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

Time and Cost Burden of Non-essential Tertiary Care Follow-up for Diabetes in Rural Patients: Implications for Decentralizing Diabetes Healthcare | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Time and Cost Burden of Non-essential Tertiary Care Follow-up for Diabetes in Rural Patients: Implications for Decentralizing Diabetes Healthcare Lasanthi Rangani Bhagya Dharmasiri, Kushalee Poornima Jayawickreme, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8212044/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract 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. Decentralization Primary care Tertiary care Diabetes Referral system Figures Figure 1 Figure 2 Introduction Diabetes has become a global burden with increasing prevalence worldwide. It is estimated that in 2022, there were 828 million adults with diabetes worldwide, with an increase of 630 million since 1990. The highest rise in prevalence was observed in low-income and middle-income countries including Southeast Asia ( 1 ) .The IDF (International Diabetes Federation) Diabetes Atlas in 2021 reported that 10.5% of the adult population aged 20–79 had diabetes and predicted that 1 in 8 adults will be having diabetes by 2045, which is a rise by 46% (2) . It revealed that 3 out of 4 adults with diabetes live in lower- and middle-income states. The prevalence of Diabetes in urban Sri Lanka is alarming was 27.6% 2018, reflecting a significant rise over the past decade. ( 3 ) ( 4 ) . A study in 2019 revealed that 23% of Sri Lankan adults had diabetes, a notable increase from the previous 14%, driven by factors such as population aging, urbanization, rising obesity rates, greater affluence, and rising prevalence among females. ( 6 ) . Evidence from 2016 revealed a prevalence of diabetes in urban areas of Sri Lanka of 14.39% which was higher than among those living in rural areas ( 7 ) . A more recent meta-analysis in 2023 showed a prevalence of diabetes in urban areas of Sri Lanka of 16.6% compared to 8.86% among rural populations. However, there is a recent rising trend in prevalence of diabetes in rural areas in Sri Lanka ( 5 ) . With the increase in prevalence of diabetes and its further spread to rural areas, rises the need in establishing an effective healthcare system with access to all, with special focus on those living in rural areas. The Sri Lankan healthcare system follows a hierarchical structure, ranging from primary care hospitals with fewer facilities to highly specialized tertiary care institutions. There has been a noticeable trend for patients to directly seek treatment from tertiary care centres and thereby bypass primary and secondary health care facilities. This is despite the availability of primary care local hospitals within close proximity to most patients’ residences. A study conducted at the Teaching Hospital Karapitiya attributed this behaviour to certain factors such as the lack of a proper referral system and also according to patients, insufficient laboratory facilities, unavailability of certain medications, and suboptimal service at primary health care centres ( 8 ) . Additionally, the proximity of some primary care hospitals to tertiary care centres encourage patients living nearby to seek follow-up care at the tertiary centres, even when primary healthcare follow up is sufficient for their care. These factors have resulted in a strain on tertiary care centres leading to congestion in hospitals and a decline in the effectiveness and quality of care provided to patients in need, as well as underutilization of primary health care facilities resulting in wasting of available resources ( 8 ) . Patients bypassing primary care local hospitals closer to home in order to attend tertiary care hospitals when tertiary care is in fact not essentially required, may also pose an additional burden on patients. As a result, there is reason for concern regarding the allocation and efficiency of utilizing healthcare resources. Diabetes poses a significant economic burden on both individuals and the healthcare system in Sri Lanka. A recent study in Sri Lanka from 2024 among patients with diabetes attending an outpatient clinic in a semi-government private hospital revealed an average yearly financial burden of 9949 Sri Lankan rupees (LKR) per patient which is equivalent to 55 United States of American dollars (USD). This figure encompasses direct medical expenses, which average LKR 6479 (USD 36) for medications and diagnostic test, as well as direct non- medical costs, such as for transportation and meals, averaging LKR 3470 (USD 19). It is significant to note that 96% of patients faced these costs even though they had access to free healthcare services ( 9 ) . A study among rural patients with diabetes from the Sainthamaruthu Divisional Secretariat Area of Ampara district in Sri Lanka indicated an average monthly economic burden per patient of LKR16,000(USD 87.93), with a considerable share of this cost shouldered by the patients’ families. This underscores the significant financial pressure faced by households in rural areas due to this expenditure ( 10 ) . Healthcare expenditure on diabetes has increased significantly on a global scale, with estimates showing a 316% rise over the last 15 years, culminating in a total of USD 966 billion. This trend highlights the growing economic burden of diabetes across the globe ( 11 ) . Decentralizing diabetes management means transferring healthcare services and responsibilities from large, centralized facilities such as tertiary hospitals to local, community-based settings. This approach aims to enhance the accessibility, affordability, and fairness of diabetes care, ultimately improving patient outcomes by bringing services closer to where people live. Many low- and middle-income countries have decentralized their public health services in an effort to improve their equity, efficiency and effectiveness ( 12 ) . Enhancing the decentralization of diabetes care in Sri Lanka is crucial for improving access, equity, and patient outcomes nationwide. Although the health care system is well established in urban areas, rural and underserved regions often face challenges such as inadequate resources, insufficient trained personals, and limited access to specialized care. The National Hospital Kandy (NHK) and the Diabetes and Endocrinology unit Kandy (DEUK) at NHK are tertiary care facilities which cater for the central province of Sri Lanka and sometimes areas beyond. The DEUK is a specialized referral centre for patients with diabetes. This study focusses on cost and time expenditure burden to patients from rural areas attending DEUK and highlights the need to improve decentralization of diabetes healthcare. Methodology This is a descriptive cross sectional analytical study carried out in DEUK at NHK among patients followed up for diabetes in the out-patient diabetic clinic. Ethical approval was obtained from the Ethics review committee at the National Hospital Kandy (NHK/ERC/85/2024). Data collection was done over a three-month period from July 2024 to October 2024. The inclusion criteria were randomly selected diabetic patients aged 14 years and above registered and regularly followed up at the DEUK out-patient clinic. 429 eligible patients were recruited to this study after informed consent. An interviewer-administered questionnaire was developed for this study and it was used to obtain data from each of the recruited patients (Annexure 1). The questionnaire gathered details on patients demographic details, cost per clinic visit including travel and other related expenses, monthly family income, level of education, time spent for the commute to attend the clinic, effect on employment of the patient and accompanying person including details on leave required, closest hospital from home, distance to closest hospital from home, diabetes control and complications. Details on diabetic retinopathy, diabetic nephropathy and macrovascular complications including cardiovascular disease, stroke, transient ischaemic attacks (TIA), and diabetic foot disease were obtained from the patients’ clinic records in addition to gathering details directly from the patient. For comparison, patients were divided into two categories; patients who require tertiary care follow up for diabetes (T) and, patients who do not require tertiary care follow up for diabetes, and can be followed up at a primary care facility (P). The criteria considered to classify patients as requiring tertiary care follow up (RTC) were HbA1c 10% or above and/ or any of the following diabetes related complications including; Any macrovascular complication (cardiovascular disease/ stroke/ TIA/ peripheral vascular disease), any degree of diabetic retinopathy, urine albumin creatinine ratio (UACR) > 300 mg/g, serum creatinine > 1.75 micromol/L, diabetic foot disease with limb amputation. Subgroup analysis was done of the cohort that did not require tertiary care follow up for diabetes (P) based on the closest hospital from their home. This cohort was further divided into two groups; patients whose closest hospital from home was NHK (K), and patients who bypassed another hospital close to home to attend NHK (NK). Those who did not require tertiary care follow up for diabetes and whose closest hospital from home was NHK were described as “P-K”, and those who did not require tertiary care follow up for diabetes and bypassed another primary care hospital close to home were described as “P-NK”. Data was analysed using the SPSS 28 package. The Mann-Whitney U test was used to compare medians of the P-K and P-NK categories. The chi square test was used to compare categorical data. A p value of < 0.05 was considered statistically significant. Results A total of 429 participants were recruited for this study, with ages ranging from 14 to 87 years. Overall,33.6% (n = 144) were K and 66.4% (n =284) were NK. Overall, 43.7% (n = 187) required tertiary care follow up for diabetes (T), out of which 29.4% (n = 55) K (T-K), and 70.6% (n = 132) NK (T-NK). 