Geographic variation in patient continuity and discontinuity in general practice in Region of Southern Denmark - a retrospective registry-based study

Geographic variation in patient continuity and discontinuity in general practice in Region of Southern Denmark - a retrospective registry-based study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Geographic variation in patient continuity and discontinuity in general practice in Region of Southern Denmark - a retrospective registry-based study Peder Ahnfeldt-Mollerup, Troels Kristensen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3846217/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background It is well known that patients in general practice live in health care systems where geography may be their destiny because of different circumstances in different geographic locations. Therefore, it is important to explore the variation in continuity of care to understand this central characteristic of the health care system. Aim To describe the geographic variation in continuity and discontinuity of care for patients listed in general practices across municipalities and between urban and rural areas in the Region of Southern Denmark. Methods This was a retrospective cohort registry study of patients older than 12 years who were enrolled in general practice in 22 municipalities in the Region of Southern Denmark from 2007–2018. Continuity of care is here the length of enrollment with a general practice, and discontinuity of care is the number of times a patient changes general practice. The data are based on civil registration numbers for patients, general practice provider numbers, patient age at each change of their general practice, and data on the municipality where each patient has their address. Results The cohort included 982,644 patients in 22 municipalities. The average duration of enrollment per patient at a general practice was 7.9 years. A total of 27.1% of patients had been enrolled for 0–5 years, 28.7% for 5–10 years and 44.2% for more than ten years. Discontinuity in terms of the number of changes between practices revealed that 44.7% of patients had no discontinuity, 28.7% had experienced one change in general practice, 13.8% had two changes, 6.3% had three changes, and 7.1% had four or more changes. The average number of times a patient changes their general practice was 1.14. Compared to rural municipalities, there is a trend toward more discontinuity and shorter times of enrollment in general practice in urban municipalities. Conclusions There was a significant difference between urban and rural settings, where at least a portion of patients in urban municipalities had shorter enrollments in general practice and more frequent changes between practices. Given that many patients change their general practice, focusing on how to address discontinuity is recommended. General practice continuity of care health service. Introduction Continuity of care is regarded as a central element for patient outcomes and has been associated with less contact with the healthcare sector, a lower rate of hospitalization, and lower mortality ( 1 – 3 ). Therefore, it is relevant to explore measures of continuity and discontinuity of care that may vary depending on geography and between rural versus urban areas. The extent of continuity of care is dependent on different factors related to both the practice sector, to patient characteristics, and personal preferences, which may vary across geography ( 4 ). The latter has rarely been explored and never in this geographic way before. In the modern world, there seems to be a continuously changing health care sector and, at the same time, geographic mobility ( 5 , 6 ). Thus, withholding a regular general practitioner (GP) can be difficult, and this will affect the continuity of care. However, continuity of care is considered a complex concept ( 7 , 8 ), but the essential part is that the physicians and/or the health care staff get to know the patient’s life story and the context in which the patient lives more thoroughly ( 7 ). In this way, a relationship of trust is created, which can have an impact on the patient’s experience of the medical service provided and can contribute to the patient’s greater adherence to the advice, guidance and treatment recommended (9, 10). Often, but not always, medical files are handed over whenever patients change their general practice. However, exposure to discontinuity of care in the general practice sector and related enrollment durations in a specific practice have rarely been analyzed ( 11 ). In municipalities in urban areas, a high proportion of the population moves to and from the city due to e.g., educational activities and job opportunities ( 4 – 6 ). Rural and remote areas have the lowest shares of the EU’s population in age groups younger than 50 years ( 12 ), and the density of general practices is not surprisingly greater in urban areas than in rural areas. Thus, continuity of care in general practice is likely to depend on geographical factors and may vary depending on where people live; however, there is little information available on this topic. Aim: To describe the geographic variation in continuity and discontinuity of care for Danish patients listed in general practices across municipalities in the Region of South Denmark and between urban and rural areas. Methods This study used a retrospective cohort study design and a unique registry dataset for the population of all patients enrolled in general practice in the Region of Southern Denmark during the entire period from 2007–2018. The cohort included individuals who were born before January 1st, 2007, and who had been registered with one or more general practices up to the end date, December 31st, 2018. Individuals who died, children younger than the age of 12 years, people who emigrated to other countries and people who migrated to Denmark during the study period were excluded. Setting The Region of Southern Denmark is one of five regions in Denmark. Since the 1st of January 2007, Denmark has been politically divided into these five regions, each of which has several municipalities. Each region is responsible for organizing the health care sector, including the general practice sector. Municipalities are responsible for taking care of social services and nursing facilities that are often coordinated with GPs. This study included patients from 22 municipalities in the Region Southern Denmark. Some of the municipalities are predominantly urban, whereas others are predominantly rural. A rural area is defined by the OECD as a “geographical area with a population density of less than 150 inhabitants per square kilometer” ( 13 ). However, the Danish Ministry of Food, Agriculture, and Fisheries has in cooperation with the Danish Institute of Agricultural Sciences, a redefined and more specific classification system showing the “rural degree” for each municipality. Municipalities can be categorized into four different types (either urban/midrange municipalities or rural/remote municipalities) ( 13 ). Five of the municipalities in the Region of Southern Denmark are urban/midrange, whereas the rest are predominantly rural/remote municipalities. The regions plan and distribute so-called `provider-numbers’ for general practice. Each `provider number´ is geographically assigned according to the population. Each general practice working under the agreement with Danish Regions and the Danish Organization of General Practitioners holds a provider number. A provider number can include one to several GPs (full-time equivalents). GPs can operate as singlehanded or partnership practices. In partnership practices, there is a common patient list for the entire clinic. Finally, both singlehanded and partnership practices can choose to collaborate with other clinics and share resources, such as accommodations, practice nurses, secretaries, and diagnostic facilities. These practices are called collaborative practices ( 14 ). The number of single-handed practices is declining, with 41% not sharing the patient list. In general, partnership practices are staffed by 2–5 GPs ( 15 , 16 ). With few exceptions, all general practices are organized as private entities on a national negotiated scheme. The system is tax-financed and covers the whole population. The primary care sector is organized as a list system in which 99% of all citizens are enrolled in a general practice and must contact their GPs to receive medical advice and care. The health care sector operates a public health insurance system in which GPs act as gatekeepers to the rest of the health care system. All citizens in Denmark have a civil registration number (CPR-number), and patients listed are registered within the official regional databases. Every time a patient changes his or her general practice for whatever reason, a new entry is put into the database. The patient can decide whether the medical files should be sent to the new general practice, and most of the files are transferred. The Danish listing system allows for the measurement of continuity of care related to each general practice provider number in terms of the number of changes and length of time each patient has been enrolled with the specific general practice. Patients can choose to be enrolled in any general practice of their choice but often choose a general practice close to where they live. Children younger than 15 years of age automatically follow their parents and are enrolled in the same general practice. Sometimes GPs retire and sell their practice to colleagues to take over, and this is also considered—and registered—as a change between general practices. Patients can also choose to change their general practice E.G. if they are discontent with their current practice. A general practice provider number can have up to 2,700 patients according to full-time equivalents, but most have approximately 1,600 patients per full-time equivalent GP. The data are based on general practice provider numbers, CPR numbers, dates of change between GPs (start and end dates), patient age at each change, and information about death and moving. These variables permitted us to measure continuity of care in terms of the length of time each patient was enrolled with a specific general practice and discontinuity in terms of the number of changes between each provider number in every municipality. Data collection and statistical methods The data were provided by the Danish Regions. A computer program has been used by the national authorities to register data on the population over the years. We were able