A cross-sectional investigation conducted among community-dwelling older adults in Berlin, Germany, has revealed that maintaining a long-term relationship with an individual general practitioner is associated with a statistically significant but modest improvement in self-rated health. The research, drawn from baseline data of the urban Ageing Well study, evaluated how different dimensions of primary care continuity relate to subjective health perceptions among adults aged 65 years and older. While continuing care with the same personal doctor yielded a measurable positive correlation, continuity at the practice site level demonstrated no meaningful statistical association with how participants evaluated their overall physical and mental state. Furthermore, comprehensive multivariable modeling demonstrated that objective clinical factors, particularly lifetime chronic morbidity and depressive symptoms, accounted for a substantially greater proportion of variance in health ratings than any metric of primary care continuity. These empirical findings indicate that although interpersonal doctor-patient relationships remain a central pillar of primary medical practice, broad patient-reported outcome measures such as global self-rated health may reflect entrenched health burdens and social determinants rather than the nuanced quality or sustained longitudinal duration of ambulatory primary care.

The demographic landscape of modern urban centers is undergoing a profound structural shift characterized by rapid population aging and an escalating prevalence of complex multimorbidity. As international projections estimate the global cohort of individuals over 65 years of age to exceed one billion, an increasing majority of older citizens will reside in metropolitan regions requiring accessible and integrated medical frameworks. Within primary healthcare systems, continuity of care represents a fundamental structural attribute endorsed by international authorities, including the World Health Organization, as essential for people-centered health services. Health systems research traditionally differentiates continuity of care into three distinct functional dimensions: informational continuity, which ensures that clinical data and patient histories follow individuals across encounters; management continuity, which harmonizes treatment plans among diverse medical specialists; and relational continuity, which centers on an ongoing therapeutic relationship between an individual patient and a familiar healthcare professional. Prior epidemiological evaluations across North America, Europe, and Asia have consistently linked higher relational continuity to lower emergency room utilization, reduced hospital readmissions, improved medication adherence, fewer duplicate prescriptions, and reduced overall mortality rates. Nevertheless, the degree to which continuous primary care directly shapes an older person’s subjective assessment of their own vitality has remained inconsistent across the international empirical literature.

Understanding how primary care engagement influences self-rated health is crucial because subjective health status is recognized as an exceptionally reliable patient-reported outcome measure capable of forecasting functional decline, hospitalization, and mortality among aging populations. Prior studies in diverse international settings have generated contradictory conclusions regarding this relationship, with some cross-sectional inquiries in developing regions identifying positive correlations between relational continuity and perceived wellness, while longitudinal investigations among multimorbid cohorts in other healthcare jurisdictions identified no significant association over time. In nations like Germany, where ambulatory healthcare allows patients unrestricted provider choice and open access to both general practitioners and ambulatory specialists, empirical evidence regarding the specific contribution of primary care continuity has remained underexplored. The research team sought to resolve this empirical ambiguity by investigating whether longitudinal continuity with primary care providers was associated with superior self-rated health among urban seniors. The investigators hypothesized that if continuous primary care meaningfully influences how older adults perceive their personal health, this favorable outcome would be systematically reflected in having an established regular general practitioner and in recording a longer cumulative duration of clinical care with that specific medical practitioner.

To investigate these dynamics within an authentic metropolitan setting, the researchers analyzed cross-sectional baseline data from the Ageing Well in the Urban Environment study conducted across three structurally and socioeconomically diverse administrative districts of Berlin: Marzahn-Hellersdorf, Spandau, and Reinickendorf. These districts encompassed seven life-space oriented structural areas, ensuring a heterogeneous urban participant base. Eligible participants were randomly sampled directly from municipal registry offices, with inclusion restricted to community-dwelling individuals aged 65 years or older who possessed valid residency registration and were living without a designated legal guardian. Data collection was carried out in two distinct temporal waves between December 2023 and June 2024, and subsequently between December 2024 and June 2025. A total of 837 older adults completed standardized, computer-assisted personal interviews conducted in their private households by trained research staff. Conducting face-to-face interviews within the domestic living environment permitted the inclusion of individuals facing mobility limitations who might otherwise have been excluded from clinical trials or clinic-based observational registries. Alongside the survey instruments, interviewers collected objective functional performance indicators, including cognitive assessments, walking speed evaluations, and handgrip strength metrics.

