Inpatient to outpatient transfer of care in urban patients with diabetes: patterns and determinants of immediate postdischarge follow-up

Arch Intern Med. 2004 Feb 23;164(4):447-53. doi: 10.1001/archinte.164.4.447.

Abstract

Background: A key opportunity for continuing diabetes care is to assure outpatient follow-up after hospitalization. To delineate patterns and factors associated with having an ambulatory care visit, we examined immediate postdischarge follow-up among a cohort of urban, hospitalized patients with diabetes mellitus.

Methods: Retrospective study of 658 inpatients of a municipal hospital. Primary data sources were inpatient surveys and electronic records.

Results: Patients were stratified into outpatient follow-up (69%), acute care follow-up (15%), and those with no follow-up (16%); differences between groups were detected for age (P =.02), percentage discharged with insulin (P =.03), and percentage receiving a full discount for care (P<.001). Among patients with a postdischarge visit, 43% were seen in our specialty diabetes clinic, and 26% in a primary care site. Adjusted analyses showed any follow-up visit significantly decreased with having to pay for care. The odds of coming to the Diabetes Clinic increased if patients were discharged with insulin, had new-onset diabetes, or had a direct referral.

Conclusions: In this patient cohort, most individuals accomplished a postdischarge visit, but a substantial percentage had an acute care visit or no documented follow-up. New efforts need to be devised to track patients after discharge to assure care is achieved, especially in this patient population particularly vulnerable to diabetes.

MeSH terms

  • Adult
  • Aftercare / statistics & numerical data*
  • Ambulatory Care / statistics & numerical data*
  • Continuity of Patient Care / statistics & numerical data*
  • Diabetes Mellitus / therapy*
  • Female
  • Georgia
  • Hospitals, Municipal
  • Humans
  • Logistic Models
  • Male
  • Medically Uninsured
  • Middle Aged
  • Outpatient Clinics, Hospital / statistics & numerical data
  • Patient Compliance
  • Retrospective Studies
  • Urban Population / statistics & numerical data
  • Utilization Review