to obtain a complete dataset from the study population for an observation period of 12 years. To comply with the rules regarding the treatment of personalized data, the data were uploaded to a protected and authorized platform at Statistics Denmark (a national databank for researchers). The CPR numbers and the provider numbers were anonymized. Municipalities with less than five general practices were blinded. The number of changes between general practice and the duration of enrollment were measured per patient during the study period. The length of patient–general practice enrollment was calculated as the time listed in each general practice. If the patient was enrolled in more than one practice, the average enrollment duration was used. Fischer’s exact test/chi 2 test was used to test for differences between the rural and urban settings. All analyses were performed using Stata Release 17 (Stata Corp, College Station, TX, USA). A p value of < 0.05 was considered to indicate statistical significance. Results Table 1 shows the patient characteristics of the cohort, which included 982,644 patients. The average age was 48.6 years, 495,569 of whom were female and 487,075 of whom were male. The average duration of continuity of care in terms of enrollment in each practice was 7.9 years (2.4 (p5) and 12.0 (p95)). The average number of times a patient changed between general practice was 1.14 (0 (p5) to 5 (p95)) at an average age of 38.69 years during the study period of 12 years. To protect anonymity, two municipalities were omitted due to the low number of general practices that would otherwise be identifiable. Table 1 Characteristics of the population of patients (N = 982,644), January 1st - December 31st, 2018* N Mean Sd Cv p5 p95 Female 495,569 Male 487,075 Average age ultimo 2018 48.6 21.02 0.43 15.00 81.00 Patient age when change of general practice 38.69 20.56 0.53 5 71 Patient-practice duration in years (continuity) 7.90 3.81 0.48 2.40 12.0 Number of changes of general practice (discontinuity) 1.13 1.56 1.38 0.0 4.0 Unique general practices per patient** 2.13 1.56 0.73 1.0 5.0 Sd: Standard deviation, Cv: Coefficient of variation , *: The population included patients who had at least on spell during the 12 years analysis period. **: The number of general practices where the individual patients have been enrolled. Table 2 shows the average duration of the enrollments that every patient had with their general practice in the 22 municipalities. On average, 27.1% of those listed had been enrolled in their general practice for 0–5 years, 28.7% had been enrolled for 5–10 years, and 44.2% had been enrolled for more than ten years. In total, 72.9% of people had been enrolled in the same general practice for more than 5 years. The four municipalities, Middelfart, Faaborg-Midtfyn, Nordfyn, and Toender, all had the lowest frequency (21%) of short-term enrollment ( 53%) of patients enrolled more than 10 years. The four municipalities Odense, Billund, Esbjerg and Varde had the highest frequency (> 30%) of short-term enrollment in general practice, but these four municipalities did not have the lowest frequency of patients enrolled more than 10 years (except for Esbjerg and Varde). In terms of long-term enrollment in general practice, Langeland, Haderslev and Aabenraa are the other three in the bottom five, where 36.2% or less of patients were enrolled in the same general practice for more than 10 years. Table 2 Municipalities and continuity of care in terms of enrollment with a specific general practice (0–5 years, 5–10 years and more than 10 years) Municipality 0-4.99 (%) 5-9.99 (%) 10- (%) Total (%) Urban municipalities Odense 50,988 (31.5) 49,288 (30.4) 61,661 (38.1) 161,937 (100.0) Kolding 19,947 (27.2) 25,390 (34.6) 27,961 (38.1) 73,298 (100.0) Vejle 21,719 (24.2) 22,129 (24.7) 45,913 (51.2) 89,761 (100.0) Middelfart 5,949 (18.9) 6,110 (19.3) 19,496 (61.8) 31,555 (100.0) Fredericia 10,880 (26.1) 11,232 (26.9) 19,638 (47.0) 41,750 (100.0) Rural municipalities Assens 8,228 (24,4) 5,680 (16.8) 19,870 (58.8) 33,778 (100.0) Faaborg-Midtfyn 8,818 (20.7) 11,120 (26.10) 22,707 (53.2) 42,645 (100.0) Kerteminde 6,091 (31.2) 4,704 (24.1) 8,738 (44.7) 19,533 (100.0) Nyborg 6,365 (24.0) 7,684 (29.0) 12,442 (47.0) 26,491 (100.0) Svendborg 12,593 (26.1) 10,923 (22.6) 24,799 (51.3) 48,315 (100.0) Nordfyn 5,048 (20.9) 4,809 (19.9) 14,340 (59.2) 24,197 (100.0) Langeland 3,161 (29,4) 4,641 (43.1) 2,957 (27.5) 10,759 (100.0) Aeroe Blinded - - 5,125 (100.0) Haderslev 12,970 (28.6) 16,002 (35.2) 16,419 (36.2) 45,391 (100.0) Billund 6,426 (30.9) 3,609 (17.3) 10,789 (51.8) 20,824 (100.0) Soenderborg 14,986 (25.1) 13,981 (23.4) 30,820 (51.5) 59,787 (100.0) Toender 5,365(17,6) 7,120 (23.4) 17,940 (59.0) 30,425 (100.0) Esbjerg 29,402 (31,6) 30,472 (32.8) 33,135 (35.6) 93,009 (100.0) Fanoe Blinded - - 2,724 (100.0) Varde 13,811 (34.3) 12,965 (32.2) 13,516 (33.5) 40,292 (100.0) Vejen 9,033 (26.6) 12,500 (36.7) 12,488 (36.7) 34,021 (100.0) Aabenraa 11,362 (24.2) 20,798 (44.2) 14,867 (31.6) 47,027 (100.0) Total 266,245 (27.1) 282,032 (28.7) 434,367 (44.2) 982,644 (100.0) Table 3 shows the frequency with which patients changed between general practices in the range from 0 to 8 shifts and above in each municipality. The majority experienced no discontinuity (44.2%), and thus, 55.8% of all people experienced at least one change between general practices. The number of changes between general practices was once (28.7%), twice (13.8%), or three times (6.2%). Fewer (7.1%) of the listed patients experienced four or more changes, and 0.7% had 8 or more changes. The municipalities with the highest frequency of multiple changes between general practices (≥ 4) were Billund (8.6%), Esbjerg (8.5%), Kolding (7.3%), and Fredericia and Svendborg (both 7,2%). The highest continuity of care in terms of no change between general practices was observed in the municipalities of Middelfart, Assens, Toender, and Nordfyn. In contrast, the four municipalities Langeland, Aabenraa, Varde and Esbjerg had the lowest frequency of no change between practices. Table 3 Municipalities and the percentages of changes of general practice Municipality 0 1 2 3 4 5 6 7 8- Total Urban municipalities Odense 38.1% 30.4% 16.3% 7.5% 3.6% 1.9% 0.1% 0.5% 0.7% 100.0% Kolding 38.1% 34.6% 13.6% 6.4% 3.3% 1.6% 1.0% 0.6% 0.8% 100.0% Vejle 51.2% 24.7% 11.4% 5.5% 2.9% 1.7% 0.9% 0.6% 0.7% 100.0% Middelfart 61.8% 19.4% 9.2% 4.4% 2.3% 1.3% 0.7% 0.4% 0.5% 100.0% Fredericia 47.0% 26.9% 13.2% 5.6% 3.0% 1.7% 1.0% 0.5% 1.0% 100.0% Rural municipalities Assens 58.8% 16.8% 13.8% 4.6% 2.7% 1.5% 0.8% 0.5% 0.7% 100.0% Faaborg-Midtfyn 53.2% 26.1% 9.9% 4.7% 2.6% 1.5% 0.8% 0.5% 0.8% 100.0% Kerteminde 44.7% 24.1% 15.8% 8.6% 3.5% 1.6% 0.8% 0.5% 0.6% 100.0% Nyborg 47.0% 29.0% 12.3% 5.6% 2.8% 1.3% 0.8% 0.5% 0.8% 100.0% Svendborg 51.3% 22.6% 13.3% 5.6% 3.0% 1.8% 1.0% 0.6% 0.8% 100.0% Nordfyn 59.3% 19.9% 10.9% 4.4% 2.6% 1.3% 0.8% 0.4% 0.5% 100.0% Langeland 27.5% 43.1% 16.0% 6.2% 3.0% 1.5% 1.1% 0.7% 0.8% 100.0% Aeroe Blinded - - - - - - - - 100.0% Haderslev 36.2% 35.3% 14.7% 6.3% 3.1% 1.7% 1.1% 0.6% 1.1% 100.0% Billund 51.8% 17.3% 15.2% 7.1% 4.0% 2.0% 1.0% 0.6% 1.0% 100.0% Soenderborg 51.5% 23.4% 13.0% 5.5% 2.9% 1.5% 0.9% 0.5% 0.7% 100.0% Toender 59.0% 23.4% 7.8% 3.8% 2.3% 1.3% 0.9% 0.6% 1.0% 100.0% Esbjerg 35.6% 32.8% 15.6% 7.5% 3.9% 2.1% 1.1% 0.6% 0.8% 100.0% Fanoe Blinded - - - - - - - - 100.0% Varde 33.5% 32.2% 20.4% 6.8% 3.0% 1.7% 1.0% 0.5% 0.8% 100.0% Vejen 36.7% 36.7% 13.0% 6.5% 3.1% 1.6% 0.9% 0.5% 0.9% 100.0% Aabenraa 31.6% 44.2% 11.8% 5.7% 2.8% 1.6% 0.9% 0.5% 0.8% 100.0% Total 44.2% 28.7% 13.8% 6.2% 3.2% 1.7% 1.0% 0.5% 0.7% 100.0% Five of the municipalities are predominantly urban municipalities (Odense, Kolding, Fredericia, Middelfart and Vejle). By taking these five municipalities and holding them against predominantly rural municipalities, one can analyze the difference in terms of the frequency of short-term continuity (0–5 years) and the frequency of long-term continuity (5 + years). Fisher exact test statistic – continuity of care in predominantly urban versus rural municipalities short terms (0–5 years) long term (> 5 years) Marginal Row Totals Urban municipalities 109,483 288,818 398,301 Rural municipalities 156,762 427,581 584,343 Marginal Column Totals 266,245 716,399 982,644 (Grand Total) The Fisher exact test statistic value was < 0.01. The result was considered significant at p < 0.05. There was a slight but statistically significant difference between predominantly urban municipalities and predominantly rural municipalities, where at least a portion of patients in urban municipalities had shorter enrollments in general practices and more changes between general practices. Discussion Continuity of care is a central value in general practice ( 8 , 17 , 18 ), and recently, there have been concerns about challenges preserving continuity of care ( 17 , 19 , 20 ). In this study, which included 982,644 patients, the majority experienced no discontinuity of care (44.7%), whereas 28.7% experienced change between general practices once, 13.8% twice, 6.3% three times and 7.1% experienced four changes between general practices or more. According to the length of continuity, 27.1% of patients were enrolled (0-4.99 years), 28.7% were enrolled (5–10 years), and 44.2% were enrolled for more than 10 years. There was a significant difference between urban and rural municipalities, where at least a portion of patients in urban municipalities had shorter enrollments in general practices and more changes between practices. In addition, there was substantial variation between the municipalities that cannot be explained solely by rural or urban settings, as some of the urban municipalities had the lowest frequency of short-term enrollments and the highest frequency of long-term enrollments. Similarly, some of the rural municipalities had a high frequency of short-term enrollments and a low frequency of long-term enrollments. Part of the circumstances for changes between general practices was likely related to other external factors, such as the retirement of doctors and takeovers ( 21 – 23 ) and otherwise patient preferences ( 4 , 24 , 25 ). However, this study demonstrated geographic variation in the continuity of care between different municipalities, including urban and rural municipalities. Although continuity of care is a core value in general practice, it is often difficult to achieve ( 17 , 19 ) and may at least partly be due to geography. Previous studies have demonstrated that the range of services provided by GPs is affected by geographical setting and not only by personal characteristics