The operationalization of continuity of care within the study protocol was adapted from the validated continuity framework of Bentler and colleagues, originally utilized in the National Health and Health Services Use Questionnaire. Although the original instrument assessed continuity across varied care environments, including outpatient specialist facilities, emergency departments, and non-specific walk-in clinics, the participant response distribution in Berlin was overwhelmingly concentrated within primary care. Specifically, 84.6 percent of the older adults identified a general practitioner practice as their usual care site, whereas other outpatient categories exhibited cell sizes too small for statistically stable regression estimations. Consequently, the researchers structured their evaluation around two discrete longitudinal dimensions: general practitioner site continuity and general practitioner doctor continuity. Site continuity quantified the categorized duration of continuous engagement with a specific general practice facility, coded as zero years for respondents who utilized alternative or non-specific care sites. Doctor continuity measured the exact cumulative duration of a patient’s therapeutic relationship with their primary general practitioner in continuous years. Methodological diagnostics demonstrated that the variance inflation factors for these two primary care measures remained below 1.5, confirming the absence of problematic multicollinearity in the analytical models.

Subjective health status served as the primary dependent variable, assessed using a standardized single-item query asking participants to evaluate their general state of health on a five-point scale encompassing poor, moderate, good, very good, and excellent. For analytical purposes, the researchers treated this ordinal scale as a continuous metric ranging from 1 to 5, an established approach in public health epidemiology that preserves nuanced variation across response categories. To isolate the specific association between continuity and health ratings, the investigators gathered a robust set of sociodemographic and clinical covariates. Sociodemographic parameters included chronological age determined from municipal birth records, self-reported gender, and subjective social status assessed through the validated German version of the MacArthur scale, which ranks perceived social hierarchy from 1 to 10. Lifetime somatic morbidity was determined by presenting participants with a standardized inventory of 26 chronic conditions derived from the Simple Segmentation Tool. For respondents with complete or near-complete data, prorated continuous morbidity scores from 0 to 26 were computed. Mental health symptoms were captured using the Patient Health Questionnaire-4, with established clinical cut-off scores of 3 or higher designating the presence of active depressive symptoms or anxiety.

The statistical protocol utilized hierarchical multivariable linear regression across three sequential models to identify optimal explanatory power based on the Akaike information criterion and adjusted R-squared statistics. Model 1 included only the primary explanatory predictors: general practitioner site continuity and general practitioner doctor continuity. Model 2 expanded this framework by incorporating sociodemographic adjustments, specifically age, gender, and subjective social status. Model 3 established the fully adjusted specification by integrating clinical covariates, including lifetime morbidity scores, depressive symptoms, and anxiety symptoms. Missing data, which accounted for less than 5 percent of values across the complete battery of variables, was handled using listwise deletion. To evaluate the possibility of attrition or selection bias, researchers executed Wilcoxon rank-sum tests and Fisher’s exact tests comparing included individuals with those removed due to incomplete records. These comparisons revealed that participants excluded from the regression models differed significantly only in their reported doctor continuity values, displaying no systematic divergence across remaining clinical, sociodemographic, or psychological parameters. Regression coefficients were expressed as unstandardized beta estimates alongside 95 percent confidence intervals, and effect sizes were quantified through partial R-squared metrics computed from t-statistics.

