly treated
the patient.
Conclusion: Both provider and information continuity was low
in patients discharged from hospital. Continuity measures can
change
extensively over time, which are usually independent of each
other, and are associated with patient and admission
characteristics. Future
studies should measure multiple components of provider and
information continuity over time to completely capture
continuity of
care. � 2010 Elsevier Inc. All rights reserved.
Keywords: Continuity of care; Time-dependent covariates;
Cohort study; Generalized linear mixed model; Continuity of
information; Communication
1. Introduction
Continuity of care is considered a cornerstone for opti-
mal patient care and is central to primary care medicine
[1]. Continuity of care occurs when a patient experiences
coherent and linked care over time and is composed primar-
ily of provider and information continuity [2]. Provider
* Corresponding author. Ottawa Hospital Research Institute,
ASBI-003

20. Carling Avenue, Ottawa, Ontario, Canada K1Y 4E9.
E-mail address: [email protected] (C. van Walraven).
0895-4356/$ - see front matter � 2010 Elsevier Inc. All rights
reserved.
doi: 10.1016/j.jclinepi.2010.01.023
continuity results from an ongoing relationship between
a patient and provider over time, whereas information con-
tinuity indicates that data from prior events are available for
a subsequent patient encounter.
The association between continuity of care and patient
outcomes has been frequently studied [3]. However, to
completely quantify the association between continuity
and patient outcomes, we believe that four issues regarding
the measurement and expression of continuitydwhich have
received limited attention in the literaturedmust be ad-
dressed. First, despite the recognition that continuity of care
has multiple components [2], none of the studies in
mailto:[email protected]
1001C. van Walraven et al. / Journal of Clinical Epidemiology
63 (2010) 1000e1010
a systematic review of continuity of care and outcome [3]
examined both provider and information continuity in a de-
fined group of patients. Such analyses are necessary to
completely describe continuity in a patient cohort.
Second, provider and information continuity measures
both will change value over time at each visit that a patient
experiences. Recognizing this by expressing continuity
measures as time-dependent variables would let researchers
examine the effect of interventions or events on continuity

21. of care. Time-dependent covariates would also improve
regression models that determine how continuity is associ-
ated with outcomes. They could be used in a proportional
hazards model [4,5] or longitudinal analysis. However, in
our systematic review [3], only four studies measured and
expressed continuity as a time-dependent covariate [6e9].
Third, the direct relationship between distinct continuity
measures has not been directly studied. It would not be
unexpected that separate continuity measures are related
because individual provider visits can have multiple charac-
teristics that individually influence those measures. Strong
relationships between these continuity measures could
introduce multicollinearity into regression models and
make their results unreliable.
Finally, the factors that influence continuity have not
been extensively studied. Although several studies have
used survey methods to examine the association of patient
factors with continuity [10e14], the influence of directly
measured patient and system factors on continuity of care
has not been commonly studied. This information is neces-
sary to identify potential confounders in analyses measur-
ing the association between continuity and outcomes and
infer why continuity might be compromised.
In this study, we addressed these four issues when we
studied continuity in a large cohort of patients discharged
from hospital to the community.
2. Methods
2.1. Study design
This was a multicenter prospective cohort study of
patients discharged to the community from the medical or
surgical services of 11 Ontario hospitals (six university-

22. affiliated hospitals and five community hospitals) in five
cities after an elective or emergent hospitalization. Included
patients had to be cognitively intact, have a telephone, and
provide written informed consent. Patients were not
included if they were less than 18 years old, discharged
from obstetrical or psychiatric services, or discharged to
nursing homes. The study was approved by the research
ethics board of each participating hospital.
We chose the postdischarge period to study continuity
because it is an ideal time period to study continuity.
Patients discharged from hospital have a high risk of poor
outcomes [15]. Postdischarge patients often have poor
provider [9] or information continuity [8,16,17].
2.2. Data collection
Before hospital discharge, patients were interviewed by
study personnel to identify their baseline functional status,
living conditions, all physicians who regularly treated the
patient (including both family physicians and consultants),
and chronic medical conditions. The latter were confirmed
by a review of the patient’s chart and hospital discharge
summary, when available. The chart and discharge sum-
mary were also used to identify diagnoses in hospital and
medications at discharge.
Patients or their designated contacts were telephoned 1,
3, and 6 months after their hospital discharge to identify the
date and physician of all visits that they had. We only
counted one visit for the study if patients saw the same phy-
sician more than once in a particular day. Emergency room
visits and hospitalizations (including same-day surgeries)
were not included in this analysis.
For each physician visit, we determined the availabil-
ity of both a discharge summary for the index hospitali-