and other features of the country's health care system ( 26 ). In urban settings, health services are more available than in rural areas, as the general practice is often the only provider here. The geographical factors include areas with shortages of GPs and a need for people to move due to educational and work purposes, lack of transport possibilities, or reorganization in the general practice sector from smaller entities to larger group practices, which is likely to increase distance to the practice. The average road distance to the nearest doctor in urban areas in the European Union is 3.5 km, while for remote rural areas, the average distance is almost 21.5 km. In Denmark, there should be no more than 15 km to the nearest GP ( 27 ). There is also a difference in socioeconomic factors according to geographical setting ( 28 ). General practices with an estimated overrepresentation of socially deprived people and elderly people in the practice population reported a wider range of services and are thus more likely to withhold continuity of care. Often, these places are rural but not consistent ( 28 ), and there is less continuity in urban areas and thus more discontinuity. Only a few studies have explored these circumstances leading to discontinuity in general practice ( 4 , 21 , 29 , 30 ). Strengths and limitations The use of a unique dataset of individual patient data for enrollment and official provider numbers in general practice for a relatively long retrospective observation period of 12 years provided a unique opportunity to explore both the continuity and discontinuity of care in the general practice sector. The data are from the regional database and cover all citizens and thus all registered patients who were enrolled during the entire period. People moving to the region or out of the region were omitted, and children born during the observation period and people who died were also omitted, leaving us with complete data. The data thus show a greater frequency of long-term enrollment, as the excluded patients all had shorter enrollment times. The data were managed by one private company for the entire study period with the same computer program, and the data were registered in the same way in the same register during the study period. Due to the organization of general practice in Denmark, we could clearly identify all citizens officially registered in the country. Continuity is measured in this way as enrollment in a practice as an organization, sometimes with more GPs and often with practice staff. The downside is that, in this way, continuity of care cannot be measured as the interpersonal relationship between a specific GP and the patient. The 12-year study period allowed us to identify several changes between general practices – enough to obtain a valid picture of everyday clinical life in practice. The length of enrollment is, however, an actual length of enrollment, as many patients may have been enrolled with the general practice for quite a long time before the start date of the study period; similarly, patients may be enrolled with the general practice for much longer at the end of the study period. The data in the tables represent individual patients, and it is a limitation that some patients may change their general practice and later return to the same practice. The length of enrollment was calculated as the average length of enrollment for each patient rather than as individual enrollment in general practice. This means that a patient might have changed twice, where two of the enrollment lengths are 6 months and the third 11 years. This process results in two enrollment lengths in the 0–4,99 years category and one in the 10 + years category; however, our data use the average length for that individual patient, which will then be 4 years and thus one observation in the 0–4,99 years category. This dataset included patient ages at the time of changes between general practices, as well as enrollment start dates and end dates. This is in contrast to the information that has been accessible in many earlier studies. We were able to determine the average age for each change for each patient using the age at the time of the change. Even if the data utilized for administrative reasons are the best available in terms of authenticity and accuracy, there may be missing registrations and errors caused by common case management issues such as typos. However, when we checked the data, there were few duplicate records. This study is based on data from municipalities, and we were able to identify a significant difference between urban and rural municipalities. However, the municipalities are large, and each municipality includes both rural and urban areas and is thus not entirely either urban or rural. With more specific data, the difference might have been more apparent. Previous literature: Compared to those in rural areas, where GPs are frequently the only providers, health services are more generally accessible in urban areas ( 26 ). The current rules for accessing and using services are more difficult to maintain in cities due to highly mobile populations and an abundance of doctors. The services provided in general practice vary, and one of the determinants of this variation is the distance to secondary care; as geographic isolation increases, GPs provide an increasingly broad spectrum of services ( 31 , 32 ). Additionally, access is harder to regulate, which increases the likelihood of inappropriate use. Thus, geography is a key determinant of access to day-to-day services and, in addition, of out-of-hours services, where call rates decrease with increasing distance to health care facilities. Thus, patients from rural areas have lower call rates, but deprivation appears to be a greater determinant in urban areas ( 33 ). For GPs who realize that health care needs often cannot be met by a single GP, the goal is the delivery of coordinated care through sharing information and integration between team members. In particular, in larger practices with more staff and integrated systems of care, various models of continuity have been developed ( 34 ), and when patients change their general practice, medical files are often transferred to the new practice. The structural/informational continuity of care can be viewed from the perspective of either the doctor or the patient. For the patient, it is important not only to be the next patient in line but also to be recognized by the GP or staff ( 35 ). Several studies have shown an association between a long doctor‒patient relationship and low use of out-of-hours services, less acute admittance to hospitals and lower mortality rates ( 17 , 36 – 38 ). Discontinuity of care can sometimes be due to practice closures. This might lead to increased usage of health care services, but a recent study found little change in primary care utilization in these circumstances. However, that study demonstrated a 17% increase in fee-for-service and the probability that the patient would initiate drug therapy. Patients were also more likely to be admitted to inpatient care for selected diseases. A few Danish studies have included survey studies or qualitative studies within the area (4, 9, 24). Many patients change their general practice because they move and change address and thus find a new general practice closer to their new home. However, some patients deliberately change practices, and the most common reasons were dissatisfaction with the GP due to lack of time allocated with the doctor, poor communication or low-quality service ( 24 ). However, continuity of care does not necessarily lead to a ‘caring relationship’. It is important to distinguish between the number of repeated encounters with the same GP and the personal experience of a caring relationship between patient and doctor ( 39 ). Conclusion We found variation in both continuity of care and discontinuity in general practice across municipalities in The Region of Southern Denmark with a significant difference between urban and rural settings. At least a portion of patients in urban municipalities had shorter enrollments in general practice and more frequent changes between practices. In addition, there was substantial variation between the municipalities that cannot be explained by rural or urban settings. However, further studies are needed to determine the circumstances or causes of this variation. Given that many patients change their general practice, focusing on how to address discontinuity is recommended. Abbreviations OECD Organization for Economic Cooperation and Development GP General practitioner EU European Union CPR-number civil registration number Declarations Ethics approval and consent to participate: In compliance with European data protection rules, the legal services at the University of Southern Denmark (Research & Innovation Organization) approved the data processing activities related to this project (journal number 10.151). Approval from the ethics committee and informed consent are not required according to section 14.2 of the Act on Research Ethics Review of Health Research Projects because the study is based solely on register data. Consent for publication: Not applicable Availability of data and material: The data that support the findings of this study are available from Danish Regions, but restrictions apply to the availability of these data, which were used under license for the current study and so are not publicly available. However, the data are available from the authors upon reasonable request and with permission from the Danish Regions. Competing interests: The authors declare that they have no conflicts of interest. Funding: The work is supported by the University of Southern Denmark, Fonden for Almen Praksis (Foundation for General Practice. Authors’ contributions: TK and PAM contributed to the study conception and design. Both authors were responsible for the data collection. TK was responsible for the data management and analysis and provided important contributions from PAM. Both authors contributed to the interpretation of findings, per their expertise. PAM was responsible for drafting the manuscript, and TK contributed to the revision of the manuscript. Both authors agreed to the final manuscript before submission. Acknowledgment Not applicable. References Gruneir A, Bronskill SE, Maxwell CJ et al. The association between multimorbidity and hospitalization is modified by individual demographics and physician continuity of care: a retrospective cohort study. BMC health services research. 2016;16:154. Barker I, Steventon A, Deeny SR. