Transition of care of patients with chronic diseases and its relation with clinical and sociodemographic characteristics

Berghetti, Larissa; Danielle, Márcia Baiocchi Amaral; Winter, Vanessa Dalsasso Batista; Petersen, Ane Gabriele Poli; Lorenzini, Elisiane; Kolankiewicz, Adriane Cristina Bernat

doi:10.1590/1518-8345.6594.4014

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Revista Latino-Americana de Enfermagem

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Original Article • Rev. Latino-Am. Enfermagem 31 • 2023 • https://doi.org/10.1590/1518-8345.6594.4014 copy

Transition of care of patients with chronic diseases and its relation with clinical and sociodemographic characteristics ^* * Paper extracted from master’s thesis “Transição do cuidado na perspectiva de pessoas com doenças crônicas”, presented to Universidade Regional do Noroeste do Estado do Rio Grande do Sul, Ijuí, RS, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

evaluate the transition of care from the perspective of people living with chronic diseases and identify its relation with clinical and sociodemographic characteristics.

Method:

cross-sectional study with 487 patients who were discharged from a hospital. Clinical and sociodemographic characterization instruments were used, as well as the Care Transitions Measure-15, which measures Preparation for self-management, Secured preferences, Understanding about medications and Care plan factors. Descriptive and inferential statistical analysis.

Results:

the transition of care was satisfactory (76.8±10.4). Average of the factors: Preparation for self-management (82.2±10.8), Secured preferences (84.7±14.3), Understanding about medications (75.7±13.7) and Care plan (64.5±13.2). Female patients had a higher average in the understanding about medications factor. Whites and residents in the urban area better evaluated the Care plan factor. The highest mean was observed for the Secured preferences factor (84.7±14.3) and the lowest for the Care plan factor (64.5±13.2). In all factors, significant differences were found in the variables (surgical patient, carrying clinical artifacts and not being hospitalized for COVID-19). Patients hospitalized for up to five days showed statistical difference in Preparation for self-management and Understanding about medications factors. In patients who were not readmitted within 30 days of discharge, Preparation for self-management was better. The better the Preparation for self-management, the lower the 30-day readmission rates.

Conclusion:

in patients living with chronic diseases, sociodemographic and clinical variables are associated with the transition of care. Patients who better evaluated preparation for self-management had fewer readmissions within 30 days.

Descriptors:
Transitional Care; Patient Readmission; Chronic Diseases; Patient Discharge; Continuity of Patient Care; Patient-Centered Care

Highlights:

(1) Brazilian study that evaluated the transition of care of patients with CNCDs.

(2) Women had a higher average in the understanding about medications factor.

(3) Whites and residents in the urban area better evaluated the care plan.

(4) Better preparation for self-management reduces length of stay and readmissions.

(5) Better preparation for understanding about medications reduces hospitalization time.

*CTM-15 Estimates (n=487)**
Factors	Average	Standard deviation	Amplitude		Median	αC ^†
Factors	Average	Standard deviation	Minimum	Maximum	Median	αC ^†
*CMT-15 GENERAL**	76.8	10.4	0.00	100	83.3	0.896
Preparation for self-management	82.2	10.8	53.6	100	82.1	0.838
Understanding about medications	75.7	13.7	33.3	100	75.0	0.763
Secured preferences	84.7	14.3	0.0	100	83.3	0.803
Care plan	64.5	13.2	25.0	100	62.6	0.659

Variables	Frequency		*CTM-15 Factors (n=487)**
	Frequency		Preparation for self-management		Understanding about medications		Secured Preferences		Care plan
	N ^‡	%	Average	SD ^§	Average	SD ^§	Average	SD ^§	Average	SD ^§
Length of stay (days)
1 to 5	269	55.2	83.5 A	10.7	77.2 A	14.3	85.8	15.0	64.3	15.7
6 to 14	166	34.1	81.3 A	10.7	73.7 B	12.9	83.8	13.7	64.0	15.2
15 or more	52	10.7	78.4 B	10.1	74.5 B	11.8	81.7	12.0	66.8	12.6
P ^\|\|			<0.003		<0.003		0.112		0.486
Treatment
Surgical	149	30.6	85.1	11.1	80.5	13.1	86.7	17.4	73.0	14.7
Clinical	338	69.4	80.9	10.3	73.6	13.4	83.8	12.6	60.7	13.9
P ^¶			<0.001		<0.001		<0.035		<0.001
Hospitalized for COVID-19
Yes	128	26.3	78.9	9.4	70.1	10.5	80.9	10.2	58.2	12.0
No	358	73.5	83.4	11.0	77.7	14.1	86.0	15.3	66.7	15.7
P ^¶			<0.001		<0.000		<0.001		<0.000
Discharge with clinical artifact
Yes	219	45	83.8	11.1	78.5	13.7	85.2	16.5	70.1	15.7
No	268	55	80.9	10.4	73.4	13.2	84.2	12.2	59.8	13.1
P ^¶			<0.003		<0.000		0.443		<0.000
Readmission within 30 days
Yes	33	6.8	76.8	9.7	75.3	14.0	80.3	19.6	62.9	12.3
No	454	93.2	82.6	11.8	75.7	13.7	85.0	13.8	64.6	15.4
P ^¶			<0.002		0.841		0.069		0.540

Variables	Frequency		*CTM-15 Factors (n=487)**
	Frequency		Preparation for self-management		Understanding about medications		Secured Preferences		Care plan
	N ^‡	%	Average	SD ^§	Average	SD ^§	Average	SD ^§	Average	SD ^§
Gender
Male	256	52.6	82.1	10.7	74.3	13.8	84.5	13.1	64.0	14.6
Female	211	47.4	82.3	10.9	77.0	13.5	84.9	15.3	64.8	15.8
P ^\|\|			0.841		<0.026		0.731		0.550
Race
Indigenous	40	8.2	81.5	9.1	75.6	13.7	83.1	13.8	54.0 B	12.1
White	372	76.4	82.2	11.1	75.8	13.7	84.9	14.7	65.7 A	15.0
Black or brown	64	13.1	82.3	9.8	75.4	14.0	83.9	12.4	63.4 A	14.0
P ^¶			0.920		0.974		0.676		<0.000
Age group
18 to 59 years old	221	45.5	81.8	10.1	74.7	13.1	83.9	13.2	64.1	14.8
60 years old or older	266	54.6	82.6	11.3	76.4	14.1	85.3	15.2	64.8	15.6
P ^\|\|			0.462		0.214		0.270		0.629
Marital status
Live in union	292	60	82.3	10.8	75.3	14.0	84.6	14.9	63.9	15.2
Does not live in union	195	40	82.0	10.7	76.2	13.1	84.7	13.5	65.4	15.3
P ^\|\|			0.809		0.625		0.421		0.966
Education
Up to 8 years	343	70.4	81.2	10.7	75.8	13.3	83.6	14.9	64.0	14.9
Above 8 years	135	27.7	84.6	10.8	75.2	14.6	87.0	12.4	66.1	15.8
P ^\|\|			0.524		0.282		0.071		0.223
Place of residence
Urban area	262	53.8	82.0	10.8	74.4	13.0	84.9	13.5	65.9	15.0
Rural area	217	44.6	82.4	10.8	77.0	14.2	84.3	15.3	63.1	15.1
P ^\|\|			0.724		<0.034		0.650		<0.047

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[1] Corresponding author:
Adriane Cristina Bernat Kolankiewicz E-mail: adri.saudecoletiva@gmail.com https://orcid.org/0000-0003-1793-7783