23. zation and information from previous postdischarge
visits that the patient had with other physicians. The
methods used to collect these data have been previously
detailed [18]. Briefly, we used three complimentary
methods to elicit this information from each follow-up
physician. First, patients gave physicians a survey on
which they listed all prior visits with other doctors for
which they had information. If this survey was not
returned, we faxed the survey to the physician or we
phoned the physician or their office staff and adminis-
tered the survey by telephone.
2.3. Continuity measures
In this study, we used the framework and terminology of
Reid et al. [2], wherein the primary components of overall
continuity of care consist of provider and information con-
tinuity. For the posthospitalization period, we measured
provider continuity for physicians who provided patient
care during three distinct phases: the prehospital period,
the hospital period, and the postdischarge period. Preho-
spital physicians were those classified by the patient as their
regular physician(s) (defined as a physician they had seen
in the past and were likely to see again in the future).
Hospital provider continuity was divided into hospital phy-
sician (i.e., the physician to whom the patient was admit-
ted) continuity and hospital consultant (i.e., another
physician who consulted on the patient during admission)
continuity. Information continuity was broken down as
discharge summary continuity and postdischarge visit
information continuity.
To quantify provider and information continuity, we
used Breslau’s Usual Provider of Continuity (UPC ) [19],
which measures the proportion of visits with the physician
of interest (for provider continuity measures) or the propor-

24. tion of visits having the information of interest (for infor-
mation continuity measures). The UPC was calculated as:
Table 1
Details
Provid
A. P
B. H
C. H
D. P
Inform
E. D
F. Po
in
Abb
1002 inical Epidemiology 63 (2010) 1000e1010
UPC 5 ni=N;
C. van Walraven et al. / Journal of Cl
where UPC ranges from 0 to 1 (where 0 is perfect discon-
tinuity and 1 is perfect continuity); ni is the number of post-
discharge visits to the physician type of interest (e.g.,

25. prehospital, hospital, and postdischarge) or the number of
visits at which the information of interest (e.g., discharge
summary) was available; and N is the total number of post-
discharge visits. Details for calculating each provider and
information continuity measure are given in Table 1.
Figure 1 illustrates how we calculated each continuity
measure over time for a fictitious patient. This figure high-
lights that (1) all continuity measures are incalculable before
the first postdischarge visit; (2) all continuity measures
change value at each visit after during patient observation;
and (3) a physician could be more than one physician type
(e.g., a physician who treated a patient before the admission
in which he/she was the attending physician would be both
a prehospital and hospital physician for that patient).
2.4. Analysis
For each continuity measure within each patient, we cal-
culated the mean daily continuity score as:
PN
1 C
N
;
where C is the continuity score on each day of observation
(Table 1). This score was summed over the total number of
postdischarge days that the patient had a measurable conti-
nuity score (i.e., N ). The mean daily continuity score can
be considered an ‘‘incidence density’’ and has two advan-
tages. First, it allows the calculation of group-level continu-
ity values by using a weighted average of individual-patient
of continuity measures and their calculation
Numerator

26. er continuity measures
readmission No. of postdischarge visits with MD who
regularly treated patient before admission
ospital No. of postdischarge visits with MD under
whom patient was admitted during index
hospitalization
ospital consultant No. of postdischarge visits with MD who
consulted on patient during index
hospitalization
ostdischarge No. of postdischarge visits with MD who
previously saw patient postdischarge
ation continuity measures
ischarge summary No. of postdischarge visits with MD who
had a copy of the discharge summary
from index hospitalization at the time
of the visit
stdischarge visit
formation

27. No. of previous postdischarge visits (with
another MD) for which information
was available
reviation: MD, physician.
continuity values. Second, the mean daily continuity ac-
counts not only for continuity values but also their duration.
We found that the mean daily continuity score for all
provider and information continuities was not normally dis-
tributed. For descriptive purposes, we categorized each
continuity measure into four groups based on their mean
daily continuity score (0; O0 to median continuity; median
up to 75th percentile continuity; and 75th percentile to
maximum continuity). Because hospital consultant continu-
ity was very low in our sample, this was categorized into
two groups (0 and O0).
To account for patient clustering within hospitals, we
used generalized linear mixed modeling (GLMM) to deter-
mine the independent association of patient and admission
factors with each continuity measure. PROC GLIMMIX in
SAS (Cary, NC, USA) was used to create the models with
a beta distribution for the continuity measure, a logit link
function, and the KenwardeRoger method was used for
computing the denominator degrees of freedom. The
GLMM methodology allowed us to express the hospital
as a random effects variable, thereby improving the gener-
alization of our findings to other hospitals. The importance
of all diagnosis nonspecific variables was first determined
with univariate GLMM models. Significant variables (i.e.,
those with a type 3 fixed effects P-value that was !0.05)
were offered to the multivariate model in a forward selec-
tion manner. Variables were retained if they remained

28. significant in the model. Goodness of fit was evaluated
using studentized residual plots.
Calculation of postdischarge visit information continuity
scores required physicians to tell us whether they had infor-
mation from previous visits that the patient had with other
physicians. As described above, this information was
provided by paper or phone survey. Of the 23,454
Denominator Notes
No. of postdischarge
MD visits
No. of postdischarge
MD visits
No. of postdischarge
MD visits
Applies only to patients who had
>1 consultation in hospital
No. of postdischarge
MD visits �1
Can be calculated only after first
postdischarge visit
No. of postdischarge
MD visits

29. No. of previous visits
with another MD
Can be calculated only if patient had
prior visits with another MD. The
mean value at each visit was averaged
to calculate continuity score over time
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
C
O
N
T
I
N

30. U
I
T
Y
S
C
O
R
E
Pre-hospital Hospital Consultant Post DC
Pre Hospital MD Hospital MD Consultant MD
Post DC MDs
Continuity Scores
WEEKS FROM DISCHARGE
Fig. 1. Illustration of provider continuity measures for a patient
following
discharge from hospital. This figure illustrates how we
calculated continu-
ity scores at each postdischarge visit for a hypothetical patient.
Here, we
focus on provider continuity. The top of the figure identifies the
physicians

