How have remote and digital approaches impacted continuity? A mixed-studies systematic review

Abstract

Background: The value of continuity in primary care has been demonstrated for multiple outcomes. However, little is known about how the expansion of remote and digital care models have impacted continuity. Aim: To conduct a mixed-methods systematic review to explore how expansion of remote and digital care models have impacted continuity. Design and Setting: A systematic search of electronic databases with snowball sampling to identify relevant qualitative and quantitative studies. Methods: 17 English-language studies (any country, 2000-2022) exploring remote or digital approaches in primary care and continuity were identified. Relevant data were extracted, analysed using GRADE-CERQual, and narratively synthesised. Results: The specific impact of remote approaches on continuity was rarely overtly addressed. Some patients expressed a preference for relational continuity depending on circumstance, problem, and context, whilst others prioritised access. Clinicians valued continuity with some viewing remote consultations more suitable for patients where there was high episodic or relational continuity. With lower continuity, patients and clinicians considered remote consultations harder, higher risk, and poorer quality. Some evidence suggested remote approaches, and/or their implementation risked worsening inequalities and causing harm by reducing continuity where it was valuable. However, if deployed strategically and flexibly, remote approaches could improve continuity. Conclusion: The dearth of evidence around continuity in a remote and digital context is troubling. Further research should explore the links between the shift to remote care, continuity and equity, using real-world evaluation frameworks to ascertain when and for whom continuity adds most value and how this can be enabled or maintained.