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data. BMJ. 2017;356. Sandvik H, Hetlevik Ø, Blinkenberg J, Hunskaar S. Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway. Br J Gen Pract. 2022;72:84–90. 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Review and qualitative synthesis of patient and physician perspectives. Canadian Family Physician. 2021;67:679–88. Frederiksen HB, Kragstrup J, Dehlholm-Lambertsen B. Attachment in the doctor-patient relationship in general practice: a qualitative study. Scand J Prim Health Care. 2010;28(3):185–90. 10.3109/02813432.2010.505447 . Epub 2010/07/21. Olsen JK, Kristensen T. Continuity and discontinuity of care among older patients in Danish general practice: a retrospective cohort study. BJGP Open. 2023:BJGPO.2023.0081. 10.3399/bjgpo.2023.0081 . A vision for Rural Areas towards 2024 [Internet]. 2021. Available from: https://rural-vision.europa.eu/maps-data/rural-areas-numbers_en . Accessed January 8, 2024. The Danish Rural Development Programme 2007–2013 [Internet]. The Danish Ministry of Food, Agriculture, and Fisheries. 2012. Available from: https://lbst.dk/fileadmin/user_upload/NaturErhverv/Filer/Tilskud/Projekttilskud/Landdistrikter/LDP_Rev_proposal_Consolid_2007-2013f.pdf . Accessed January 8, 2024. Pedersen KM, Andersen JS, Sondergaard J. General practice and primary health care in Denmark. J Am Board Fam Med. 2012;25(Suppl 1):34–8. Praktiserende, Lægers. Organisation [Organization of General Practitioners in Denmark]. [PLO factsheet 2022] - [Article in Danish]. 2022. URL: https://laeger.dk/media/1e3cuftt/plo_faktaark_2022.pdf . Accessed January 8th 2024. Praktiserende Lægers Organisation [Organization of General Practitioners in Denmark]. [PLO physician and patient population 1977–2022]. [Article in Danish]. 2022.URL: https://laeger.dk/media/3kkkkp1l/laege-_og_praksispopulationen_1977-2022.pdf . Accessed January 8, 2024. Rourke EJ. Continuity, Fragmentation, and Adam Smith. N Engl J Med. 2021;385:1810–4. Starfield B. Continuous confusion? American journal of public health. 1980;70:117–9. Bodenheimer T, Haq C, Lehmann W. Continuity and Access in the Era of Part-Time Practice. Ann Fam Med. 2018;16:359–60. Parisi R, Lau Y-S, Bower P, Checkland K, Rubery J, Sutton M, et al. Predictors and population health outcomes of persistent high GP turnover in English general practices: a retrospective observational study. BMJ Qual Saf; 2023. Simonsen M, Skipper L, Skipper N, Thingholm PR. Discontinuity in care: Practice closures among primary care providers and patient health care utilization. J Health Econ. 2021;80:102551. Bischof T, Kaiser B. Who cares when you close down? The effects of primary care practice closures on patients. Health Econ. 2021;30:2004–25. Sabety AH, Jena AB, Barnett ML. Changes in Health Care Use and Outcomes After Turnover in Primary Care. JAMA Intern Med. 2021;181:186–94. Bjerrum L, Sørensen AS. Hvorfor skifter patienter læge? [Why do patients change GP’s?]. Ugeskr Laeger. 1992;154:3587–9. Vasileva BI, Karcheva MD. Reasons for chnage of general practitioner - study among patients. J of IMAB. 2021;27(3):3847–50. Boerma WGW, Groenewegen PP, Van der Zee J. General practice in urban and rural Europe: The range of curative services. Soc Sci Med. 1998;47(4):445–53. Sundhedsloven. [The Danish Health legislation]. Koch MB, Davidsen M, Juel K. [Life expectancy in municipalities and districts - The importance of smoking and alcohol] [Article in Danish]. Sundhedsstyrelsen - Elektronisk ISBN: 978-87-7104-021-0: Statens Institut for Folkesundhed, Syddansk Universitet, 2014. Billinghurst B, Whitfield M. Why do patients change their general practitioner? A postal questionnaire study of patients in Avon. Br J Gen Pract. 1993;43:336–8. Mold JW, Fryer GE, Roberts AM. When do older patients change primary care physicians? J Am Board Fam Pract. 2004;17:453–60. Hutten-Czapski P, Pitblado R, Slade S. Short report: Scope of family practice in rural and urban settings. Can family physician Medecin de famille canadien. 2004;50:1548–50. Weigel PAM, Ullrich F, Shane DM, Mueller KJ. Variation in Primary Care Service Patterns by Rural-Urban Location. J Rural Health. 2016;32:196–203. Turnbull J, Martin D, Lattimer V, Pope C, Culliford D. Does distance matter? Geographical variation in GP out-of-hours service use: an observational study. Br J Gen Pract. 2008;58(552):471–7. https://doi.org/10.3399/bjgp08X319431 . Gulliford M, Naithani S, Morgan M. What is continuity of care? J Health Serv Res Policy. 2006;11:248–50. Frederiksen HB, Kragstrup J, Dehlholm-Lambertsen G. It's all about recognition! Qualitative study of the value of interpersonal continuity in general practice. BMC Fam Pract. 2009;10:47. 10.1186/1471-2296-10-47 . Bakker AB, Schaufeli WB, Sixma HJ, Bosveld W, Van Dierendonck D. Patient demands, lack of reciprocity, and burnout: a five-year longitudinal study among general practitioners. J Organizational Behav. 2000;21:425–41. Bochatay N, Bajwa NM, Blondon KS, Junod Perron N, Cullati S, Nendaz MR. Exploring group boundaries and conflicts: a social identity theory perspective. Med Educ. 2019;53:799–807. Waibel S, Vargas I, Coderch J, Vázquez M-L. Relational continuity with primary and secondary care doctors: a qualitative study of perceptions of users of the Catalan national health system. BMC Health Serv Res. 2018;18:257. Williams GC, Frankel RM, Campbell TL, Deci EL. Research on relationship-centered care and healthcare outcomes from the Rochester biopsychosocial program: A self-determination theory integration. Families Syst Health. 2000;18:79–90. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3846217","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":266612771,"identity":"92eea2c4-7f27-469e-be43-11f26a8f1626","order_by":0,"name":"Peder Ahnfeldt-Mollerup","email":"data:image/png;base64,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","orcid":"","institution":"Research Unit of General Practice, Department of Public Health, University of Southern Denmark","correspondingAuthor":true,"prefix":"","firstName":"Peder","middleName":"","lastName":"Ahnfeldt-Mollerup","suffix":""},{"id":266612772,"identity":"6d70b688-d9c7-4051-b538-9a40bc33fc45","order_by":1,"name":"Troels Kristensen","email":"","orcid":"","institution":"Danish Centre for Health Economics (DaCHE), Department of Public Health, University of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Troels","middleName":"","lastName":"Kristensen","suffix":""}],"badges":[],"createdAt":"2024-01-08 19:29:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3846217/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3846217/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51436259,"identity":"70a5596d-6190-4e57-b640-ab8cfad44ee1","added_by":"auto","created_at":"2024-02-21 15:18:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":322899,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3846217/v1/425f72cb-a48f-47a0-a016-cf180bd958bd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Geographic variation in patient continuity and discontinuity in general practice in Region of Southern Denmark - a retrospective registry-based study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eContinuity of care is regarded as a central element for patient outcomes and has been associated with less contact with the healthcare sector, a lower rate of hospitalization, and lower mortality (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Therefore, it is relevant to explore measures of continuity and discontinuity of care that may vary depending on geography and between rural versus urban areas.\u003c/p\u003e \u003cp\u003eThe extent of continuity of care is dependent on different factors related to both the practice sector, to patient characteristics, and personal preferences, which may vary across geography (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The latter has rarely been explored and never in this geographic way before.\u003c/p\u003e \u003cp\u003eIn the modern world, there seems to be a continuously changing health care sector and, at the same time, geographic mobility (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Thus, withholding a regular general practitioner (GP) can be difficult, and this will affect the continuity of care. However, continuity of care is considered a complex concept (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), but the essential part is that the physicians and/or the health care staff get to know the patient\u0026rsquo;s life story and the context in which the patient lives more thoroughly (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In this way, a relationship of trust is created, which can have an impact on the patient\u0026rsquo;s experience of the medical service provided and can contribute to the patient\u0026rsquo;s greater adherence to the advice, guidance and treatment recommended (9, 10). Often, but not always, medical files are handed over whenever patients change their general practice. However, exposure to discontinuity of care in the general practice sector and related enrollment durations in a specific practice have rarely been analyzed (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn municipalities in urban areas, a high proportion of the population moves to and from the city due to e.g., educational activities and job opportunities (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Rural and remote areas have the lowest shares of the EU\u0026rsquo;s population in age groups younger than 50 years (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e12\u003c/span\u003e), and the density of general practices is not surprisingly greater in urban areas than in rural areas. Thus, continuity of care in general practice is likely to depend on geographical factors and may vary depending on where people live; however, there is little information available on this topic.\u003c/p\u003e \u003cp\u003eAim: To describe the geographic variation in continuity and discontinuity of care for Danish patients listed in general practices across municipalities in the Region of South Denmark and between urban and rural areas.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study used a retrospective cohort study design and a unique registry dataset for the population of all patients enrolled in general practice in the Region of Southern Denmark during the entire period from 2007\u0026ndash;2018. The cohort included individuals who were born before January 1st, 2007, and who had been registered with one or more general practices up to the end date, December 31st, 2018. Individuals who died, children younger than the age of 12 years, people who emigrated to other countries and people who migrated to Denmark during the study period were excluded.