56.3% (n = 242) did not require tertiary care follow up for diabetes(P), among which 36.9% (n = 89) K (P-K) and 63.1% (n = 153) NK (P-NK) (Figure 1). Overall, there were 35.8% (n = 153) patients who bypassed a primary-care local hospital closer to home to attend a tertiary care diabetic clinic (NK), while in fact they did not require tertiary care follow up for diabetes (P-NK). 20.7% (n = 89) individuals did not require tertiary care follow up for diabetes (P) but invariably followed up at the tertiary care diabetic clinic at Kandy, because it was the closest hospital from home (P-K) (Figure 2). On subgroup analysis of those who did not require tertiary care follow up for diabetes (P) there was no significant difference in median age (58 vs. 55 years; p = 0.3), and sex proportions between P-K and P-NK (table 1 and 2). Level of education and monthly income A significantly higher proportion of P-NK had a higher level of education compared to P-K (38.2% vs. 19.1%; p = 0.002) (Table 2). The median average monthly family income was significantly higher among P-NK compared to P-K (40,000 [USD 137] vs. LKR 30,000 [USD 103]; p = 0.000) (table 1). A majority among both groups; P-K and P-NK had an average monthly income between LKR 20,000 [USD 65] and 50,000 [USD 171] (table 2). Cost burden on patients to attend the tertiary care diabetic clinic The median total both ways cost for travel to attend a visit to the diabetic clinic (CTV) was significantly higher among P-NK compared to P-K. Five patients who were K had no cost at all to travel to the clinic visit, while all NK patients had travel costs associated with their clinic visits. The median CTV was LKR 120.00 [USD 0.41] (ranging between LKR 0 – 1200 [USD 4.1]) among P-K and was LKR 230.00 [USD 0.8] (ranging between LKR 38[USD 0.13] – 2400 [USD 7.93]) (p = 0.000) among P-NK (table 1). None of K required overnight stay elsewhere to attend the clinic, while 2 patients among NK required overnight stay at a relative’s residence in Kandy, but required no cost for accommodation. However, neither of them required tertiary care follow up for diabetes (P). They both spent a significant duration of time to travel (5 – 6 hours) to attend the tertiary-care diabetic clinic, and one patient spent a significant percentage; 17.6% of their monthly family income on travel cost (Table 3). The median proportion of monthly family income spent on travel to attend the clinic visit (PICV) was significantly higher among P-NK being 0.6%, compared to 0.4% among P-K (p = 0.002) (table 1). There were 9 patients who spent more than 10% of their monthly family income on travel costs to attend the diabetic clinic visit. Among them, one attended the tertiary care diabetic clinic as NHK was the closest hospital from home, though they did not infact require tertiary care follow up for diabetes (P-K). This patient was a 78-year-old unemployed elderly lady who lived 1.6 km from NHK and travelled by three-wheeler to attend clinic incurring a cost of LKR 1000 for a round trip. Eight of the nine patients who spent >10% of their monthly family income on travel costs for a diabetic clinic visit bypassed primary care local hospital close to home (NK); 3 of them required tertiary care follow up for diabetes (T), while 5 of them did not (P). Among the 9 who spent >10% of their monthly family income, 6 were elderly patients over the age of 60 years and were all unemployed without a regular income. Two of them survived on financial assistance through the ASWASUMA government support program, amounting to LKR 2500 [USD 8.6] as a monthly allowance. Neither of these patients required tertiary care follow up for diabetes (P) (table 4). Burden of time spent on travel and mode of transport for patients to attend the tertiary care diabetic clinic The median total both ways time taken to travel to hospital 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) (table 1). 34.1% (n = 30) among P-K compared to 9.2% (n = 14) among P-NK spent less than 30 minutes to TT, while 21.1% (n = 32) among P-NK compared to 1.1% (n = 1) among P-K spent more than 2 hours to TT (p = 0.070) (table 2). One of the two K patients who took > 2 hours TT lived in Aruppola, located 3 kilometers (km) from NHK which was the closest hospital from home. She typically relied on public transport to travel from home to the NHK, which included walking for 25 minutes from home to the nearest bus stand, followed by 15 minutes for the bus ride, and then walking for 20 minutes from the final bus stop to the NHK. The TT was 120 minutes, including 90 minutes of walking and 30 minutes on the bus. The other K patient who took > 2 hours TT lived in Lewella area, located 4.5 km from the NHK. She relied on public transport to travel from home to the NHK, which included walking for 25 minutes to the nearest bus stand, followed by 18 minutes for the bus ride, and then walked for another 17 minutes from the final bus stop to the NHK. The TT was 120 minutes, including 84 minutes of walking and 36 minutes on the bus, and she did not require tertiary care follow up for diabetes. Although traveling by a personal or hired vehicle would have reduced the total travel time to just 25 minutes both ways for both of these patients, they both were unable to afford this option due to financial constraints and had to rely on the more time-consuming alternative via public transport. Both these patients had no other primary care local hospital closer to home, making NHK the closest hospital from home. Among the NK patients, 71.5% (n = 191) bypassed another primary care hospital located within 5 km of their residence to attend the tertiary care diabetic clinic, out of which only 44% (n = 84) required tertiary care for diabetes (T). 66.4% (n =87) among K did not have another primary care local hospital within 5 km from home, hence had to attend the tertiary care diabetic clinic at DEUK-NHK. However, only 41.4% (n = 36) of them required tertiary care follow up for diabetes (T). The predominant mode of transport was public transport via bus in the whole cohort, accounting for 69.7% (n=62) among P-K and 78.9% (n=120) among P-NK. Predominantly travelling by foot was the main mode of transport in 12.4% (n=11) among P-K and 2.6% (n= 4) among P-NK (p = 0.000)(table 2). Four out of five NK patients who predominantly travelled by foot to attend the diabetic clinic did not require tertiary care diabetes follow up, out of which two walked from their place of employment, which was close to the NHK, with a TT of 10 and 30 minutes respectively. One of them bypassed a primary care local hospital located 1.5 km from home; which takes only 6 minutes TT from home. Three of them predominantly spent TT of 1.5, 3, and 3.25 hours, which would have taken only 12, 16, and 20 minutes TT by foot if they attended the primary care local hospital closest to home instead (table 5). A significant majority of 78.7% (n = 70) among P-K and 80.3% (n = 122) among P-K had no other activity planned in the vicinity when travelling to attend the tertiary care diabetic clinic. (table 2). Time lost off work hours from place of employment 25.8% (n = 23) among P-K and 30.9% (n = 47) among P-NK were employed (p = 0.402). The main type of leave required to attend the diabetic clinic was full day leave (table 2). There was no significant difference in the proportion of patients who required an accompanying to attend the clinic visit at DEUK among the groups (p = 0.887). 