31. who treated this patient (prehospital physician: Dr Circle;
hospital physi-
cian: Dr Diamond; and hospital consultant: Dr Square). This
patient’s first
postdischarge was with Dr Circle. As a result, the prehospital
provider con-
tinuity score at the first visit was 1.0 (1 over 1). The rest of the
provider
continuity scores were 0. All continuity scores stayed at these
values until
the second visit with Dr Triangle, whom the patient had never
seen below.
Because Dr Triangle is not a prehospital physician, the
prehospital pro-
vider continuity score drops to 0.5 (1 over 2). All of the other
provider con-
tinuity scores remain at 0. The third visit was with Dr Square, a
hospital
consultant. As a result, the consultant continuity score increases
to 0.33
(1 over 3). The prehospital continuity score drops to the same
value. This
process was repeated at each visit to calculate all provider
continuity

32. scores at each day of the patient’s observation. Details for
calculating con-
tinuity scores are given in Table 1.
Recruited
5035
1+ Follow-up Interview
4761 (94.6%)
No Follow-Up
274 (5.4%)
1+ MD visit recorded
4553 (90.4%)
No MD visits
208 (4.0%)
Complete Follow-Up
100 (2.0%)
Incomplete Follow-Up
108 (2.1%)
Complete Follow-Up
4222 (83.8%)
Incomplete Follow-Up
331 (7.3%)
Fig. 2. Patient follow-up. The study cohort (n 5 4,553) is
indicated in
green. Its creation from the originally recruited patients is

33. illustrated.
Red boxes indicate recruited patients with incomplete follow-
up. Blue
boxes indicate patients with complete follow-up. Details for
loss to
follow-up are given in the study text.
1003C. van Walraven et al. / Journal of Clinical Epidemiology
63 (2010) 1000e1010
postdischarge visits, we had complete information for
18,087 (77.1%).
We therefore imputed missing data with a logistic model
that contained all relevant variables, including those from
a previous study that examined factors influencing informa-
tion continuity [18]. This model had 37 variables, and it
estimated the probability that information from each previ-
ous visit with another physician was available. Using this
point estimate and its standard error, we randomly selected
the estimated probability that information was available for
a previous visit. This estimated probability was then used in
a Bernoulli draw to impute a value of 0 or 1 indicating
whether information was available for that particular visit.
A total of 10 imputations were used for the analysis. We
determined the important variables to be included in the
model using a complete case analysis (i.e., visits with miss-
ing information were excluded). A GLMM model was then
created for each imputed data set. The parameter estimates
from each regression model were combined using PROC
MIANALYZE (SAS, Cary, NC, USA).
Imputation was not required for discharge summary con-
tinuity because the summary identified the date on which it

34. was created and all physicians to whom a discharge sum-
mary was sent. Comparing this information with the visit
date and physician allowed us to infer whether the physi-
cian had a copy of the discharge summary at the time of
the visit. As in a previous study [20], we allowed a time
lapse of 3 days for the summary to be sent to the receiving
physician.
3. Results
Between October 2002 and July 2006, we enrolled 5,035
patients from 11 hospitals (Fig. 2). Four thousand five hun-
dred fifty-three (90.4%) patients made it into our study, of
whom 4,222 (83.8% of the original cohort) had complete
follow-up for the entire 6-month study. Seven hundred thir-
teen (14.2%) patients had incomplete follow-up because
300 were lost to follow-up; 169 refused participation; 128
died; 86 were readmitted to hospital; and 30 were trans-
ferred into a nursing home.
Study patients are described in Table 2. Patients were
observed in the study for a median of 175 days (interquar-
tile range [IQR]: 175e178). During this time, they had
a median of four physician visits (IQR: 3e6). The first post-
discharge physician visit occurred on a median of 11 days
(IQR: 6e20) after discharge from hospital.
3.1. Provider and information continuity
Figure 3 summarizes the mean daily continuity scores
for all measures. All continuity distributions, with the
exception of consultant continuity scores, had bimodal dis-
tributions with modes occurring at the minimum and max-
imum values. All continuity measures had median values
below 0.5 with hospital physician and hospital consultant
continuity having the lowest values (median: 0.078, IQR:
0e0.468 and 0 IQR: 0-0, respectively). The highest
provider continuity measure was the postdischarge physi-

35. cian continuity score with a median value of 0.410 (IQR:
0.190e0.792). The median (IQR) discharge summary and
postdischarge visit information continuity was 0.427
(0e0.842) and 0.220 (0e0.775), respectively.
Table 2
Description of patient cohort (N 5 4,553)
Factor Value N (%)
Mean patient age (SD) 61.4 (16.8)
Female 2,396 (52.6)
Lives alone 1,053 (23.1)
Charlson score 0 3,508 (77.0)
1 145 (3.2)
2 615 (13.5)
O2 285 (6.2)
Chronic disease
Hypertension 1,813 (39.8)
Dyslipidemia 893 (19.6)
Diabetes mellitus 788 (17.3)
Coronary artery disease 650 (14.3)

