Chronic Disease

Fragmentation of care for complex diabetes patients may be associated with greater use of the emergency department

Providing coordinated care is challenging in managing the myriad complications that accompany diabetes. The benefit of referrals to specialists for diabetes-related complications, such as kidney or eye problems, may be negated by the fragmentation of care that often ensues, concludes a new study. Using a fragmentation of care index (FCI) developed for their study, researchers examined the effects of fragmentation on emergency department (ED) use among 623 patients with diabetes and kidney impairment.

The FCI, derived from a previously existing Continuity-of-Care index, was based on the number of visits to unique specialty clinics, the proportion of visits to each of these clinics, and the total number of visits. The FCI can vary from 0 (all visits to the same clinic) to 1 (each visit takes place at a different clinic). On average, patients made 19 visits to outpatient clinics and had 1.2 ED visits over the 2-year period, with almost half making at least one visit. The mean FCI was 0.42, with 14.2 percent of patients having an FCI of 0. After controlling for patient sociodemographic and clinical characteristics, a 0.1 increase in the FCI was associated with a 15 percent increase in the number of ED visits.

These findings raise concerns about the risks and effect of referrals to specialists for patients with diabetes, particularly considering that the diabetes care provided in primary care practices is often poorly integrated with specialist consultants. Because the study did not identify the timing or source of specialist referrals, they were unable to ascribe a causal relationship between fragmented care and ED use. Their study was supported by the Agency for Healthcare Research and Quality (HS15123).

See "Care fragmentation and emergency department use among complex patients with diabetes," by Constance W. Liu, M.D., Ph.D., Doug Einstadter, M.D., and Randall D. Cebul, M.D., in the American Journal of Managed Care 16(6), pp. 413-420, 2010.

Return to Contents
Proceed to Next Article