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSetting\u003c/strong\u003e \u003cp\u003eThe Region of Southern Denmark is one of five regions in Denmark. Since the 1st of January 2007, Denmark has been politically divided into these five regions, each of which has several municipalities. Each region is responsible for organizing the health care sector, including the general practice sector. Municipalities are responsible for taking care of social services and nursing facilities that are often coordinated with GPs. This study included patients from 22 municipalities in the Region Southern Denmark. Some of the municipalities are predominantly urban, whereas others are predominantly rural. A rural area is defined by the OECD as a \u0026ldquo;geographical area with a population density of less than 150 inhabitants per square kilometer\u0026rdquo; (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, the Danish Ministry of Food, Agriculture, and Fisheries has in cooperation with the Danish Institute of Agricultural Sciences, a redefined and more specific classification system showing the \u0026ldquo;rural degree\u0026rdquo; for each municipality. Municipalities can be categorized into four different types (either urban/midrange municipalities or rural/remote municipalities) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Five of the municipalities in the Region of Southern Denmark are urban/midrange, whereas the rest are predominantly rural/remote municipalities.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe regions plan and distribute so-called `provider-numbers\u0026rsquo; for general practice. Each `provider number\u0026acute; is geographically assigned according to the population. Each general practice working under the agreement with Danish Regions and the Danish Organization of General Practitioners holds a provider number. A provider number can include one to several GPs (full-time equivalents). GPs can operate as singlehanded or partnership practices. In partnership practices, there is a common patient list for the entire clinic. Finally, both singlehanded and partnership practices can choose to collaborate with other clinics and share resources, such as accommodations, practice nurses, secretaries, and diagnostic facilities. These practices are called collaborative practices (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The number of single-handed practices is declining, with 41% not sharing the patient list. In general, partnership practices are staffed by 2\u0026ndash;5 GPs (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWith few exceptions, all general practices are organized as private entities on a national negotiated scheme. The system is tax-financed and covers the whole population. The primary care sector is organized as a list system in which 99% of all citizens are enrolled in a general practice and must contact their GPs to receive medical advice and care. The health care sector operates a public health insurance system in which GPs act as gatekeepers to the rest of the health care system. All citizens in Denmark have a civil registration number (CPR-number), and patients listed are registered within the official regional databases. Every time a patient changes his or her general practice for whatever reason, a new entry is put into the database. The patient can decide whether the medical files should be sent to the new general practice, and most of the files are transferred. The Danish listing system allows for the measurement of continuity of care related to each general practice provider number in terms of the number of changes and length of time each patient has been enrolled with the specific general practice.\u003c/p\u003e \u003cp\u003ePatients can choose to be enrolled in any general practice of their choice but often choose a general practice close to where they live. Children younger than 15 years of age automatically follow their parents and are enrolled in the same general practice. Sometimes GPs retire and sell their practice to colleagues to take over, and this is also considered\u0026mdash;and registered\u0026mdash;as a change between general practices. Patients can also choose to change their general practice E.G. if they are discontent with their current practice. A general practice provider number can have up to 2,700 patients according to full-time equivalents, but most have approximately 1,600 patients per full-time equivalent GP.\u003c/p\u003e \u003cp\u003eThe data are based on general practice provider numbers, CPR numbers, dates of change between GPs (start and end dates), patient age at each change, and information about death and moving. These variables permitted us to measure continuity of care in terms of the length of time each patient was enrolled with a specific general practice and discontinuity in terms of the number of changes between each provider number in every municipality.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData collection and statistical methods\u003c/h2\u003e \u003cp\u003eThe data were provided by the Danish Regions. A computer program has been used by the national authorities to register data on the population over the years. We were able to obtain a complete dataset from the study population for an observation period of 12 years.\u003c/p\u003e \u003cp\u003eTo comply with the rules regarding the treatment of personalized data, the data were uploaded to a protected and authorized platform at Statistics Denmark (a national databank for researchers). The CPR numbers and the provider numbers were anonymized. Municipalities with less than five general practices were blinded.\u003c/p\u003e \u003cp\u003eThe number of changes between general practice and the duration of enrollment were measured per patient during the study period. The length of patient\u0026ndash;general practice enrollment was calculated as the time listed in each general practice. If the patient was enrolled in more than one practice, the average enrollment duration was used. Fischer\u0026rsquo;s exact test/chi\u003csup\u003e2\u003c/sup\u003e test was used to test for differences between the rural and urban settings. All analyses were performed using Stata Release 17 (Stata Corp, College Station, TX, USA). A p value of \u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the patient characteristics of the cohort, which included 982,644 patients. The average age was 48.6 years, 495,569 of whom were female and 487,075 of whom were male. The average duration of continuity of care in terms of enrollment in each practice was 7.9 years (2.4 (p5) and 12.0 (p95)). The average number of times a patient changed between general practice was 1.14 (0 (p5) to 5 (p95)) at an average age of 38.69 years during the study period of 12 years. To protect anonymity, two municipalities were omitted due to the low number of general practices that would otherwise be identifiable.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of the population of patients (N\u0026thinsp;=\u0026thinsp;982,644), January 1st - December 31st, 2018*\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSd\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCv\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep5\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep95\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e495,569\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e487,075\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAverage age ultimo 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e81.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient age when change of general practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient-practice duration in years (continuity)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of changes of general practice (discontinuity)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnique general practices per patient**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eSd: Standard deviation, Cv: Coefficient of variation\u003c/em\u003e, *: The population included patients who had at least on spell during the 12 years analysis period. **: The number of general practices where the individual patients have been enrolled.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the average duration of the enrollments that every patient had with their general practice in the 22 municipalities. On average, 27.1% of those listed had been enrolled in their general practice for 0\u0026ndash;5 years, 28.7% had been enrolled for 5\u0026ndash;10 years, and 44.2% had been enrolled for more than ten years. In total, 72.9% of people had been enrolled in the same general practice for more than 5 years.\u003c/p\u003e\n\u003cp\u003eThe four municipalities, Middelfart, Faaborg-Midtfyn, Nordfyn, and Toender, all had the lowest frequency (21%) of short-term enrollment (\u0026lt;\u0026thinsp;5 years). These four municipalities and Assens also had the highest frequency (\u0026gt;\u0026thinsp;53%) of patients enrolled more than 10 years.\u003c/p\u003e\n\u003cp\u003eThe four municipalities Odense, Billund, Esbjerg and Varde had the highest frequency (\u0026gt;\u0026thinsp;30%) of short-term enrollment in general practice, but these four municipalities did not have the lowest frequency of patients enrolled more than 10 years (except for Esbjerg and Varde). In terms of long-term enrollment in general practice, Langeland, Haderslev and Aabenraa are the other three in the bottom five, where 36.2% or less of patients were enrolled in the same general practice for more than 10 years.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMunicipalities and continuity of care in terms of enrollment with a specific general practice (0\u0026ndash;5 years, 5\u0026ndash;10 years and more than 10 years)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMunicipality\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e0-4.99 (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e5-9.99 (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e10- (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldUnderline\"\u003eUrban municipalities\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOdense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50,988 (31.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49,288 (30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61,661 (38.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e161,937 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKolding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19,947 (27.