36. Cancer 529 (11.6)
Previous surgical procedures
CABG 529 (11.6)
Laparoscopic cholecystectomy 283 (6.2)
Appendectomy 310 (6.8)
Hip arthroplasty 255 (5.6)
Knee arthroplasty 113 (2.5)
No. of admissions in previous 6 months 0 3,091 (67.9)
1 1,089 (23.9)
O1 373 (8.2)
No. of activities of daily living requiring
aids
0 4,261 (93.6)
1 165 (3.6)
O1 127 (2.8)
No. of MDs who see patient regularly 0 347 (7.6)
1 3,944 (86.6)
2 203 (4.5)
O2 59 (1.3)
Index hospitalization description

37. Median length of stay in days (IQR) 4 (2e8)
Median total number of discharge
medications (IQR)
4 (2e7)
Emergent admission 2,589 (56.9)
Admitted to medical service 1,999 (43.9)
Acute diagnoses
CAD 296 (6.5)
Neoplasm of unspecified nature 246 (5.4)
Heart failure 198 (4.3)
Influenza 141 (3.1)
Cardiac dysrhythmias 123 (2.7)
Acute procedures
CABG 216 (4.7)
Total knee arthroplasty 190 (4.2)
Total hip arthroplasty 124 (2.7)
Appendectomy 113 (2.5)
Colectomy/colostomy 79 (1.7)

38. No. of complications in hospital 0 3,989 (87.6)
1 396 (8.7)
O1 168 (3.7)
No. of consultations in hospital 0 2,829 (62.1)
1 1,402 (30.8)
O1 322 (7.1)
Abbreviations: IQR, interquartile range; CABG, coronary artery
bypass
graft; CAD, coronary artery disease.
1004 C. van Walraven et al. / Journal of Clinical Epidemiology
63 (2010) 1000e1010
3.2. Time-dependent nature of continuity
Individual patient continuity measures varied exten-
sively during their observation period (Table 3). For pread-
mission and postdischarge provider continuity, the median
individual-patient range was 0.333 (or one-third of the
continuity scale). For all continuity measures except hospi-
tal consultant continuity, the 75th percentile of the
individual-patient range was at least one-half of the entire
continuity scale (i.e., 0.5).
As with the patient level, group-level continuity measures
also varied extensively over time (Fig. 4). For each continuity
measure, the proportion of people at each continuity score
range changed extensively over time. For example, more than
80% of people had no follow-up with a hospital physician in
the first week after discharge from hospital. However, this

39. proportion decreased to 50% by 6 months. Such large varia-
tions in continuity were seen in all continuity measures
except that for hospital consultant, which remained consis-
tently low throughout the study with approximately 90% of
patients never seeing a hospital consultant in follow-up. In
addition, dissemination of information between postdi-
scharge physicians improved as time progressed, but infor-
mation for any previous visit was always absent in more
than one-third of patients throughout in the study.
3.3. Correlation between continuity measures
Figure 5 illustrates that most continuity measures were
independent of each other or were only weakly associated
with several notable exceptions. Prehospital physician and
discharge summary continuity were significantly and posi-
tively correlated. Prehospital physician and hospital physi-
cian continuity were negatively associated with each other.
The strongest correlations existed between postdischarge
physician and postdischarge information continuity with
values of approximately 0.5.
Figure 5 also illustrates the correlations between conti-
nuity measures over time. Most of the correlations changed
in the first month after discharge, likely reflecting instabil-
ity of the individual continuity measures when the total
number of follow-up visits was small. More than a month
after discharge from hospital, most correlations remained
stable with two exceptions. The correlation between postdi-
scharge physician and postdischarge information, as well as
that between prehospital and hospital physician, both
significantly trended toward unity as time progressed.
3.4. Factors influencing continuity
Table 4 details the independent association of baseline fac-
tors with each continuity measure. Some findings are notable.
Older patients had significantly better prehospital physician

40. continuity but worse hospital and consultant continuity. As
the complexity of patient chronic problems (as reflected by
the Charlson score) increased, prehospital provider continuity
decreased significantly. An increased number of regular
physicians were associated with increased preadmission phy-
sician continuity but decreased hospital physician, postdi-
scharge physician, and postdischarge information continuity.
Patients who stayed in hospital longer had significantly worse
Fig. 3. Provider and information continuity in study patients.
This figure summarizes mean daily continuity scores for four
provider continuity measures
(AeD) and two information continuity measure (EeF). Each plot
presents patient continuity scores for the entire study
observation period (see Table 1
for details regarding the calculation of the six continuity
measures). Each figure presents these scores (horizontal axis)
by groups of 0.1 width. The midpoint
value of each category is presented on the horizontal axis. The
vertical axis presents the number of people in each category.
Below each plot, we present the
median (‘‘Q2’’) and 75th percentile (‘‘Q3’’) value for each
continuity measure.
1005C. van Walraven et al. / Journal of Clinical Epidemiology
63 (2010) 1000e1010
hospital physician continuity but much better discharge sum-
mary continuity. This pattern, where worse hospital physician
continuity was balanced by improved discharge summary
continuity, was also seen when patients were admitted to med-