28.9% (n = 44) among P-NK required an accompanying person to attend the diabetic clinic, out of which 25% (n = 11) of the accompanying persons were employed, and 36.4 % (n = 4) of them required full day leave from their place of employment to attend the diabetic clinic. Diabetes control and related complications 37.6% among those who bypassed a primary care local hospital and 24.4% among those whose closest hospital from home was NHK had HbA1c of 10% (p=0.300). The presence of active foot ulcer (2.9% vs. 0.7%; p = 0.148) and amputation (1.4% vs. 0.7%; p = 0.518) was non-significantly higher among those who bypassed a primary care local hospital compared to those who closest hospital was NHK. Discussion This study highlights the cost and time expenditure burden to diabetic patients from rural areas who attend a tertiary care diabetic clinic, with special focus on those who in fact do not require tertiary care follow up for diabetes but by-pass a primary care local hospitals closer to home in order to directly attend a specialised tertiary care facility for diabetes care. NK individuals showed a higher proportion of advanced education, likely reflecting a better understanding of implications of proper diabetes management and its potential complications, as well as higher expectations on diabetes management leading to seek the best care available. As a result, they may prefer seeking follow-up care at an ideal tertiary care centre, even when a closer, resource-limited primary care facility is available. Higher educational attainment has shown to be associated with better diabetes self-care management practices, increased utilization of healthcare resources effectively, and better long-term glycaemic control ( 13 )( 14 ) . Along with better education associated with the understanding of the need for specialised diabetic care with better resources and close screening for potential complications, these individuals seek follow-up care at better equipped specialist lead tertiary care centres, due to the lack of faith in receiving the same care at primary care local hospitals even if they may be closer to home. Understandably, those with higher education levels had better employment states, resulting in higher incomes and better financial resources, which was seen among the NK cohort ( 15 ) . This likely lead to them being more financially equipped to afford the required cost to travel longer distance to attend the tertiary care centre. Some diabetic medications and investigations which are freely available at tertiary care hospitals are often not available at primary care centres. Hence, in such situations those followed up at tertiary care centres would get these medications or investigations free of charge, while those following up at local hospitals often must pay to receive these same resources from the private sector. This is often a reason why some individuals with lower income states prefer to bypass a closer local hospital to attend a tertiary care facility to get these resources free of charge from, even though it means having to spend more on travel expenses for an additional visit to the tertiary care centre. This additional travel expense in-turn would be an additional financial burden to those with financial difficulties. Although we did not specifically assess the expenses incurred for private-sector laboratory tests, it is clear that this practice arises from the difficulty many patients face in dedicating another day solely to visit NHK for complimentary testing. Income disparities affect healthcare access and quality, with lower-income individuals facing greater challenges. Targeted policies are needed to improve communication and satisfaction. Economic factors, such as income and occupation, also influence access to healthcare by mediating the education-health link ( 16 )( 17 ) . Patients among NK, face significantly higher travel costs. Irrespective of a patient’s financial status, the overall financial burden of these costs remains substantial for all patients. Despite the availability of free healthcare services in Sri Lanka, patients often incur additional out-of-pocket expenses during clinic visits, including payments for certain medications and laboratory tests not available at hospital, transportation, and other non-medical expenditures owing to longer time spent on long distance travel like meals and if needed accommodation. A recent study on out-of-pocket healthcare expenditure among patients with chronic disease in Sri Lanka found an average cost of LKR 3,000 per clinic visit, with 13.5% of them spending a significant proportion of household income (18). Our study also showed that NK patients spent a higher proportion of their household income on travel to attend the clinic visit. Notably, patients admitted to private hospitals faced 2.61 times higher cost compared to those admitted to government hospitals ( 18 ) . Though this study did not specify the frequency of clinic visits per patient, which also varies based on diabetes control. Thus, more frequent clinic visits increase this cost and time expenditure accordingly. Kumara et al. showed that Sri Lankan households with multiple elderly members, preschool children, chronic illnesses, and literate household heads are at significant risk of incurring such expenses and bearing a higher financial burden. Rural and estate sector households were more likely to experience a higher burden. The study emphasized the need for expanding government healthcare infrastructure and implementing policies to reduce the financial burden on Sri Lankan households, particularly the poor ( 19 ) . The cumulative effect of these expenses can have profound implications on their overall quality of life, potentially limiting access to essential healthcare services, and medical emergencies increasing financial stress, and reducing funds available for other basic daily necessities. This disparity underscores the urgent need for interventions to alleviate the economic burden on vulnerable populations, ensuring equitable access to healthcare and better long-term outcomes for all patients. While the commonest mode of transport was via bus, road traffic congestion in Sri Lanka leads some individuals to opt to travel via public transport despite owning private vehicles, due to higher cost spent on fuel, and due to the hassle associated with driving in traffic ( 20 ) . However, on the other hand, public transport including buses and trains in Sri Lanka are often overcrowded, unclean and uncomfortable making it an unpleasant experience to travel. Due to lack of planning of infrastructure and travel routes in public transport systems in Sri Lanka, many individuals face challenges with reaching public transport, including having to walk for long periods to reach a bus or train station. These challenges lead to patients missing regular clinic appointments and delaying emergency attention at a close-by primary care facility in instances where patients often opt to bypass primary care facilities ( 21 ) . NK individuals faced extensive time spent on travel, with some requiring a both ways travel of up to 11 hours. In addition to travel time, the wait time; especially due to overcrowding of tertiary care clinics was not taken into consideration, which adds further burden on time expenditure. This time expenditure significantly impacts their daily lives, necessitating substantial time off work, family and personal commitments and routine daily activities. The resultant loss of income from time off work creates a vicious cycle of financial strain, which not only affects the individual but also places a considerable burden on their family. Furthermore, frequent absences from work due to travel and medical appointments can jeopardize job security, thereby exacerbating financial instability. Extended travel times to attend healthcare providers have shown to significantly diminish the health-related quality of life (HRQoL) of individuals with type 2 diabetes, affecting difficult choices on the balance of employment and healthcare, creating a cycle of financial instability and health decline ( 22 )( 23 )( 24 ) . Patients traveling long distances to attend clinic follow-up at a tertiary care facility often require the support of an accompanying person. The accompanying person frequently faces disruptions to their own schedule, including time away from work or other responsibilities, which can be particularly challenging for those with limited flexibility. Moreover, the time commitment involved in such travel, compounded by potential waiting periods and overnight stays, can create further hardships for both the patient and their companion. Primary care local hospitals face significant resource shortages, including a lack of trained healthcare personals, limited diagnostic facilities, and inconsistent medication supplies, which hinder effective patient care, particularly for chronic diseases. Drug availability disparities between healthcare facilities affect patient behaviour, with patients often bypassing local hospitals for tertiary care centres to have continuous access to essential medications. These gaps must be addressed to improve healthcare outcomes and ensure equitable access. Drug shortages in peripheral hospitals have shown to often be attributed to resource allocation challenges, supply chain inefficiencies, and insufficient funding for consistent procurement ( 25 ) . A study conducted in Sri Lanka found that Local hospitals in Sri Lanka have shown to experienced stock shortages of critical medications more frequently compared to tertiary care centres, leading to disruptions in patient care and adherence to treatment regimens ( 26 ) . Furthermore, patients may perceive tertiary hospitals as more reliable for medication availability, prompting a preference for these facilities despite the additional time and travel costs involved. Patients often express a lack of faith in the care provided at local hospitals. A study conducted in Sri Lanka revealed that a significant proportion of patients expressed dissatisfaction with the services provided in public hospitals, citing long waiting times, overcrowding, and a perceived lack of empathy from healthcare workers as primary concerns ( 27 ) . Similar findings were observed in a study from India, where patient dissatisfaction was strongly associated with perceived disparities in the quality of care between government and private hospitals ( 28 ) . Furthermore, a systematic review of patient perspectives across low- and middle-income countries emphasized that trust in healthcare systems is undermined when patients experience inconsistent care, lack of communication, and limited access to essential medical interventions ( 29 ) . These findings align with global observations