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25,390 (34.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27,961 (38.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73,298 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVejle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21,719 (24.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22,129 (24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45,913 (51.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89,761 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddelfart\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,949 (18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,110 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19,496 (61.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31,555 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFredericia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,880 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,232 (26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19,638 (47.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41,750 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldUnderline\"\u003eRural municipalities\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAssens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,228 (24,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,680 (16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19,870 (58.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33,778 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFaaborg-Midtfyn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,818 (20.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,120 (26.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22,707 (53.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42,645 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKerteminde\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,091 (31.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,704 (24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8,738 (44.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19,533 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNyborg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,365 (24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,684 (29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,442 (47.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26,491 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSvendborg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,593 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,923 (22.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24,799 (51.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48,315 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNordfyn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,048 (20.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,809 (19.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14,340 (59.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24,197 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLangeland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,161 (29,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,641 (43.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,957 (27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,759 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAeroe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlinded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,125 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHaderslev\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,970 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16,002 (35.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16,419 (36.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45,391 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBillund\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6,426 (30.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,609 (17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,789 (51.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20,824 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSoenderborg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14,986 (25.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,981 (23.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30,820 (51.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59,787 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eToender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,365(17,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,120 (23.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17,940 (59.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30,425 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEsbjerg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29,402 (31,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30,472 (32.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33,135 (35.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e93,009 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFanoe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlinded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,724 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVarde\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,811 (34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,965 (32.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,516 (33.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40,292 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVejen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,033 (26.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,500 (36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,488 (36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34,021 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAabenraa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11,362 (24.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20,798 (44.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14,867 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47,027 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e266,245 (27.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e282,032 (28.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e434,367 (44.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e982,644 (100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e shows the frequency with which patients changed between general practices in the range from 0 to 8 shifts and above in each municipality. The majority experienced no discontinuity (44.2%), and thus, 55.8% of all people experienced at least one change between general practices. The number of changes between general practices was once (28.7%), twice (13.8%), or three times (6.2%). Fewer (7.1%) of the listed patients experienced four or more changes, and 0.7% had 8 or more changes. The municipalities with the highest frequency of multiple changes between general practices (\u0026ge;\u0026thinsp;4) were Billund (8.6%), Esbjerg (8.5%), Kolding (7.3%), and Fredericia and Svendborg (both 7,2%).\u003c/p\u003e\n\u003cp\u003eThe highest continuity of care in terms of no change between general practices was observed in the municipalities of Middelfart, Assens, Toender, and Nordfyn.\u003c/p\u003e\n\u003cp\u003eIn contrast, the four municipalities Langeland, Aabenraa, Varde and Esbjerg had the lowest frequency of no change between practices.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMunicipalities and the percentages of changes of general practice\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMunicipality\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e8-\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldUnderline\"\u003eUrban municipalities\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOdense\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKolding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVejle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddelfart\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFredericia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"BoldUnderline\"\u003eRural municipalities\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAssens\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFaaborg-Midtfyn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKerteminde\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNyborg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSvendborg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNordfyn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLangeland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAeroe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlinded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHaderslev\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBillund\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSoenderborg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eToender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEsbjerg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFanoe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlinded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVarde\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVejen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAabenraa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFive of the municipalities are predominantly urban municipalities (Odense, Kolding, Fredericia, Middelfart and Vejle). By taking these five municipalities and holding them against predominantly rural municipalities, one can analyze the difference in terms of the frequency of short-term continuity (0\u0026ndash;5 years) and the frequency of long-term continuity (5\u0026thinsp;+\u0026thinsp;years).