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 Table of Contents  
Year : 2022  |  Volume : 1  |  Issue : 2  |  Page : 43-46

Fragmentation of care in diabetes and endocrinology: What is the way forward?

Providence Endocrine and Diabetes Specialty Centre, Thiruvananthapuram, Kerala, India

Date of Submission23-Jun-2022
Date of Acceptance23-Jun-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Mathew John
Providence Endocrine and Diabetes Specialty Centre, T. C 96/148, Prasanth Nagar, Medical College P. O, Thiruvananthapuram - 695 011, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cdrp.cdrp_14_22

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How to cite this article:
John M. Fragmentation of care in diabetes and endocrinology: What is the way forward?. Chron Diabetes Res Pract 2022;1:43-6

How to cite this URL:
John M. Fragmentation of care in diabetes and endocrinology: What is the way forward?. Chron Diabetes Res Pract [serial online] 2022 [cited 2023 Mar 29];1:43-6. Available from: https://cdrpj.org//text.asp?2022/1/2/43/351233

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? Top

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 requisition with esoteric labs such as LabCorp and Quest, this system is still not used widely in India.[8]

Variable reimbursement and insurance practices

Certain hospitals and health systems may be reimbursable for specific procedures but not others. For example, coronary artery bypass grafting may be covered only in a particular hospital, but cardiology consultations may be covered in various hospitals. Similarly, lack of access to care may lead to the movement of health-care consumers across hospitals or systems.

Availability of “super” specialists

Especially in the case of rare specialties or specialized procedures (e.g., robotic surgery), expertise may be limited to certain hospitals. Patients may undergo the specialized procedure in that hospital and subsequently shift to another physician for long-term care according to convenience.

Challenges in the transfer of medical information

There can be challenges in medical documentation and the transfer of medical records across health systems and practitioners. Documentation used to transfer care is sometimes brief and may miss many details. It may lead to limitations in conveying the complete information to the new physician. For example, it is common to find discharge summaries without the final histopathology reports, and patients seldom collect the full histopathology reports.

Lack of interoperability of electronic medical records

The current EHRs in India do not have interoperability. Further, physicians cannot electronically access laboratory reports generated by private stand-alone laboratories. This can lead to repeated laboratory testing and increasing fragmentation of care.

Telemedicine and aggregators

With the advent of telemedicine and virtual consultations, consultation is done at convenience with doctors who may not be the regular caregivers of the patient.[8] This leads to changes in therapies and new investigations which may not be captured by the regular doctor caring for the patient. Online medical aggregators may also shift patients from one provider to another, fragmenting care.

Care providers with overlapping expertise

In certain multimorbidities such as diabetes with hypertension, diabetic kidney disease, and cardiovascular disease, the health-care providers may have expertise in managing multiple morbidities, for example, the endocrinologist, cardiologist, and nephrologist may manage hypertension. However, this could lead to dose modifications or the addition of new medicines without coordination. A similar situation can arise as patients get managed by a primary care physician and specialists without proper communication and transfer of records.

Various systems of medicine

When there are options for attending various systems of medicine (e.g., modern medicine and traditional medicine), it is quite common to move between various systems for the same illness, leading to higher fragmentation.[9]

  How Can this be Measured? Top

There are various measures of continuity of care (COC). This can be measured by the Bice-Boxerman COC index, Herfindahl index, usual provider of care, and Sequential Continuity Index.[10] The COC index is based on the number of different providers visited, the proportion of attended visits to each provider, and the total number of visits. The fragmentation of care index (FCI) or reverse Bice-Boxerman COC index is a modification of the COC index and is calculated as 1-COC (1 minus COC).[1],[11] A higher FCI denotes a higher dispersion of care from the primary caregiver.

Although these indices reflect the COC (or lack of it), they do not inform us about the quality of care and its outcomes on the individual patient. For example, the referral of a person with angina on exertion from the endocrine department to cardiology may result in evaluation, optimization of medical therapy, or an intervention like angioplasty, leading to better long-term outcomes. However, this would be recorded in indices like FCI as higher fragmentation. The index would not categorize people who fail to follow-up, thereby worsening long-term outcomes. Further, many of these measures may be misleading in cases like those mentioned at the beginning of this article.