that highlight trust as a cornerstone of effective healthcare delivery and patient satisfaction. Addressing this mistrust requires targeted interventions, including strengthening the capacity of local hospitals, improving patient-provider communication, and fostering a patient-centred approach in care delivery. By prioritizing these aspects, healthcare systems can enhance patient confidence and ensure better engagement with locally available health services. Patients with diabetic foot disease, particularly chronic foot wounds demand more frequent follow-up for foot care and wound dressing than what is typically provided for glycaemic control at most clinics. Therefore, rural patients who attend a distant tertiary care diabetic clinic tend to neglect of foot disease due to inconsistency of attending foot care. The lack of specialized diabetic foot care at local healthcare facilities leads to delayed diagnoses, worsening foot complications, and higher amputation risks ( 30 ) . Long-distance travel, particularly over extended durations to attend clinic at a distant tertiary care hospital, can significantly increase the risk of developing callosities and foot wounds, especially in financially strained individuals who have limited access to specialized footwear. Diabetic patients living in rural areas have shown to be more likely to develop foot ulcers due to the lack of proper footwear and limited access to specialized care ( 31 )( 32 ) . The overall glycaemic control evidenced by HbA1c and management of diabetic complications was slightly more optimal among those who had their diabetic follow up in close proximity to home, indicating the positive impact of resourceful healthcare facility closer to home. The convenience of travel reduced missed appointments and facilitated consistent monitoring and adjustments to therapy. Geographic barriers, including distance from the healthcare facility have shown to negatively impact chronic disease management, with longer travel distances correlating with poorer glycaemic outcomes ( 33 ) . Addressing these disparities requires robust policies to improve drug supply chains, equitable resource distribution, and strengthening the capacity of local hospitals to meet the healthcare needs of their communities. Implementing a more decentralized approach can facilitate comprehensive diabetes management by strengthening primary healthcare facilities, and expanding community health programs in rural areas. Potential steps to implement decentralization of Diabetes care in Sri Lanka Rural patients should receive routine clinic follow-up for diabetes at local healthcare centres, with referrals to tertiary centres for specialized care as and when indicated. This system ensures continuity of care, efficient resource use, and patient convenience by reducing travel and costs. Standardized referral protocols and communication between care providers should be established to streamline the process. Steps need to be taken to optimise healthcare at primary care local hospitals and to build trust in the patients about its care. Health care personals should be trained in optimal diabetes management with adherence to guidelines, addressing patients concerns with professionalism, expanding community health programmes in rural areas, providing continuous access to medications and investigations including diagnostic tools. By empowering local healthcare centres with resources, training, and technology, early detection and preventive measures for diabetes and related complications can be implemented more effectively. Adopting a general practitioner (GP) system in Sri Lanka could transform primary care by enabling GPs to provide holistic care, manage a range of medical issues, and ensure early diagnosis of both chronic and acute conditions. Acting as gatekeepers, GPs would coordinate referrals, directing patients to specialists when needed, and foster patient trust through continuity of care. This system would be particularly beneficial in rural health centres, bridging the gap between local communities and tertiary healthcare services. GP-based diabetes care is associated with better glycaemic control, increased patient satisfaction, and reduced diabetes-related complications [34] . Additionally, GP-centred models often include integrated care pathways that combine lifestyle modification guidance, pharmacological interventions, and screening for complications, which are essential for comprehensive diabetes care. Furthermore, the GP approach can reduce the burden on tertiary care centres. When diabetes care is managed effectively at the primary care level, hospital admissions for preventable complications, such as diabetic ketoacidosis or foot ulcers, decrease significantly [35] . A systematic review revealed that integrating diabetes care into primary care settings resulted in fewer referrals to specialists and improved utilization of healthcare resources [36] . Implementing such a system in Sri Lanka could alleviate the strain on tertiary care facilities, enhance early diagnosis, and foster better long-term outcomes for patients. For patients requiring specialized input, a system of "SOS reviews" can be implemented. This would include scheduled infrequent consultations at tertiary care centres, telemedicine for remote consultations with a tertiary care facility, and multidisciplinary teams for comprehensive evaluations and patient centred care. "SOS reviews" or similar systems have shown to improve patient outcomes, reduce hospital stays, and enhance patient satisfaction. For example, the "Advice and Guidance" system in the UK National Health Service (NHS) allows primary care providers to seek advice from specialists electronically, reducing unnecessary referrals and expediting critical consultation ( 37 ) . By integrating these components, a proper referral system, the introduction of a GP model, and SOS reviews, Sri Lanka can achieve a more equitable and efficient healthcare system, ensuring that patients in rural areas receive timely and appropriate care while optimizing resources at tertiary care centres. Telemedicine and telehealth solutions can significantly reduce costs and time spent on travel by minimizing the need for patients to physically visit tertiary care centres. Sri Lanka's success with mobile-based consultations during the COVID-19 pandemic underscores the feasibility of adopting such systems for SOS reviews ( 38 ) . Patients receiving telehealth intervention were found to have better HbA1c control than those routinely attending clinic visits ( 39 ) . This approach not only enhances accessibility but also alleviates the burden on patients and healthcare providers, creating a more sustainable and patient-centred healthcare system. Decentralization of Diabetes care in Sri Lanka by shifting routine clinic follow up to primary care local hospitals relieves the cost burden to both individual patient and the health sector on the whole. Decentralization strengthens primary healthcare systems by promoting investments in local infrastructure and workforce development. It also ensures equity in healthcare delivery, expanding diabetes care to marginalized and rural communities, not just urban populations. Decentralization of DM healthcare is a timely and necessary solution for enhancing the welfare of both patients and the overall health sector. This approach involves shifting the focus of diabetes care delivery from centralized, urban-based tertiary care hospitals to more accessible primary and secondary healthcare facilities in rural and underserved areas. By doing so, it addresses critical challenges such as limited access, overburdened healthcare systems, and inequities in service delivery which is timely need in Diabetes care in Sri Lanka. Recommendations for channeling patient care based on their tertiary care requirement and proximity to a tertiary care facility : Those who require tertiary care follow for diabetes will need to attend the diabetic clinic at the specialist lead tertiary care hospital irrespective if they bypass a primary care local hospital close to home (T-K and T-NK). Those who do not require tertiary care follow up for diabetes, but have no other local hospital other than the tertiary care hospital close to home (P-K) can follow up at a non-specialist lead primary care clinic by trained medical officers either at the same tertiary care hospital or at a separate medical centre with access to specialized diabetic clinic referral if and when the need arises only. Those whose closest hospital from home is a primary care local hospital and do not require tertiary care follow up for diabetes (P-NK) can follow up at the closest primary care local hospital with improved healthcare services and a good referral system to a tertiary care diabetic service if and when the need arises only. Abbreviations NHK National Hospital Kandy DEUK Diabetes and Endocrinology Unit Kandy LKR Sri Lankan rupees USD United States of American dollars T Patients who require tertiary care follow up for diabetes P Patients who do not require tertiary care follow up for diabetes, and can be followed up at a primary care facility RTC The criteria considered to classify patients as requiring tertiary care follow up K Patients whose closest hospital from home was NHK NK Patients who bypassed another hospital close to home to attend NHK P K-Those who did not require tertiary care follow up for diabetes and whose