\u003c/p\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eFisher exact test statistic \u0026ndash; continuity of care in predominantly urban versus rural municipalities\u003c/h2\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Taba\" style=\"width: 573.875px;\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth style=\"width: 128px;\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth style=\"width: 148px;\" align=\"left\"\u003e\n \u003cp\u003eshort terms (0\u0026ndash;5 years)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 132px;\" align=\"left\"\u003e\n \u003cp\u003elong term (\u0026gt;\u0026thinsp;5 years)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth style=\"width: 125px;\" align=\"left\"\u003e\n \u003cp\u003eMarginal Row Totals\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n \u003cp\u003eUrban municipalities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\" align=\"left\"\u003e\n \u003cp\u003e109,483\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\" align=\"left\"\u003e\n \u003cp\u003e288,818\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\" align=\"left\"\u003e\n \u003cp\u003e398,301\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n \u003cp\u003eRural municipalities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\" align=\"left\"\u003e\n \u003cp\u003e156,762\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\" align=\"left\"\u003e\n \u003cp\u003e427,581\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\" align=\"left\"\u003e\n \u003cp\u003e584,343\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n \u003cp\u003eMarginal Column Totals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\" align=\"left\"\u003e\n \u003cp\u003e266,245\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\" align=\"left\"\u003e\n \u003cp\u003e716,399\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 125px;\" align=\"left\"\u003e\n \u003cp\u003e982,644\u0026nbsp;(Grand Total)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cem\u003eThe Fisher exact test statistic value was \u0026lt;\u0026thinsp;0.01. The result was considered significant at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eThere was a slight but statistically significant difference between predominantly urban municipalities and predominantly rural municipalities, where at least a portion of patients in urban municipalities had shorter enrollments in general practices and more changes between general practices.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eContinuity of care is a central value in general practice (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e), and recently, there have been concerns about challenges preserving continuity of care (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In this study, which included 982,644 patients, the majority experienced no discontinuity of care (44.7%), whereas 28.7% experienced change between general practices once, 13.8% twice, 6.3% three times and 7.1% experienced four changes between general practices or more. According to the length of continuity, 27.1% of patients were enrolled (0-4.99 years), 28.7% were enrolled (5\u0026ndash;10 years), and 44.2% were enrolled for more than 10 years. There was a significant difference between urban and rural municipalities, where at least a portion of patients in urban municipalities had shorter enrollments in general practices and more changes between practices. In addition, there was substantial variation between the municipalities that cannot be explained solely by rural or urban settings, as some of the urban municipalities had the lowest frequency of short-term enrollments and the highest frequency of long-term enrollments. Similarly, some of the rural municipalities had a high frequency of short-term enrollments and a low frequency of long-term enrollments. Part of the circumstances for changes between general practices was likely related to other external factors, such as the retirement of doctors and takeovers (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and otherwise patient preferences (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e25\u003c/span\u003e). However, this study demonstrated geographic variation in the continuity of care between different municipalities, including urban and rural municipalities. Although continuity of care is a core value in general practice, it is often difficult to achieve (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and may at least partly be due to geography. Previous studies have demonstrated that the range of services provided by GPs is affected by geographical setting and not only by personal characteristics and other features of the country's health care system (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e). In urban settings, health services are more available than in rural areas, as the general practice is often the only provider here. The geographical factors include areas with shortages of GPs and a need for people to move due to educational and work purposes, lack of transport possibilities, or reorganization in the general practice sector from smaller entities to larger group practices, which is likely to increase distance to the practice. The average road distance to the nearest doctor in urban areas in the European Union is 3.5 km, while for remote rural areas, the average distance is almost 21.5 km. In Denmark, there should be no more than 15 km to the nearest GP (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e27\u003c/span\u003e). There is also a difference in socioeconomic factors according to geographical setting (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e28\u003c/span\u003e). General practices with an estimated overrepresentation of socially deprived people and elderly people in the practice population reported a wider range of services and are thus more likely to withhold continuity of care. Often, these places are rural but not consistent (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e28\u003c/span\u003e), and there is less continuity in urban areas and thus more discontinuity. Only a few studies have explored these circumstances leading to discontinuity in general practice (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eThe use of a unique dataset of individual patient data for enrollment and official provider numbers in general practice for a relatively long retrospective observation period of 12 years provided a unique opportunity to explore both the continuity and discontinuity of care in the general practice sector.\u003c/p\u003e \u003cp\u003eThe data are from the regional database and cover all citizens and thus all registered patients who were enrolled during the entire period. People moving to the region or out of the region were omitted, and children born during the observation period and people who died were also omitted, leaving us with complete data. The data thus show a greater frequency of long-term enrollment, as the excluded patients all had shorter enrollment times. The data were managed by one private company for the entire study period with the same computer program, and the data were registered in the same way in the same register during the study period.\u003c/p\u003e \u003cp\u003eDue to the organization of general practice in Denmark, we could clearly identify all citizens officially registered in the country. Continuity is measured in this way as enrollment in a practice as an organization, sometimes with more GPs and often with practice staff. The downside is that, in this way, continuity of care cannot be measured as the interpersonal relationship between a specific GP and the patient.\u003c/p\u003e \u003cp\u003eThe 12-year study period allowed us to identify several changes between general practices \u0026ndash; enough to obtain a valid picture of everyday clinical life in practice. The length of enrollment is, however, an actual length of enrollment, as many patients may have been enrolled with the general practice for quite a long time before the start date of the study period; similarly, patients may be enrolled with the general practice for much longer at the end of the study period.\u003c/p\u003e \u003cp\u003eThe data in the tables represent individual patients, and it is a limitation that some patients may change their general practice and later return to the same practice. The length of enrollment was calculated as the average length of enrollment for each patient rather than as individual enrollment in general practice. This means that a patient might have changed twice, where two of the enrollment lengths are 6 months and the third 11 years. This process results in two enrollment lengths in the 0\u0026ndash;4,99 years category and one in the 10\u0026thinsp;+\u0026thinsp;years category; however, our data use the average length for that individual patient, which will then be 4 years and thus one observation in the 0\u0026ndash;4,99 years category.\u003c/p\u003e \u003cp\u003eThis dataset included patient ages at the time of changes between general practices, as well as enrollment start dates and end dates. This is in contrast to the information that has been accessible in many earlier studies. We were able to determine the average age for each change for each patient using the age at the time of the change.\u003c/p\u003e \u003cp\u003eEven if the data utilized for administrative reasons are the best available in terms of authenticity and accuracy, there may be missing registrations and errors caused by common case management issues such as typos. However, when we checked the data, there were few duplicate records.\u003c/p\u003e \u003cp\u003eThis study is based on data from municipalities, and we were able to identify a significant difference between urban and rural municipalities. However, the municipalities are large, and each municipality includes both rural and urban areas and is thus not entirely either urban or rural. With more specific data, the difference might have been more apparent.