41. ical instead of surgical services. Emergent admissions had bet-
ter continuity with both preadmission physicians and
postdischarge physicians but worse continuity with hospital
Table 3
Ranges of continuity measures for individual patients
Minimum 25th Percentile
Provider continuity
A. Preadmission 0 0
B. Attending 0 0
C. In-hospital consultanta 0 0
D. Postdischarge 0 0.087
Information continuity
E. Discharge summary 0 0
F. Postdischarge visit 0 0
a Applies only to those patients who had an in-hospital
consultation (n 5 1,
physicians. Finally, having a complication in hospital did
not increase hospital physician continuity.
4. Discussion
To our knowledge, this is the most in-depth examination
of patient continuity after discharge from hospital. Overall,
Median 75th Percentile Maximum
0.333 0.500 0.923

42. 0 0.500 0.952
0 0 0.917
0.333 0.500 0.894
0.200 0.500 0.923
0.214 0.950 0.950
724).
Fig. 4. Group-level continuity measures over time. These plots
present each continuity measure in the study cohort during their
observation period after
discharge from hospital. In each plot, the horizontal presents the
months from discharge, and the vertical axis presents the
percent of people with each con-
tinuity value range. The continuity values that consist each
range are presented below each plot. In each plot, gray indicates
a continuity measure of 0; light
blue indicates continuity measures between 0 and the median;
dark blue indicates continuity measures between median and the
75th percentile; and black
indicates continuity measures between 75th percentile and 1.
1006 C. van Walraven et al. / Journal of Clinical Epidemiology
63 (2010) 1000e1010
we found that continuity was low in all spheres of both pro-

43. vider and information continuity; each of these measures
can change extensively over time for both individual pa-
tients and the entire population; the individual continuity
scores were mostly independent of each other; and provider
and information continuity was significantly influenced by
a few patient and hospitalization factors.
Our results highlight the poor continuity of care that pa-
tients experience when they are discharged from the hospi-
tal. The median score was less than 50% for all continuity
measures. In the 6 months after discharge from hospital, al-
most one-third of patients did not see one of their regular
treating physicians. In the same period, one-half of patients
never saw the hospital physician who treated them during
their admission. Consultants who saw patients during their
admission rarely saw them after discharge from hospital.
We found it encouraging that more than half of patients
had a discharge summary available for more than 50% of
their follow-up visits. However, more than half of patients
haddon averagedonly a one-in-five chance or less that
information from previous visits with other doctors was
available at their follow-up visit. These results show the
large room for improvement in continuity of patient care
when they are discharged from the hospital.
Because increased continuity of care is associated with
improved patient outcomes [3], our findings demonstrate
a large opportunity to increase continuity of care, which
could lead to better patient outcomes after discharge from
hospital. This could be accomplished by consciously ensur-
ing that patients are seen in follow-up by their preadmission
and hospital physicians. We hope that improved information
technologies and enhanced provider integration will increase
information continuity. These interventions will increase
overall patient continuity in the postdischarge period.

44. Fig. 5. Correlation between continuity measures over time. The
correlation between all combinations of continuity measures is
presented over time. The
specific continuity measures in each plot are listed along the top
row and left column. In each plot, correlation (vertical axis) is
presented as the Spearman
correlation coefficient ranging from �1 to þ1. The horizontal
axis presents the number of months since hospital discharge
(ranging from 0 to 6). MD 5
physician.
1007C. van Walraven et al. / Journal of Clinical Epidemiology
63 (2010) 1000e1010
However, our analysis shows that increasing one conti-
nuity measure could decrease another continuity measure.
For example, we found that prehospital physician continu-
ity was negatively correlated with hospital physician conti-
nuity (Fig. 5). We also found that factorsdincluding
patient age, the number of regular physicians, emergent ad-
missions, and admission to a medical servicedthat were
significantly associated with increased prehospital physi-
cian continuity were also associated with decreased hospi-
tal continuity (Table 4). It is possible that the various
continuity components would have different influences on
patient outcomes. We therefore believe that it is essential
to accurately quantify the influence of the various compo-
nents of continuity of care on patient outcomes prior to in-
troducing interventions designed to change patient
continuity.
We believe that our study makes several notable con-
clusions for future studies regarding continuity of care in

45. patients. First, our findings highlight that continuity of
care can change extensively over time for both individual
patients (Table 3) and entire patient groups (Fig. 4). This
extensive variation in continuity over time highlights the
importance of measuring continuity of care in a time-
dependent fashion and expressing them as such in analy-
ses. Failure to do so could threaten studies that try to
determine the influence of continuity on patient outcomes
[21]. Second, our findings show the importance of measur-
ing multiple components of continuity of care [2]. Our
results quantitatively support this proposition given the
complete independence between most continuity measures
(Fig. 5).
Several factors were often associated with continuity.
Patients from medical services had significantly better con-
tinuity for prehospital physician, postdischarge physician,
discharge summary, and postdischarge information,
whereas surgical patients were significantly more likely to
have follow-up by the hospital physician (Table 4). Emer-
gent admissions also had significantly increased prehospital
Table 4
Independent influence of factors on provider and information
continuity rates
Adjusted relative percent change (95% confidence interval)
Provider continuity Information continuity
Baseline factors Comparitor Prehospital MD Hospital
Consultanta Postdischarge, MD