closest hospital from home was NHK P NK-Those who did not require tertiary care follow up for diabetes and bypassed another primary care hospital close to home T K-Those who require tertiary care follow up for diabetes and whose closest hospital from home was NHK T NK-Those who require tertiary care follow up for diabetes and bypassed another primary care hospital close to home CTV Cost for travel to attend a visit to the diabetic clinic PICV Proportion of monthly family income spent on travel to attend the clinic visit TT Total both ways time taken to travel to hospital to attend a visit to the diabetic clinic GP General practitioner Declarations Ethics approval and consent to participate – The study is adhered to the Declaration of Helsinki and it was approved by local Ethics Committee of the National Hospital, Kandy on 09/12/2024 ( Reference: NHK/ERC/85/2024). Informed written consent was obtained from all patients prior to recruiting to the study. Consent for publication – Not applicable. Competing Interest: The authors have declared that they have no competing interest. Funding - No funding was received for this study Author Contribution CNA, LRBD, KPJ, and HKL contributed to the research planning and formulation of the study. DB, MDMSBD, KGRLBW, KPJ, and LRBD were responsible for data collection. ST, LRBD, and KPJ performed the data analysis. KPJ and LRBD drafted the manuscript under the guidance of CNA. All authors reviewed and approved the final version of the manuscript. Acknowledgement We would like to acknowledge Dr. Dhulashiha Jegavanthan, Consultant Endocrinologist at the District General Hospital, Vavuniya, Sri Lanka, and Dr. Sonali Gunathilaka, Consultant Endocrinologist at the National Hospital, Kandy, Sri Lanka, for generously contributing their time, knowledge, and expertise to this article. We are also grateful to all the patients who participated in this study, as well as the nurses and staff of the Diabetes and Endocrinology Unit, National Hospital, Kandy, Sri Lanka, for their invaluable support. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Zhou B, Rayner AW, Gregg EW, Sheffer KE, Carrillo-Larco RM, Bennett JE et al. Worldwide Trends in Diabetes Prevalence and Treatment from 1990 to 2022: a Pooled Analysis of 1108 population-representative Studies with 141 Million Participants. Lancet. 2024;404(10467). Sun H, Saeedi P, Karuranga S, Pinkepank M, Ogurtsova K, Duncan BB et al. IDF Diabetes Atlas: Global, Regional and country-level Diabetes Prevalence Estimates for 2021 and Projections for 2045. Diabetes Res Clin Pract. 2021;183(109119). Somasundaram N, Ranathunga I, Gunawardana K, Ahamed M, Ediriweera D, Antonypillai CN, et al. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8212044","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":569032328,"identity":"4931fb51-5508-46fa-b56b-6dddecfc7faa","order_by":0,"name":"Lasanthi Rangani Bhagya 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13:26:46","extension":"html","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":153704,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8212044/v1/24e844ccc1d3d8cf98eb1a47.html"},{"id":99602856,"identity":"3cdb9fa7-5172-45ee-82cb-be2441dea514","added_by":"auto","created_at":"2026-01-06 10:55:10","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":223071,"visible":true,"origin":"","legend":"\u003cp\u003eOrganizational chart classifying the patients with diabetes depending on their requirement of tertiary care for diabetes and if their closest hospital from home is the tertiary care hospital (National hospital Kandy) or not.\u003c/p\u003e\n\u003cp\u003e(T = patients who require tertiary care follow up for diabetes, P = patients who do not require tertiary care follow up for diabetes, K = patients whose closest hospital from home is the tertiary care hospital [National hospital Kandy], NK = patients who bypass a primary care local hospital closer to home to attend a tertiary care facility)\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8212044/v1/103fcedab8e3e949210df61e.jpg"},{"id":99793582,"identity":"0ed856c4-4e58-4a86-9a01-4ce6e61a3a41","added_by":"auto","created_at":"2026-01-08 13:31:54","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":251848,"visible":true,"origin":"","legend":"\u003cp\u003eProportions of patients in the four subgroups based on their requirement of tertiary care follow up for diabetes, and if they bypass a primary care hospital to attend a tertiary care facility or attend the closest hospital from home.\u003c/p\u003e\n\u003cp\u003e(T-K = patients who require tertiary care follow up for diabetes, and the closest hospital from home in the tertiary care hospital, T-NK = patients who require tertiary care follow up for diabetes, and bypass a primary care local hospital closer to home to attend the tertiary care hospital, P-K = patients who do not require tertiary care follow up for diabetes, but attend the tertiary care hospital as it is the closest hospital from home, P-NK = patients who do not require tertiary care follow up for diabetes, and bypass a primary care local hospital close to home to attend the tertiary care hospital)\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8212044/v1/acdf8656414abaa29d0d256f.jpg"},{"id":99804178,"identity":"01eab1d4-fa87-4a27-8605-66eb7c75a3b2","added_by":"auto","created_at":"2026-01-08 14:12:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1130766,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8212044/v1/0912716c-8b9a-46d7-8ca8-2cdb0405b021.pdf"},{"id":99602896,"identity":"00723e75-3c5c-4fb9-897f-eeb2409e01ae","added_by":"auto","created_at":"2026-01-06 10:55:11","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14765,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8212044/v1/4246ad417f9f165b5ab7b772.docx"},{"id":99602854,"identity":"8e1661de-b26c-4950-b859-04e3cc9918e5","added_by":"auto","created_at":"2026-01-06 10:55:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19742,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8212044/v1/9ac1f28ec8a8179ea090f9c5.docx"},{"id":99602903,"identity":"218bef0a-f73b-4319-8dd0-7c96fc30a6f5","added_by":"auto","created_at":"2026-01-06 10:55:12","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":13946,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8212044/v1/c45a9fce8c495bef42dcb545.docx"},{"id":99793100,"identity":"e9a80653-c024-4087-b894-626f74c01cce","added_by":"auto","created_at":"2026-01-08 13:31:00","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":14071,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.docx","url":"https://assets-eu.researchsquare.com/files/rs-8212044/v1/d75b6f5c52433c185c4082ee.docx"},{"id":99602857,"identity":"a6b08f71-88d9-4597-b49f-15191a28c504","added_by":"auto","created_at":"2026-01-06 10:55:10","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":14256,"visible":true,"origin":"","legend":"","description":"","filename":"Table5.docx","url":"https://assets-eu.researchsquare.com/files/rs-8212044/v1/77d6c0871e923b76174d46c8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTime and Cost Burden of Non-essential Tertiary Care Follow-up for Diabetes in Rural Patients: Implications for Decentralizing Diabetes Healthcare\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetes has become a global burden with increasing prevalence worldwide. It is estimated that in 2022, there were 828\u0026nbsp;million adults with diabetes worldwide, with an increase of 630\u0026nbsp;million since 1990. The highest rise in prevalence was observed in low-income and middle-income countries including Southeast Asia \u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e.The IDF (International Diabetes Federation) Diabetes Atlas in 2021 reported that 10.5% of the adult population aged 20\u0026ndash;79 had diabetes and predicted that 1 in 8 adults will be having diabetes by 2045, which is a rise by 46% \u003csup\u003e(2)\u003c/sup\u003e. It revealed that 3 out of 4 adults with diabetes live in lower- and middle-income states. The prevalence of Diabetes in urban Sri Lanka is alarming was 27.6% 2018, reflecting a significant rise over the past decade. \u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e. A study in 2019 revealed that 23% of Sri Lankan adults had diabetes, a notable increase from the previous 14%, driven by factors such as population aging, urbanization, rising obesity rates, greater affluence, and rising prevalence among females. \u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003e. Evidence from 2016 revealed a prevalence of diabetes in urban areas of Sri Lanka of 14.39% which was higher than among those living in rural areas \u003csup\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003e. A more recent meta-analysis in 2023 showed a prevalence of diabetes in urban areas of Sri Lanka of 16.6% compared to 8.86% among rural populations. However, there is a recent rising trend in prevalence of diabetes in rural areas in Sri Lanka \u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e. With the increase in prevalence of diabetes and its further spread to rural areas, rises the need in establishing an effective healthcare system with access to all, with special focus on those living in rural areas.