title: Care fragmentation and emergency department use among complex patients with diabetes.
abstract: OBJECTIVE
  To evaluate the association between patterns of fragmented care and emergency department (ED) use among adult patients with diabetes and chronic kidney disease.
  
  
  METHODS
  Observational study in an open healthcare system.
  
  
  METHODS
  The study sample included patients with diabetes and chronic kidney disease (mean estimated glomerular filtration rate, 20-60 mL/min) and with an established primary care provider. Dispersion of care was defined by a fragmentation of care index (range, 0-1), with zero reflecting all care in 1 outpatient clinic and 1 reflecting each visit at a different clinic site. We used a negative binomial model to estimate the influence of fragmentation on ED use after adjusting for patient demographic characteristics, insurance, diabetes control, and number of comorbidities; results are reported as incidence rate ratios and associated 95% confidence intervals (CIs). The main outcome measure was the number of ED visits from 2002 to 2003.
  
  
  RESULTS
  Of 3873 patients with diabetes having an established primary care provider, 623 (16.1%) had chronic kidney disease and comprised the final study sample. On average, patients made 19.0 (95% CI, 18.5-20.4) outpatient visits and 1.2 (95% CI, 1.1-1.4) ED visits over the 2-year period. The median fragmentation of care index was 0.48; 14.3% of subjects had a fragmentation of care index of zero. In the adjusted model, a 0.1-U increase in the fragmentation of care index was associated with a 15% increase in the number of ED visits (incidence rate ratio, 1.15; 95% CI, 1.09-1.21).
  
  
  CONCLUSIONS
  The posited benefits of specialist referrals among patients with complex diabetes may be partially negated by care fragmentation. Better models for care coordination and stronger evidence of the marginal benefits of referrals are needed.
authors.affiliation: Case Western Reserve University, Cleveland, OH 44016, USA. constance.liu@case.edu
authors.forename: Constance W
authors.initials: CW
authors.lastname: Liu
authors.forename: Doug
authors.initials: D
authors.lastname: Einstadter
authors.forename: Randall D
authors.initials: RD
authors.lastname: Cebul
mesh_terms: D000328:Adult; D000368:Aged; D015897:Comorbidity; D003266:Continuity of Patient Care / Q000458:organization & administration*; D048909:Diabetes Complications / Q000453:epidemiology / Q000628:therapy*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D019983:Guideline Adherence; D006302:Health Services Research; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000628:therapy*; D008297:Male; D008511:Medicine / Q000458:organization & administration; D008875:Middle Aged; D015999:Multivariate Analysis; D009820:Ohio / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000458:organization & administration*; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000458:organization & administration; D012044:Regression Analysis