46. Discharge
summary
Postdischarge
information
Patient age increased
by 1 decade
d 14.1 (11.0, 17.2) �10.7 (�13.6, �7.7) �10.3 (�18.1, �1.7) d
d d
Female Male 17.3 (7.8, 27.6) d �37.3 (�53.8, �14.9) d d d
Charlson score
1 Score of 0 1.4 (�20.0, 28.6) �28.1 (�50.4, 4.4) d d d d
2 �13.9 (�24.1, �2.3) �17.4 (�30.0, �2.5) d d d d
O2 �19.3 (�32.5, �3.6) �21.5 (�42.5, 7.1) d d d d
Admissions in last 6 months
1 None d �14.2 (�26.1, �0.4) d d d d
O1 d �21.7 (�37.5, �1.8) d d d d
No. of MDs who see patient regularly
1 None b �29.2 (�41.6, �14.2) d 10.5 (�6.8, 30.9) d �1.1
(�19.1, 20.8)
2 97.7 (60.5, 143.5) �45.1 (�60.4, �24.1) d �11.8 (�32.1,
14.5) d �32.8 (�51.6, �6.8)
O2 141.8 (65.8, 252.7) �55.4 (�73.9, �24.0) d �43.8 (�62.9,
�14.8) d �57.8 (�75.6, �27.2)

47. Hospital length of stay
2e3 days !2 days d �14.8 (�27.1, �0.5) d d 31.7 (12.6, 54.0) d
4e7 days d �21.2 (�32.0, �8.7) d d 62.4 (40.5, 87.7) d
O7 days d �40.7 (�50.1, �29.6) d d 54.4 (32.5, 79.8) d
Emergent admission Elective 12.4 (1.2, 24.9) �41.0 (�47.6,
�33.5) d 11.8 (0.9, 23.9) d 18.0 (4.2, 33.6)
Admitted to medical
service
Surgery 73.2 (55.0, 93.4) �82.2 (�84.8, �79.2) d 29.1 (16.2,
43.5) 103 (83.0, 125) 15.1 (1.0, 31.1)
No. of complications in hospital
1 None 20.8 (3.8, 40.5) d d d d d
O1 �11.8 (�29.7, 10.5) d d d d d
Consultation in hospital None d 2.0 (0.4, 3.5) c d d d
Abbreviation: MD, physician.
This table presents the independent association of baseline
factors with each of the six continuity measures. These
associations are expressed as the adjusted relative percent
change in the mean daily
continuity score. Positive values indicate that the baseline
factor increased continuity compared with the comparator.
a
Applies only to those patients who had an in-hospital
consultation (n 5 1,724).
b

48. For the Prehospital Physician Continuity model, the comparator
was patients with 0 or 1 physician.
c This variable was not included in the model (because its value
was ‘‘1’’ for all people in this analysis).
1
0
0
8
C
.
v
a
n
W
a
lra
v
e
n
e
t
a
l.
/
Jo

49. u
rn
a
l
o
f
C
lin
ic
a
l
E
p
id
e
m
io
lo
g
y
6
3
(2
0

50. 1
0
)
1
0
0
0
e
1
0
1
0
1009C. van Walraven et al. / Journal of Clinical Epidemiology
63 (2010) 1000e1010
physician, postdischarge physician, and postdischarge
information continuity but significantly worse hospital
physician continuity. These findings indicate that the influ-
ence of patient factors on various aspects of continuity can
vary extensively.
Our study has several strengths that increase the reliabil-
ity of its results. We included a large collection of patients
who were discharged to the community from 11 different
hospitals across Ontario. Our follow-up and data collection
for these patients was very complete. Our data allowed us
to calculate multiple provider and information continuities
for all patients at all times of their follow-up. This allowed

51. us to examine overall patient continuity from multiple
views over a protracted period of time.
Our study also has some noteworthy issues that need to
be considered when interpreting its results. First, we are
uncertain how representative our results would be in other
health care environments. It is possible that continuity of
care differs greatly in other countries with different health
care systems and practice. However, because our study had
very inclusive inclusion criteria and was successful in re-
cruiting a large proportion of patients being discharged
from the study hospitals, we are confident that our results
are representative of patients in Ontario. In addition, our
analysisdin which the hospital was expressed as a random
effects termdshould improve the validity of generalizing
our results to other hospitals in Ontario. Second, our study
excluded patients discharged from obstetrical and psychi-
atric wards. As such, we are uncertain how our results
would apply to these patient populations. Third, we did
not measure the patients’ perception of their continuity
of care. Eliciting the patient’s view would strengthen the
study’s measurement of continuity. Fourth, our measure
of information continuity was limited to the presence or
absence of information about a previous physician encoun-
ter. We did not measure the relevance of that information
or whether that information was actually used during the
current patient encounter. Finally, our analysis treated all
visits the same when calculating the continuity scores
and this may be inappropriately simple. For example, hav-
ing access to the hospital discharge summary is likely
more important to patient care in the early postdischarge
period. Future analyses examining how continuity of care
influences outcomes may determine the interaction of
physician visit types on the association of continuity of
care on outcomes.

