Fragmentation of Care in Diabetes and Endocrinology

Abstract

A 70-year-old male on follow-up for diabetes, hypertension, and dyslipidemia for the past 3 years at an endocrine specialty center, presented to the emergency with pedal edema. Since the triage physician could not find a reason to explain edema, he presumed it was due to amlodipine. He substituted it with ramipril and discharged the person. A routine visit to the endocrine center 2 weeks later shows serum potassium of 6 mEq/L and electrocardiogram changes of hyperkalemia. The person was admitted for emergency treatment. He had a previous episode of angiotensin-converting enzyme inhibitor-induced hyperkalemia 6 months back. Unfortunately, the triage physician did not have access to previous records. A 36-year-old male was admitted with severe diabetic ketoacidosis following pneumonia. At the time of admission, he was on a combination of sulphonylureas and metformin. He was diagnosed at 30 years with diabetes in an academic medical center. Initial investigations showed positive urine ketones, positive Glutamic acid decarboxylase (GAD) antibody, and low C-peptide suggestive of insulinopenic autoimmune diabetes. Hence, he was started on insulin. Subsequent physicians without access to his records discontinued insulin. He missed multiple regular follow-up visits, leading to poor glucose control and subsequent ketoacidosis. We have mentioned two examples of what we believe is fragmented clinical care in diabetes. When different caregivers participate in the care of a person without proper integration of the care, we can describe it as “fragmented medical care.”[1] Fragmentation of care could happen across individual health-care providers or health-care organizations. Since most studies are from developed countries and involve insurance databases, the magnitude of fragmentation in predominantly self-funded medical care systems is unknown. Most chronic diseases are complex and would involve multiple organ systems. Therefore, every person with a chronic disease must receive the optimum care available, involving multiple providers. Proper care coordination and communication between providers would be the key to optimum health outcomes. Without this coordination, fragmented care would lead to more testing, higher costs, more procedures, poor quality of care, and less patient satisfaction compared to less fragmented care.[1,2,3] Studies have also found that fragmented care is associated with higher hospital admissions and emergency department (ED) visits.[1,2,3,4] Fragmentation significantly impacts in-hospital care and is linked to various adverse outcomes, including readmission, increased mortality, and extended hospital stay.[5] Recurrent diabetic ketoacidosis and increased mortality in people with diabetes were associated with fragmented health care.[6] In people with newly diagnosed diabetes mellitus followed up for 3 years in Taiwan, those with continuity of care (COC) were associated with less number of hospital admissions, length of hospital stays, and a number of emergency room visits.[7] WHY DOES FRAGMENTATION OF MEDICAL CARE OCCUR? Fragmentation of care can be due to patient-related or provider-related causes: Patient preferences It is not uncommon for patients to prefer a surgeon in one hospital for foot ulcer management and an endocrinologist in a clinic for long-term diabetes care. Patient convenience In India, it is common for consumers to undergo on-demand or physician-requested testing at various stand-alone laboratories or hospitals and bring these reports for care visits. The volume of these reports, varying methodology of tests, varying test units, and potential for transcription errors during manual entry would result in many of the providers limiting the use of these reports.[8] Since these reports are not mapped to the investigation fields of electronic health records (EHRs), it may not be accessible for comparison or research at a later stage. Although large EHR providers such as EPIC have interfaces for laboratory