Since most studies have considered outcomes such as visits to ED, death, acute coronary syndrome, or stroke as the outcomes, less severe but important outcomes that may affect the quality of life and care of patients, especially those with rarer diseases, have not been studied.[1],[4],[12],[13]

  Who are the Most Affected? Top

Studies have shown that the most affected due to fragmented care are the elderly, those in low-socioeconomic status, ethnic minorities, and those with complex diseases and multiple comorbid conditions.[1],[3],[9],[14],[15] They suffer from increased visits to ED and hospitalization due to fragmented care. Higher fragmentation of care is seen in certain specialties.[16] In a study of patients attending specialist clinics, visits to endocrinology, anesthesiology, and hematology had higher fragmented care. Those attending ophthalmology, medical oncology, and orthopedics had the least fragmented care. This trend is likely because specialties such as endocrinology, anesthesiology, and hematology are primarily referrals and involve comanagement with various other specialties.[16] Other than diabetes, there is limited data on care fragmentation in specific endocrine diseases.[3]

  How Can We Avoid Fragmented Care? Top

The best solution for more integrative medical care is cooperation and information sharing between health-care providers and systems. In countries like the US with a predominantly insurance-based system or the UK with a predominantly state-funded system, aligning incentives and payments to systems that provide integrated care may help reduce fragmentation and its ill effects.

In countries like India, private and public health care coexist, and integrating care across them would be a significant challenge. Interoperability of electronic medical records would be a good step for providers scattered across institutions to access vital patient health information. This would avoid duplication of tests, understand drug allergies, avoid dangerous drug interactions, and have faster access to diagnosis across various providers. Universal EHR where every patient's EHR is connected to a single national system with a unique patient identifier would help the transfer of vital health data across various layers of health care.[17] The Unique Health Identification project of the Government of India is a step in a similar direction.[18] eHealth Kerala is one example that links outpatient records across the government hospitals of Kerala.[19] However, it is essential to dispel concerns regarding data safety, and misuse of health information should be addressed at every stage.[17]

Institutional protocols for managing chronic diseases and their complications can help collect appropriate clinical data, investigations, and treatment in one place. Software-based methods to flag missing investigations or evaluations would avoid patients falling off the system, for example, alerts for diabetic retinopathy screening in diabetes software.[20] Registries for patients with rarer diseases like cancer that require follow-up can help identify patients without adequate visits and investigations. These registries could be linked to EHR to ensure that follow-ups are completed and data be used for research.[21] Care coordinators can monitor these systems, periodically audit records, and ensure compliance with medicines and follow-ups.[22] Care coordinators will also be helpful in diseases which require multidisciplinary care. For example, a person with differentiated thyroid cancer will require surgery, nuclear imaging, ultrasound imaging, biochemical investigations, and follow-ups with surgery, nuclear medicine, and endocrinology.

Patient education will go a long way in ensuring COC. Clear instructions on the role of specialists and who will be the primary care coordinator will help ensure the COC. The primary care physician or the endocrinologist can be the coordinator in chronic diseases such as diabetes mellitus without significant kidney or cardiovascular disease. If cardiovascular disease or kidney disease is the major problem in a person with diabetes, the cardiologist or nephrologist should be the coordinator.

In short, fragmentation of medical care is a real problem that interferes with the appropriate follow-up and management of patients with chronic diseases. Although mechanisms at the macro levels are desired to ensure the COC, this is seldom a priority. Instead, individual physicians, practices, and professional organizations should devise methods to prevent fragmentation. This will provide best practices and guideline-based care, avoid repetition of investigations, and provide faster care at lesser costs to the consumer.

