Inpatient to Outpatient Transfer of Care in Urban Patients with Diabetes: Patterns and Determinants of Immediate Postdischarge Follow-up

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.