52. We assessed continuity of care for more than 4,000
patients discharged from 11 community and university-
affiliated hospitals. Our study shows that continuity of
care for most patients after they leave the hospital is
poor. However, accurate representation of patient conti-
nuity requires multiple provider and information mea-
sures over time. Future studies need to determine the
independent association of these continuity measures
with important patient outcomes after discharge from
hospital. Before the introduction of interventions to
increase continuity, studies are necessary to determine
the independent association of each continuity compo-
nent with outcomes.
Acknowledgments
None of the authors have any potential conflicts of inter-
est, financial interests, relationships, or affiliations relevant
to the subject of their manuscript.
Dr van Walraven had full access to all of the data in the
study and takes responsibility for the integrity of the data
and the accuracy of the data analysis.
This study was conducted using funding from Canadian
Institutes for Health Research and the Physicians’ Services
Incorporated Foundation. Neither funding agency had any
role in the conduct of the study.
Dr Forster is a Career Scientist with the Ontario Ministry
of Health and Long-Term Care.
References
[1] Harris MF, Frith JF. Continuity of care: in search of the
Holy Grail of
general practice. Med J Aust 1996;164:456e7.

53. [2] Reid R, Haggerty J, McKendry R. Defusing the confusion:
concepts
and measures of continuity of healthcare. Ottawa, Canada:
Canadian
Health Services Research Foundation; 2002. pp. 1e50.
[3] van Walraven C, Oake N, Jennings A, Forster AJ. The
association be-
tween continuity of care and outcomes: a systematic and critical
re-
view. J Eval Clin Pract 2010 Jun 11. [Epub ahead of print].
[4] Allison PD, editor. Estimating Cox-regression models with
PROC
PHREG. In: Survival analysis using the SAS system. Cary, NC:
SAS Institute Inc.; 2000. p. 111e84.
[5] Fisher LD, Lin DY. Time-dependent covariates in the Cox
proportional-hazards regression model. Annu Rev Public Health
1999;20:145e57.
[6] Christakis DA, Wright JA, Koepsell TD, Emerson S,
Connell FA. Is
greater continuity of care associated with less emergency
department
utilization? Pediatrics 1999;103(4 Pt 1):738e42.

54. [7] Christakis DA, Mell L, Koepsell TD, Zimmerman FJ,
Connell FA.
Association of lower continuity of care with greater risk of
emer-
gency department use and hospitalization in children. Pediatrics
2001;107:524e9.
[8] van Walraven C, Seth R, Austin PC, Laupacis A. Effect of
discharge
summary availability during post-discharge visits on hospital
read-
mission. J Gen Intern Med 2002;17(3):186e92.
[9] van Walraven C, Mamdani MM, Fang J, Austin PC.
Continuity of
care and patient outcomes after hospital discharge. J Gen Intern
Med 2004;19:624e45.
[10] Turner D, Tarrant C, Windridge K, Bryan S, Boulton M,
Freeman G,
et al. Do patients value continuity of care in general practice?
An
investigation using stated preference discrete choice
experiments.
J Health Serv Res Policy 2007;12:132e7.

55. [11] Baker R, Boulton M, Windridge K, Freeman GK.
Interpersonal con-
tinuity of care: a cross-sectional survey of primary care
patients’ pref-
erences and their experiences. Br J Gen Pract
2007;57(537):283e9.
[12] Mainous AG III, Goodwin MA, Stange KC. Patient-
physician shared
experiences and value patients place on continuity of care. Ann
Fam
Med 2004;2:452e4.
[13] Love MM, Mainous AG III, Talbert JC, Hager GL.
Continuity of care
and the physician-patient relationship: the importance of
continuity
for adult patients with asthma. J Fam Pract 2000;49:998e1004.
1010 C. van Walraven et al. / Journal of Clinical Epidemiology
63 (2010) 1000e1010
[14] Christakis DA, Kazak AE, Wright JA, Zimmerman FJ,
Bassett AL,
Connell FA. What factors are associated with achieving high
continu-
ity of care? Fam Med 2004;36(1):55e60.

56. [15] Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW.
The
incidence and severity of adverse events affecting patients
after discharge from the hospital. Ann Intern Med 2003;138(3):
161e7.
[16] Bell CM, Schnipper JL, Auerbach AD, Kaboli PJ,
Wetterneck TB,
Gonzales DV, et al. Association of communication between
hospital-based physicians and primary care providers with
patient
outcomes. J Gen Intern Med 2009;24:381e6.
[17] Kripalani S, LeFevre F, Phillips CO, Williams MY,
Basaviah P,
Baker DW. Deficits in communication and information transfer
between hospital-based and primary care physicians:
implications
for patient safety and continuity of care. JAMA
2007;297:831e41.
[18] van Walraven C, Taljaard M, Bell C, Williams MV,
Basaviah P,
Baker DW. Information exchange among physicians caring for
the

57. same patient in the community. Can Med Assoc J
2008;179:1013e8.
[19] Breslau N, Reeb KG. Continuity of care in a university-
based
practice. J Med Educ 1975;965e9.
[20] van Walraven C, Seth R, Laupacis A. Dissemination of
discharge
summaries. Not reaching follow-up physicians. Can Fam
Physician
2002;48:737e42.
[21] van Walraven C, Davis D, Forster AJ, Wells GA. Time-
dependent
bias due to improper analytical methodology is common in
promi-
nent medical journals. J Clin Epidemiol 2004;57:672e82.
A prospective cohort study found that provider and information
continuity was low after patient discharge from
hospitalIntroductionMethodsStudy designData
collectionContinuity measuresAnalysisResultsProvider and
information continuityTime-dependent nature of
continuityCorrelation between continuity measuresFactors
influencing continuityDiscussionAcknowledgmentsReferences