\u003c/p\u003e \u003cp\u003eThe Sri Lankan healthcare system follows a hierarchical structure, ranging from primary care hospitals with fewer facilities to highly specialized tertiary care institutions. There has been a noticeable trend for patients to directly seek treatment from tertiary care centres and thereby bypass primary and secondary health care facilities. This is despite the availability of primary care local hospitals within close proximity to most patients\u0026rsquo; residences. A study conducted at the Teaching Hospital Karapitiya attributed this behaviour to certain factors such as the lack of a proper referral system and also according to patients, insufficient laboratory facilities, unavailability of certain medications, and suboptimal service at primary health care centres \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e. Additionally, the proximity of some primary care hospitals to tertiary care centres encourage patients living nearby to seek follow-up care at the tertiary centres, even when primary healthcare follow up is sufficient for their care. These factors have resulted in a strain on tertiary care centres leading to congestion in hospitals and a decline in the effectiveness and quality of care provided to patients in need, as well as underutilization of primary health care facilities resulting in wasting of available resources \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e. Patients bypassing primary care local hospitals closer to home in order to attend tertiary care hospitals when tertiary care is in fact not essentially required, may also pose an additional burden on patients. As a result, there is reason for concern regarding the allocation and efficiency of utilizing healthcare resources.\u003c/p\u003e \u003cp\u003eDiabetes poses a significant economic burden on both individuals and the healthcare system in Sri Lanka. A recent study in Sri Lanka from 2024 among patients with diabetes attending an outpatient clinic in a semi-government private hospital revealed an average yearly financial burden of 9949 Sri Lankan rupees (LKR) per patient which is equivalent to 55 United States of American dollars (USD). This figure encompasses direct medical expenses, which average LKR 6479 (USD 36) for medications and diagnostic test, as well as direct non- medical costs, such as for transportation and meals, averaging LKR 3470 (USD 19). It is significant to note that 96% of patients faced these costs even though they had access to free healthcare services \u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e. A study among rural patients with diabetes from the Sainthamaruthu Divisional Secretariat Area of Ampara district in Sri Lanka indicated an average monthly economic burden per patient of LKR16,000(USD 87.93), with a considerable share of this cost shouldered by the patients\u0026rsquo; families. This underscores the significant financial pressure faced by households in rural areas due to this expenditure \u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e. Healthcare expenditure on diabetes has increased significantly on a global scale, with estimates showing a 316% rise over the last 15 years, culminating in a total of USD 966\u0026nbsp;billion. This trend highlights the growing economic burden of diabetes across the globe \u003csup\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDecentralizing diabetes management means transferring healthcare services and responsibilities from large, centralized facilities such as tertiary hospitals to local, community-based settings. This approach aims to enhance the accessibility, affordability, and fairness of diabetes care, ultimately improving patient outcomes by bringing services closer to where people live. Many low- and middle-income countries have decentralized their public health services in an effort to improve their equity, efficiency and effectiveness \u003csup\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/sup\u003e. Enhancing the decentralization of diabetes care in Sri Lanka is crucial for improving access, equity, and patient outcomes nationwide. Although the health care system is well established in urban areas, rural and underserved regions often face challenges such as inadequate resources, insufficient trained personals, and limited access to specialized care. The National Hospital Kandy (NHK) and the Diabetes and Endocrinology unit Kandy (DEUK) at NHK are tertiary care facilities which cater for the central province of Sri Lanka and sometimes areas beyond. The DEUK is a specialized referral centre for patients with diabetes. This study focusses on cost and time expenditure burden to patients from rural areas attending DEUK and highlights the need to improve decentralization of diabetes healthcare.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis is a descriptive cross sectional analytical study carried out in DEUK at NHK among patients followed up for diabetes in the out-patient diabetic clinic. Ethical approval was obtained from the Ethics review committee at the National Hospital Kandy (NHK/ERC/85/2024). Data collection was done over a three-month period from July 2024 to October 2024. The inclusion criteria were randomly selected diabetic patients aged 14 years and above registered and regularly followed up at the DEUK out-patient clinic. 429 eligible patients were recruited to this study after informed consent. An interviewer-administered questionnaire was developed for this study and it was used to obtain data from each of the recruited patients (Annexure 1). The questionnaire gathered details on patients demographic details, cost per clinic visit including travel and other related expenses, monthly family income, level of education, time spent for the commute to attend the clinic, effect on employment of the patient and accompanying person including details on leave required, closest hospital from home, distance to closest hospital from home, diabetes control and complications. Details on diabetic retinopathy, diabetic nephropathy and macrovascular complications including cardiovascular disease, stroke, transient ischaemic attacks (TIA), and diabetic foot disease were obtained from the patients\u0026rsquo; clinic records in addition to gathering details directly from the patient. For comparison, patients were divided into two categories; patients who require tertiary care follow up for diabetes (T) and, patients who do not require tertiary care follow up for diabetes, and can be followed up at a primary care facility (P). The criteria considered to classify patients as requiring tertiary care follow up (RTC) were HbA1c 10% or above and/ or any of the following diabetes related complications including; Any macrovascular complication (cardiovascular disease/ stroke/ TIA/ peripheral vascular disease), any degree of diabetic retinopathy, urine albumin creatinine ratio (UACR)\u0026thinsp;\u0026gt;\u0026thinsp;300 mg/g, serum creatinine\u0026thinsp;\u0026gt;\u0026thinsp;1.75 micromol/L, diabetic foot disease with limb amputation. Subgroup analysis was done of the cohort that did not require tertiary care follow up for diabetes (P) based on the closest hospital from their home. This cohort was further divided into two groups; patients whose closest hospital from home was NHK (K), and patients who bypassed another hospital close to home to attend NHK (NK). Those who did not require tertiary care follow up for diabetes and whose closest hospital from home was NHK were described as \u0026ldquo;P-K\u0026rdquo;, and those who did not require tertiary care follow up for diabetes and bypassed another primary care hospital close to home were described as \u0026ldquo;P-NK\u0026rdquo;.\u003c/p\u003e \u003cp\u003eData was analysed using the SPSS 28 package. The Mann-Whitney U test was used to compare medians of the P-K and P-NK categories. The chi square test was used to compare categorical data. A p value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 429 participants were recruited for this study, with ages ranging from 14 to 87 years. Overall,33.6% (n = 144) were K and 66.4% (n =284) were NK. Overall, 43.7% (n = 187) required tertiary care follow up for diabetes (T), out of which 29.4% (n = 55) K (T-K), and 70.6% (n = 132) NK (T-NK). 56.3% (n = 242) did not require tertiary care follow up for diabetes(P), among which 36.9% (n = 89) K (P-K) and 63.1% (n = 153) NK (P-NK) (Figure 1). Overall, there were 35.8% (n = 153) patients who bypassed a primary-care local hospital closer to home to attend a tertiary care diabetic clinic (NK), while in fact they did not require tertiary care follow up for diabetes (P-NK). 20.7% (n = 89) individuals did not require tertiary care follow up for diabetes (P) but invariably followed up at the tertiary care diabetic clinic at Kandy, because it was the closest hospital from home (P-K) (Figure 2). On subgroup analysis of those who did not require tertiary care follow up for diabetes (P) there was no significant difference in median age (58 vs. 55 years; p = 0.3), and sex proportions between P-K and P-NK (table 1 and 2).