Among the 836 older adults with valid subjective health data, participants exhibited an age span ranging from 65 to 100 years, with a sample mean of 75.74 years, and women comprising 60.8 percent of the cohort. Lifetime morbidity averaged 4.78 diagnosed conditions, with individual counts extending up to 16.25 conditions. Approximately 66.42 percent of respondents reported attending their primary general practice for five years or longer, while the mean duration of interpersonal care with the identical general practitioner stood at 7.41 years. Subjective health was most frequently rated as good by 41.6 percent of respondents, generating a mean sample score of 2.65. The fully adjusted regression model explained 23.6 percent of the total variance in self-rated health. Within this model, individual general practitioner continuity showed a statistically significant positive association with subjective health, yielding an unstandardized coefficient of 0.008 with a 95 percent confidence interval spanning 0.002 to 0.015. Conversely, duration of care at the general practice facility level was not statistically associated with health perceptions. Lifetime morbidity exhibited the largest independent impact, explaining 15.7 percent of the unique variance with an unstandardized coefficient of negative 0.132. Depressive symptoms were strongly linked to poorer perceived health with a coefficient of negative 0.396, whereas subjective social status showed a positive association of 0.054. Advanced age and male gender were also associated with modest decreases in health scores, while anxiety demonstrated no independent statistical association.

To rigorously verify the stability of these findings, the research team performed several planned sensitivity and exploratory subgroup evaluations. A major sensitivity analysis addressed potential distortion from extreme values by excluding nine participants who reported continuous care with an individual general practitioner exceeding 40 years. This trimmed re-analysis produced findings fully consistent with the primary specification, maintaining a statistically significant association between doctor continuity and perceived health with a coefficient of 0.010 and a 95 percent confidence interval from 0.003 to 0.017. A parallel sensitivity analysis operationalized somatic illness as a proportional morbidity ratio rather than a prorated count, which confirmed identical directions and comparable effect magnitudes across all clinical variables. Furthermore, exploratory regression models incorporating effect-coded geographic variables for the three municipal districts revealed no significant interaction effects between neighborhood environments and continuity metrics. This geographic stability demonstrates that the modest positive relationship observed between individual general practitioner continuity and subjective health remained uniform regardless of the specific urban socioeconomic environment or neighborhood residential context across the German capital.

In evaluating the broader implications of their data, the authors concluded that while personal continuity with an individual general practitioner exerts a measurable benefit, the effect size is exceptionally small and of questionable clinical magnitude. The prominent influence of cumulative multimorbidity and depressive symptoms suggests that broad patient-reported outcome measures reflect enduring physical deterioration and emotional distress that cannot be easily offset by longitudinal primary care. Moreover, the investigators emphasized several methodological and structural limitations. The cross-sectional design precludes any causal assertions, and bidirectional countervailing processes may exist: chronically ill patients may attend clinics more frequently and establish prolonged tenures out of medical necessity, while healthier older adults may engage with doctors intermittently. In addition, urban cohort recruitment may have introduced a healthy participant effect, underrepresenting severely incapacitated or socially isolated seniors. The open-access German ambulatory healthcare environment also allows patients to switch doctors freely or consult ambulatory specialists without gatekeeping, which complicates patient recall when distinguishing practice longevity from individual physician relationships. The authors suggest that future health services research should utilize prospective longitudinal tracking, integrate administrative billing records, and prioritize process-oriented metrics such as patient trust, communication quality, and care coordination to capture the true therapeutic value of sustained primary medical relationships.

Subject of Research: Continuity of primary care and self-rated health among older adults in Berlin

Article Title: Which aspects of continuity of care in primary care are associated with better self-rated health? A cross-sectional study among older adults in Berlin

Article References: Zhou, Y., Bolster, M., Gerstorf, D., Kohl, R., Haase, D., Wolff, M., Chan, A., Gellert, P., & Herrmann, W. J. (2026). Which aspects of continuity of care in primary care are associated with better self-rated health? A cross-sectional study among older adults in Berlin. BMC Primary Care, 27(1), Article 339. https://doi.org/10.1186/s12875-026-03566-1

Image Credits: AI Generated

DOI: 10.1186/s12875-026-03566-1

Keywords: continuity of care, primary care, general practitioners, self-rated health, older adults, Berlin, Ageing Well study, relational continuity, multimorbidity, lifetime morbidity, patient-reported outcome measures, depressive symptoms, subjective social status, computer-assisted personal interviews, cross-sectional study, linear regression analysis, Patient Health Questionnaire-4, German Register for Clinical Studies