58. Research Critique Guidelines
To write a critical appraisal that demonstrates comprehension of
the research study conducted, address each component below
for qualitative study in the Topic 2 assignment and the
quantitative study in the Topic 3 assignment.
Successful completion of this assignment requires that you
provide a rationale, include examples, or reference content from
the study in your responses.
Qualitative Study
Background of Study:
· Identify the clinical problem and research problem that led to
the study. What was not known about the clinical problem that,
if understood, could be used to improve health care delivery or
patient outcomes? This gap in knowledge is the research
problem.
· How did the author establish the significance of the study? In
other words, why should the reader care about this study? Look
for statements about human suffering, costs of treatment, or the
number of people affected by the clinical problem.
· Identify the purpose of the study. An author may clearly state
the purpose of the study or may describe the purpose as the
study goals, objectives, or aims.
· List research questions that the study was designed to answer.
If the author does not explicitly provide the questions, attempt
to infer the questions from the answers.
· Were the purpose and research questions related to the
problem?
Method of Study:
· Were qualitative methods appropriate to answer the research
questions?
· Did the author identify a specific perspective from which the
study was developed? If so, what was it?
· Did the author cite quantitative and qualitative studies
relevant to the focus of the study? What other types of literature
did the author include?
· Are the references current? For qualitative studies, the author

59. may have included studies older than the 5-year limit typically
used for quantitative studies. Findings of older qualitative
studies may be relevant to a qualitative study.
· Did the author evaluate or indicate the weaknesses of the
available studies?
· Did the literature review include adequate information to build
a logical argument?
· When a researcher uses the grounded theory method of
qualitative inquiry, the researcher may develop a framework or
diagram as part of the findings of the study. Was a framework
developed from the study findings?
Results of Study
· What were the study findings?
· What are the implications to nursing?
· Explain how the findings contribute to nursing
knowledge/science. Would this impact practice, education,
administration, or all areas of nursing?
Ethical Considerations
· Was the study approved by an Institutional Review Board?
· Was patient privacy protected?
· Were there ethical considerations regarding the treatment or
lack of?
Conclusion
· Emphasize the importance and congruity of the thesis
statement.
· Provide a logical wrap-up to bring the appraisal to completion
and to leave a lasting impression and take-away points useful in
nursing practice.
· Incorporate a critical appraisal and a brief analysis of the
utility and applicability of the findings to nursing practice.
· Integrate a summary of the knowledge learned.
Quantitative Study

60. Background of Study:
· Identify the clinical problem and research problem that led to
the study. What was not known about the clinical problem that,
if understood, could be used to improve health care delivery or
patient outcomes? This gap in knowledge is the research
problem.
· How did the author establish the significance of the study? In
other words, why should the reader care about this study? Look
for statements about human suffering, costs of treatment, or the
number of people affected by the clinical problem.
· Identify the purpose of the study. An author may clearly state
the purpose of the study or may describe the purpose as the
study goals, objectives, or aims.
· List research questions that the study was designed to answer.
If the author does not explicitly provide the questions, attempt
to infer the questions from the answers.
· Were the purpose and research questions related to the
problem?
Methods of Study
· Identify the benefits and risks of participation addressed by
the authors. Were there benefits or risks the authors do not
identify?
· Was informed consent obtained from the subjects or
participants?
· Did it seem that the subjects participated voluntarily in the
study?
· Was institutional review board approval obtained from the
agency in which the study was conducted?
· Are the major variables (independent and dependent variables)
identified and defined? What were these variables?
· How were data collected in this study?
· What rationale did the author provide for using this data
collection method?
· Identify the time period for data collection of the study.
· Describe the sequence of data collection events for a
participant.

61. · Describe the data management and analysis methods used in
the study.
· Did the author discuss how the rigor of the process was
assured? For example, does the author describe maintaining a
paper trail of critical decisions that were made during the
analysis of the data? Was statistical software used to ensure
accuracy of the analysis?
· What measures were used to minimize the effects of researcher
bias (their experiences and perspectives)? For example, did two
researchers independently analyze the data and compare their
analyses?
Results of Study
· What is the researcher's interpretation of findings?
· Are the findings valid or an accurate reflection of reality? Do
you have confidence in the findings?
· What limitations of the study were identified by researchers?
· Was there a coherent logic to the presentation of findings?
· What implications do the findings have for nursing practice?
For example, can the findings of the study be applied to general
nursing practice, to a specific population, or to a specific area
of nursing?
· What suggestions are made for further studies?
Ethical Considerations
· Was the study approved by an Institutional Review Board?
· Was patient privacy protected?
· Were there ethical considerations regarding the treatment or
lack of?
Conclusion
· Emphasize the importance and congruity of the thesis
statement.
· Provide a logical wrap-up to bring the appraisal to completion
and to leave a lasting impression and take-away points useful in
nursing practice.
· Incorporate a critical appraisal and a brief analysis of the
utility and applicability of the findings to nursing practice.
· Integrate a summary of the knowledge learned.

62. Reference
Burns, N., & Grove, S. (2011). Understanding nursing research
(5th ed.). St. Louis, MO: Elsevier.
© 2016. Grand Canyon University. All Rights Reserved.
4