\u003c/p\u003e \u003cp\u003ePrevious literature:\u003c/p\u003e \u003cp\u003eCompared to those in rural areas, where GPs are frequently the only providers, health services are more generally accessible in urban areas (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The current rules for accessing and using services are more difficult to maintain in cities due to highly mobile populations and an abundance of doctors. The services provided in general practice vary, and one of the determinants of this variation is the distance to secondary care; as geographic isolation increases, GPs provide an increasingly broad spectrum of services (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdditionally, access is harder to regulate, which increases the likelihood of inappropriate use. Thus, geography is a key determinant of access to day-to-day services and, in addition, of out-of-hours services, where call rates decrease with increasing distance to health care facilities. Thus, patients from rural areas have lower call rates, but deprivation appears to be a greater determinant in urban areas (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor GPs who realize that health care needs often cannot be met by a single GP, the goal is the delivery of coordinated care through sharing information and integration between team members. In particular, in larger practices with more staff and integrated systems of care, various models of continuity have been developed (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e34\u003c/span\u003e), and when patients change their general practice, medical files are often transferred to the new practice. The structural/informational continuity of care can be viewed from the perspective of either the doctor or the patient. For the patient, it is important not only to be the next patient in line but also to be recognized by the GP or staff (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral studies have shown an association between a long doctor‒patient relationship and low use of out-of-hours services, less acute admittance to hospitals and lower mortality rates (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37\" citationid=\"CR35\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDiscontinuity of care can sometimes be due to practice closures. This might lead to increased usage of health care services, but a recent study found little change in primary care utilization in these circumstances. However, that study demonstrated a 17% increase in fee-for-service and the probability that the patient would initiate drug therapy. Patients were also more likely to be admitted to inpatient care for selected diseases. A few Danish studies have included survey studies or qualitative studies within the area (4, 9, 24).\u003c/p\u003e \u003cp\u003eMany patients change their general practice because they move and change address and thus find a new general practice closer to their new home. However, some patients deliberately change practices, and the most common reasons were dissatisfaction with the GP due to lack of time allocated with the doctor, poor communication or low-quality service (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, continuity of care does not necessarily lead to a \u0026lsquo;caring relationship\u0026rsquo;. It is important to distinguish between the number of repeated encounters with the same GP and the personal experience of a caring relationship between patient and doctor (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e We found variation in both continuity of care and discontinuity in general practice across municipalities in The Region of Southern Denmark with a significant difference between urban and rural settings. At least a portion of patients in urban municipalities had shorter enrollments in general practice and more frequent changes between practices. In addition, there was substantial variation between the municipalities that cannot be explained by rural or urban settings. However, further studies are needed to determine the circumstances or causes of this variation. Given that many patients change their general practice, focusing on how to address discontinuity is recommended.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOECD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOrganization for Economic Cooperation and Development\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral practitioner\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEuropean Union\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPR-number\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecivil registration number\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e\n\u003cp\u003eIn compliance with European data protection rules, the legal services at\u0026nbsp;the University of Southern Denmark (Research \u0026amp; Innovation Organization) approved the data processing activities related to this project (journal number 10.151). Approval from the ethics committee and informed consent are not required according to section 14.2 of the Act on Research Ethics Review of Health Research Projects because the study is based solely on register data.\u003c/p\u003e\n\u003ch2\u003eConsent for publication:\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and material:\u003c/h2\u003e\n\u003cp\u003eThe data that support the findings of this study are available from Danish Regions, but restrictions apply to the availability of these data, which were used under license for the current study and so are not publicly available. However, the data are available from the authors upon reasonable request and with permission from the Danish Regions.\u003c/p\u003e\n\u003ch2\u003eCompeting interests:\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eThe work is supported by the University of Southern Denmark, Fonden for Almen Praksis (Foundation for General Practice.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions:\u003c/h2\u003e\n\u003cp\u003eTK and PAM contributed to the study conception and design. Both authors were responsible for\u0026nbsp;the data collection. TK was responsible for\u0026nbsp;the data management and analysis and provided\u0026nbsp;important contributions from PAM. Both authors contributed to the interpretation of findings, per their expertise. PAM was responsible for drafting the manuscript,\u0026nbsp;and TK contributed to the revision of the manuscript. Both authors agreed to the final manuscript before submission.\u003c/p\u003e\n\u003ch2\u003eAcknowledgment\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGruneir A, Bronskill SE, Maxwell CJ et al. The association between multimorbidity and hospitalization is modified by individual demographics and physician continuity of care: a retrospective cohort study. BMC health services research. 2016;16:154.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarker I, Steventon A, Deeny SR. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data. BMJ. 2017;356.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSandvik H, Hetlevik \u0026Oslash;, Blinkenberg J, Hunskaar S. 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J Health Serv Res Policy. 2006;11:248\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrederiksen HB, Kragstrup J, Dehlholm-Lambertsen G. It's all about recognition! Qualitative study of the value of interpersonal continuity in general practice. BMC Fam Pract. 2009;10:47. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1471-2296-10-47\u003c/span\u003e\u003cspan address=\"10.1186/1471-2296-10-47\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBakker AB, Schaufeli WB, Sixma HJ, Bosveld W, Van Dierendonck D. Patient demands, lack of reciprocity, and burnout: a five-year longitudinal study among general practitioners. J Organizational Behav. 2000;21:425\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBochatay N, Bajwa NM, Blondon KS, Junod Perron N, Cullati S, Nendaz MR. Exploring group boundaries and conflicts: a social identity theory perspective. Med Educ. 2019;53:799\u0026ndash;807.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaibel S, Vargas I, Coderch J, V\u0026aacute;zquez M-L. Relational continuity with primary and secondary care doctors: a qualitative study of perceptions of users of the Catalan national health system. BMC Health Serv Res. 2018;18:257.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams GC, Frankel RM, Campbell TL, Deci EL. Research on relationship-centered care and healthcare outcomes from the Rochester biopsychosocial program: A self-determination theory integration. Families Syst Health. 2000;18:79\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"General practice, continuity of care, health service.","lastPublishedDoi":"10.21203/rs.3.rs-3846217/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3846217/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is well known that patients in general practice live in health care systems where geography may be their destiny because of different circumstances in different geographic locations. Therefore, it is important to explore the variation in continuity of care to understand this central characteristic of the health care system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo describe the geographic variation in continuity and discontinuity of care for patients listed in general practices across municipalities and between urban and rural areas in the Region of Southern Denmark.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a retrospective cohort registry study of patients older than 12 years who were enrolled in general practice in 22 municipalities in the Region of Southern Denmark from 2007–2018. Continuity of care is here the length of enrollment with a general practice, and discontinuity of care is the number of times a patient changes general practice. The data are based on civil registration numbers for patients, general practice provider numbers, patient age at each change of their general practice, and data on the municipality where each patient has their address.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe cohort included 982,644 patients in 22 municipalities. The average duration of enrollment per patient at a general practice was 7.9 years. A total of 27.1% of patients had been enrolled for 0–5 years, 28.7% for 5–10 years and 44.2% for more than ten years. Discontinuity in terms of the number of changes between practices revealed that 44.7% of patients had no discontinuity, 28.7% had experienced one change in general practice, 13.8% had two changes, 6.3% had three changes, and 7.1% had four or more changes. The average number of times a patient changes their general practice was 1.14. Compared to rural municipalities, there is a trend toward more discontinuity and shorter times of enrollment in general practice in urban municipalities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was a significant difference between urban and rural settings, where at least a portion of patients in urban municipalities had shorter enrollments in general practice and more frequent changes between practices. Given that many patients change their general practice, focusing on how to address discontinuity is recommended.\u003c/p\u003e","manuscriptTitle":"Geographic variation in patient continuity and discontinuity in general practice in Region of Southern Denmark - a retrospective registry-based study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-16 19:49:34","doi":"10.21203/rs.3.rs-3846217/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f8f4350c-b0c9-4352-bd24-7a1346c6ecc8","owner":[],"postedDate":"January 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-21T15:18:02+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-16 19:49:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3846217","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3846217","identity":"rs-3846217","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}