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLevel of education and monthly income\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A significantly higher proportion of P-NK had a higher level of education compared to P-K (38.2% vs. 19.1%; p = 0.002) (Table 2). The median average monthly family income was significantly higher among P-NK compared to P-K (40,000 [USD 137] vs. LKR 30,000 [USD 103]; p = 0.000) (table 1). A majority among both groups; P-K and P-NK had an average monthly income between LKR 20,000 [USD 65] and 50,000 [USD 171] (table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCost burden on patients to attend the tertiary care diabetic clinic\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe median total both ways cost for travel to attend a visit to the diabetic clinic (CTV) was significantly higher among P-NK compared to P-K. Five patients who were K had no cost at all to travel to the clinic visit, while all NK patients had travel costs associated with their clinic visits. The median CTV was LKR 120.00 [USD 0.41] (ranging between LKR 0 – 1200 [USD 4.1]) among P-K and was LKR 230.00 [USD 0.8] (ranging between LKR 38[USD 0.13] – 2400 [USD 7.93]) (p = 0.000) among P-NK (table 1). None of K required overnight stay elsewhere to attend the clinic, while 2 patients among NK required overnight stay at a relative’s residence in Kandy, but required no cost for accommodation. However, neither of them required tertiary care follow up for diabetes (P). They both spent a significant duration of time to travel (5 – 6 hours) to attend the tertiary-care diabetic clinic, and one patient spent a significant percentage; 17.6% of their monthly family income on travel cost (Table 3).\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;median proportion of monthly family income spent on travel to attend the clinic visit (PICV) was significantly higher among P-NK being 0.6%, compared to 0.4% among P-K (p = 0.002) (table 1). There were 9 patients who spent more than 10% of their monthly family income on travel costs to attend the diabetic clinic visit. Among them, one attended the tertiary care diabetic clinic as NHK was the closest hospital from home, though they did not infact require tertiary care follow up for diabetes (P-K). This patient was a 78-year-old unemployed elderly lady who lived 1.6 km from NHK and travelled by three-wheeler to attend clinic incurring a cost of LKR 1000 for a round trip. Eight of the nine patients who spent \u0026gt;10% of their monthly family income on travel costs for a diabetic clinic visit bypassed primary care local hospital close to home (NK); 3 of them required tertiary care follow up for diabetes (T), while 5 of them did not (P). Among the 9 who spent \u0026gt;10% of their monthly family income, 6 were elderly patients over the age of 60 years and were all unemployed without a regular income. Two of them survived on financial assistance through the ASWASUMA government support program, amounting to LKR 2500 [USD 8.6] as a monthly allowance. Neither of these patients required tertiary care follow up for diabetes (P) (table 4).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBurden of time spent on travel and mode of transport for patients to attend the tertiary care diabetic clinic\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe median total both ways time taken to travel to hospital to attend a visit to the diabetic clinic (TT) was significantly higher among P-NK compared to P-K. \u0026nbsp;(median 40; range 10 minutes – 3 hours vs. median 1.5 hours; range 15 minutes – 11 hours) (p = 0.000) (table 1). 34.1% (n = 30) among P-K compared to 9.2% (n = 14) among P-NK spent less than 30 minutes to TT, while 21.1% (n = 32) among P-NK compared to 1.1% (n = 1) among P-K spent more than 2 hours to TT (p = 0.070) (table 2).\u003c/p\u003e\n\u003cp\u003eOne of the two K patients who took \u0026gt; 2 hours TT lived in Aruppola, located 3 kilometers (km) from NHK which was the closest hospital from home. She typically relied on public transport to travel from home to the NHK, which included walking for 25 minutes from home to the nearest bus stand, followed by 15 minutes for the bus ride, and then walking for 20 minutes from the final bus stop to the NHK. The TT was 120 minutes, including 90 minutes of walking and 30 minutes on the bus. The other K \u0026nbsp;patient who took \u0026gt; 2 hours TT lived in Lewella area, located 4.5 km from the NHK. She relied on public transport to travel from home to the NHK, which included walking for 25 minutes to the nearest bus stand, followed by 18 minutes for the bus ride, and then walked for another 17 minutes from the final bus stop to the NHK. The TT was 120 minutes, including 84 minutes of walking and 36 minutes on the bus, and she did not require tertiary care follow up for diabetes. Although traveling by a personal or hired vehicle would have reduced the total travel time to just 25 minutes both ways for both of these patients, they both were unable to afford this option due to financial constraints and had to rely on the more time-consuming alternative via public transport. Both these patients had no other primary care local hospital closer to home, making NHK the closest hospital from home.\u0026nbsp;Among the NK patients, 71.5% (n = 191) bypassed another primary care hospital located within 5 km of their residence to attend the tertiary care diabetic clinic, out of which only 44% (n = 84) required tertiary care for diabetes (T). 66.4% (n =87) among K did not have another primary care local hospital within 5 km from home, hence had to attend the tertiary care diabetic clinic at DEUK-NHK. However, only\u0026nbsp;41.4% (n = 36) of them required tertiary care follow up for diabetes (T).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The predominant mode of transport was public transport via bus in the whole cohort, accounting for 69.7% (n=62) among P-K and 78.9% (n=120) among P-NK. Predominantly travelling by foot was the main mode of transport in 12.4% (n=11) among P-K and 2.6% (n= 4) among P-NK (p = 0.000)(table 2). Four out of five NK patients who predominantly travelled by foot to attend the diabetic clinic did not require tertiary care diabetes follow up, out of which two walked from their place of employment, which was close to the NHK, with a TT of 10 and 30 minutes respectively. One of them bypassed a primary care local hospital located 1.5 km from home; which takes only 6 minutes TT from home. Three of them predominantly spent TT of 1.5, 3, and 3.25 hours, which would have taken only 12, 16, and 20 minutes TT by foot if they attended the primary care local hospital closest to home instead (table 5). A significant majority of 78.7% (n = 70) among P-K and 80.3% (n = 122) among P-K had no other activity planned in the vicinity when travelling to attend the tertiary care diabetic clinic. (table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTime lost off work hours from place of employment\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e25.8% (n = 23) among P-K and 30.9% (n = 47) among P-NK were employed (p = 0.402). The main type of leave required to attend the diabetic clinic was full day leave (table 2). There was no significant difference in the proportion of patients who required an accompanying to attend the clinic visit at DEUK among the groups (p = 0.887). 28.9% (n = 44) among P-NK required an accompanying person to attend the diabetic clinic, out of which 25% (n = 11) of the accompanying persons were employed, and 36.4 % (n = 4) of them required full day leave from their place of employment to attend the diabetic clinic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDiabetes control and related complications\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e37.6% among those who bypassed a primary care local hospital and 24.4% among those whose closest hospital from home was NHK had HbA1c of 10% (p=0.300). The presence of active foot ulcer (2.9% vs. 0.7%; p = 0.148) and amputation (1.4% vs. 0.7%; p = 0.518) was non-significantly higher among those who bypassed a primary care local hospital compared to those who closest hospital was NHK.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights the cost and time expenditure burden to diabetic patients from rural areas who attend a tertiary care diabetic clinic, with special focus on those who in fact do not require tertiary care follow up for diabetes but by-pass a primary care local hospitals closer to home in order to directly attend a specialised tertiary care facility for diabetes care.\u003c/p\u003e \u003cp\u003eNK individuals showed a higher proportion of advanced education, likely reflecting a better understanding of implications of proper diabetes management and its potential complications, as well as higher expectations on diabetes management leading to seek the best care available. As a result, they may prefer seeking follow-up care at an ideal tertiary care centre, even when a closer, resource-limited primary care facility is available. Higher educational attainment has shown to be associated with better diabetes self-care management practices, increased utilization of healthcare resources effectively, and better long-term glycaemic control \u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e. Along with better education associated with the understanding of the need for specialised diabetic care with better resources and close screening for potential complications, these individuals seek follow-up care at better equipped specialist lead tertiary care centres, due to the lack of faith in receiving the same care at primary care local hospitals even if they may be closer to home.