Transition of Patients with Diabetes From Specialist To Primary Care: A Survey Of Specialists on Tools, Determinants & Barriers for Transition

The Tools For TransitionTM Program: Characteristics and Disposition of Patients referred to a Multidisciplinary Diabetes Clinic *CHETNA TAILOR, JANINE C MALCOLM, JULIE MARANGER, ERIN KEELY, SHARON BREZ, SHERYL IZZI, MONICA TALJAARD, TEIK CHYE OOI Division of Endocrinology & Metabolism, University of Ottawa. The Tools for TransitionTM Program at the University of Ottawa was developed to improve the transition of patients with type 2 diabetes (T2D) from specialists back to their primary care physicians (PCP). To understand the current situation, a chart review of 120 T2D patients referred to the Foustanellas Endocrine and Diabetes Center from January 1, 2005 to June 30, 2005 by PCP was completed to Nov 2007 to Feb 2008 to document demographic data, medical status, medication use, process and outcome of care indicators. Results: mean age 59.5 years, mean duration of diabetes 8.84 years, 60% male, HTN 74%, dyslipidemia 75%, CVD 20%, nephropathy 28%, neuropathy 26%, retinopathy 17%, and psychiatric illness 19%, 27% were on insulin at the time of referral, and 18% were later placed on insulin by the clinic. 23/120 (19%) were discharged back to their primary care physician after attending the clinic for a mean duration of 12 months, 38/120 (32%) continue to be followed in the clinic and 55/120 (46%) were lost to follow-up (patient did not attend clinic despite scheduled visit), 2/120 (1.5%) died and 2/120 (1.5%) were transferred to another clinic. As expected, a high proportion of patients referred to a speciality diabetes clinic have complications of diabetes, co-morbid conditions, and are treated with insulin Only 1 in 5 patients were discharged within the audit period of about 3 years. An unexpectedly high proportion of patients were lost to follow-up. This has inadvertently helped to relieve the build-up of follow-up patients in the centre caused by a low discharge rate. Further study into the low discharge rate and possible reasons for the loss to follow-up is warranted. ABSTRACT #197