  References Top

Kern LM, Ringel JB, Rajan M, Colantonio LD, Casalino LP, Pinheiro LC, et al. Ambulatory care fragmentation and subsequent hospitalization: Evidence from the REGARDS study. Med Care 2021;59:334-40.  Back to cited text no. 1
Frandsen BR, Joynt KE, Rebitzer JB, Jha AK. Care fragmentation, quality, and costs among chronically ill patients. Am J Manag Care 2015;21:355-62.  Back to cited text no. 2
Liu CW, Einstadter D, Cebul RD. Care fragmentation and emergency department use among complex patients with diabetes. Am J Manag Care 2010;16:413-20.  Back to cited text no. 3
Kern LM, Ringel JB, Rajan M, Colantonio LD, Casalino LP, Reshetnyak E, et al. Ambulatory care fragmentation and incident stroke. J Am Heart Assoc 2021;10:e019036.  Back to cited text no. 4
Snow K, Galaviz K, Turbow S. Patient outcomes following interhospital care fragmentation: A systematic review. J Gen Intern Med 2020;35:1550-8.  Back to cited text no. 5
Mays JA, Jackson KL, Derby TA, Behrens JJ, Goel S, Molitch ME, et al. An evaluation of recurrent diabetic ketoacidosis, fragmentation of care, and mortality across Chicago, Illinois. Diabetes Care 2016;39:1671-6.  Back to cited text no. 6
Li YC. Continuity of care for newly diagnosed diabetic patients: A population-based study. PLoS One 2019;14:e0221327.  Back to cited text no. 7
Anne Paxton Skirting the Pitfalls of Merging Lab Results; 2018. Available from: https://www.captodayonline.com/skirting-pitfalls-merging-lab-results/. [Last accessed on 2022 Jun 15].  Back to cited text no. 8
Wharton GA, Sood HS, Sissons A, Mossialos E. Virtual primary care: Fragmentation or integration? Lancet Digit Health 2019;1:e330-1.  Back to cited text no. 9
Liu S, Yeung PC. Measuring fragmentation of ambulatory care in a tripartite healthcare system. BMC Health Serv Res 2013;13:176.  Back to cited text no. 10
Pollack CE, Hussey PS, Rudin RS, Fox DS, Lai J, Schneider EC. Measuring care continuity: A comparison of claims-based methods. Med Care 2016;54:e30-4.  Back to cited text no. 11
Kern LM, Seirup JK, Rajan M, Jawahar R, Stuard SS. Fragmented ambulatory care and subsequent healthcare utilization among Medicare beneficiaries. Am J Manag Care 2018;24:e278-84.  Back to cited text no. 12
Kern LM, Seirup JK, Casalino LP, Safford MM. Healthcare fragmentation and the frequency of radiology and other diagnostic tests: A cross-sectional study. J Gen Intern Med 2017;32:175-81.  Back to cited text no. 13
Kern LM, Rajan M, Ringel JB, Colantonio LD, Muntner PM, Casalino LP, et al. Healthcare fragmentation and incident acute coronary heart disease events: A cohort study. J Gen Intern Med 2021;36:422-9.  Back to cited text no. 14
Kaltenborn Z, Paul K, Kirsch JD, Aylward M, Rogers EA, Rhodes MT, et al. Super fragmented: A nationally representative cross-sectional study exploring the fragmentation of inpatient care among super-utilizers. BMC Health Serv Res 2021;21:338.  Back to cited text no. 15
Kailasam M, Guo W, Hsann YM, Yang KS. Prevalence of care fragmentation among outpatients attending specialist clinics in a regional hospital in Singapore: A cross-sectional study. BMJ Open 2019;9:e022965.  Back to cited text no. 16
Gamal A, Barakat S, Rezk A. Letter to Editor (Response from author): Toward a universal electronic health record system. J Biomed Inform 2021;117:103770.  Back to cited text no. 17
National Health Authority 2022, Ayushman Bharat Digital Mission. Available from: https://ndhm.gov.in/. [Last accessed on 2022 Jun 15].  Back to cited text no. 18
ehealth Kerala 2022, State Digital Health Mission. Available from: http://ehealth.kerala.gov.in/. [Last accessed on 2022 Jun 15].  Back to cited text no. 19
Singh RP, Scott IU. Using EHR Tools to Optimize Ophthalmologic Outcomes in Patients with Diabetes. Retina Today; 2016. p. 71-3. Available from: http://www.retinatoday.com. [Last accessed on 2022 Jun 15].  Back to cited text no. 20
Thompson CA, Kurian AW, Luft HS. Linking electronic health records to better understand breast cancer patient pathways within and between two health systems. EGEMS (Wash DC) 2015;3:1127.  Back to cited text no. 21
What Is Care Coordination? 2018 NEJM Catalyst. Available from: https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0291. [Last accessed on 2022 Jun 15].  Back to cited text no. 22


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