Time and Cost Burden of Non-essential Tertiary Care Follow-up for Diabetes in Rural Patients: Implications for Decentralizing Diabetes Healthcare

Background Patients with diabetes who bypass a primary-care hospital to attend a tertiary-care diabetes facility face certain challenges and need to weigh with if they essentially require tertiary-care follow up for diabetes. Methods A descriptive study on patients attending the tertiary-care Diabetic clinic at the National Hospital Kandy (NHK), comparing time and cost burden among patients who did not require tertiary care follow up for diabetes (P) based on if their closest hospital was NHK (K) or bypassed a primary-care hospital to attend NHK (NK). Results Among 429 patients, 56.3% (n = 242) did not require tertiary care follow up for diabetes (P), among which 36.9% (n = 89) P-K and 63.1% (n = 153) P-NK. A higher proportion of P-NK had a higher level of education compared to P-K (38.2% vs. 19.1%; p = 0.002) and a higher median average monthly family income (MFI) LKR 40,000 (USD 137) compared to P-K; LKR 30,000 (USD 103) (p = 0.000). P-NK patients had a higher median travel-cost per visit (TCV) (LKR 230.00 [USD 0.8]) compared to P-K (LKR 120.00 [USD 0.41] )(p = 0.000). P-NK spent a higher proportion of their MFI on TCV compared to P-K (p = 0.002). Among 9 patients who spent > = 10% of their MFI, 5 did not require tertiary care follow up for diabetes and P-NK. Median both ways travel time to attend a visit to the diabetic clinic (TT) was significantly higher among P-NK compared to P-K (median 40; range 10 minutes – 3 hours vs. median 1.5 hours; range 15 minutes – 11 hours) (p = 0.000). 2 patients among NK required overnight stay. neither of them required tertiary care follow up for diabetes (P-NK). Conclusions There is a significant avoidable burden of cost and time-consuming travel for rural patients who un-necessarily bypass a primary-care hospital to attend a tertiary-care diabetic clinic. This calls for decentralizing diabetes healthcare.