\u003c/p\u003e \u003cp\u003eUnderstandably, those with higher education levels had better employment states, resulting in higher incomes and better financial resources, which was seen among the NK cohort \u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e. This likely lead to them being more financially equipped to afford the required cost to travel longer distance to attend the tertiary care centre. Some diabetic medications and investigations which are freely available at tertiary care hospitals are often not available at primary care centres. Hence, in such situations those followed up at tertiary care centres would get these medications or investigations free of charge, while those following up at local hospitals often must pay to receive these same resources from the private sector. This is often a reason why some individuals with lower income states prefer to bypass a closer local hospital to attend a tertiary care facility to get these resources free of charge from, even though it means having to spend more on travel expenses for an additional visit to the tertiary care centre. This additional travel expense in-turn would be an additional financial burden to those with financial difficulties. Although we did not specifically assess the expenses incurred for private-sector laboratory tests, it is clear that this practice arises from the difficulty many patients face in dedicating another day solely to visit NHK for complimentary testing. Income disparities affect healthcare access and quality, with lower-income individuals facing greater challenges. Targeted policies are needed to improve communication and satisfaction. Economic factors, such as income and occupation, also influence access to healthcare by mediating the education-health link \u003csup\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePatients among NK, face significantly higher travel costs. Irrespective of a patient\u0026rsquo;s financial status, the overall financial burden of these costs remains substantial for all patients. Despite the availability of free healthcare services in Sri Lanka, patients often incur additional out-of-pocket expenses during clinic visits, including payments for certain medications and laboratory tests not available at hospital, transportation, and other non-medical expenditures owing to longer time spent on long distance travel like meals and if needed accommodation.\u003c/p\u003e \u003cp\u003eA recent study on out-of-pocket healthcare expenditure among patients with chronic disease in Sri Lanka found an average cost of LKR 3,000 per clinic visit, with 13.5% of them spending a significant proportion of household income (18). Our study also showed that NK patients spent a higher proportion of their household income on travel to attend the clinic visit. Notably, patients admitted to private hospitals faced 2.61 times higher cost compared to those admitted to government hospitals \u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/sup\u003e. Though this study did not specify the frequency of clinic visits per patient, which also varies based on diabetes control. Thus, more frequent clinic visits increase this cost and time expenditure accordingly. \u003cem\u003eKumara et al.\u003c/em\u003e showed that Sri Lankan households with multiple elderly members, preschool children, chronic illnesses, and literate household heads are at significant risk of incurring such expenses and bearing a higher financial burden. Rural and estate sector households were more likely to experience a higher burden. The study emphasized the need for expanding government healthcare infrastructure and implementing policies to reduce the financial burden on Sri Lankan households, particularly the poor \u003csup\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe cumulative effect of these expenses can have profound implications on their overall quality of life, potentially limiting access to essential healthcare services, and medical emergencies increasing financial stress, and reducing funds available for other basic daily necessities. This disparity underscores the urgent need for interventions to alleviate the economic burden on vulnerable populations, ensuring equitable access to healthcare and better long-term outcomes for all patients.\u003c/p\u003e \u003cp\u003eWhile the commonest mode of transport was via bus, road traffic congestion in Sri Lanka leads some individuals to opt to travel via public transport despite owning private vehicles, due to higher cost spent on fuel, and due to the hassle associated with driving in traffic \u003csup\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/sup\u003e. However, on the other hand, public transport including buses and trains in Sri Lanka are often overcrowded, unclean and uncomfortable making it an unpleasant experience to travel. Due to lack of planning of infrastructure and travel routes in public transport systems in Sri Lanka, many individuals face challenges with reaching public transport, including having to walk for long periods to reach a bus or train station. These challenges lead to patients missing regular clinic appointments and delaying emergency attention at a close-by primary care facility in instances where patients often opt to bypass primary care facilities \u003csup\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eNK individuals faced extensive time spent on travel, with some requiring a both ways travel of up to 11 hours. In addition to travel time, the wait time; especially due to overcrowding of tertiary care clinics was not taken into consideration, which adds further burden on time expenditure. This time expenditure significantly impacts their daily lives, necessitating substantial time off work, family and personal commitments and routine daily activities. The resultant loss of income from time off work creates a vicious cycle of financial strain, which not only affects the individual but also places a considerable burden on their family. Furthermore, frequent absences from work due to travel and medical appointments can jeopardize job security, thereby exacerbating financial instability. Extended travel times to attend healthcare providers have shown to significantly diminish the health-related quality of life (HRQoL) of individuals with type 2 diabetes, affecting difficult choices on the balance of employment and healthcare, creating a cycle of financial instability and health decline \u003csup\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePatients traveling long distances to attend clinic follow-up at a tertiary care facility often require the support of an accompanying person. The accompanying person frequently faces disruptions to their own schedule, including time away from work or other responsibilities, which can be particularly challenging for those with limited flexibility. Moreover, the time commitment involved in such travel, compounded by potential waiting periods and overnight stays, can create further hardships for both the patient and their companion.\u003c/p\u003e \u003cp\u003ePrimary care local hospitals face significant resource shortages, including a lack of trained healthcare personals, limited diagnostic facilities, and inconsistent medication supplies, which hinder effective patient care, particularly for chronic diseases. Drug availability disparities between healthcare facilities affect patient behaviour, with patients often bypassing local hospitals for tertiary care centres to have continuous access to essential medications. These gaps must be addressed to improve healthcare outcomes and ensure equitable access. Drug shortages in peripheral hospitals have shown to often be attributed to resource allocation challenges, supply chain inefficiencies, and insufficient funding for consistent procurement \u003csup\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/sup\u003e. A study conducted in Sri Lanka found that Local hospitals in Sri Lanka have shown to experienced stock shortages of critical medications more frequently compared to tertiary care centres, leading to disruptions in patient care and adherence to treatment regimens \u003csup\u003e(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/sup\u003e. Furthermore, patients may perceive tertiary hospitals as more reliable for medication availability, prompting a preference for these facilities despite the additional time and travel costs involved.\u003c/p\u003e \u003cp\u003ePatients often express a lack of faith in the care provided at local hospitals. A study conducted in Sri Lanka revealed that a significant proportion of patients expressed dissatisfaction with the services provided in public hospitals, citing long waiting times, overcrowding, and a perceived lack of empathy from healthcare workers as primary concerns \u003csup\u003e(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/sup\u003e. Similar findings were observed in a study from India, where patient dissatisfaction was strongly associated with perceived disparities in the quality of care between government and private hospitals \u003csup\u003e(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/sup\u003e. Furthermore, a systematic review of patient perspectives across low- and middle-income countries emphasized that trust in healthcare systems is undermined when patients experience inconsistent care, lack of communication, and limited access to essential medical interventions \u003csup\u003e(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/sup\u003e. These findings align with global observations that highlight trust as a cornerstone of effective healthcare delivery and patient satisfaction. Addressing this mistrust requires targeted interventions, including strengthening the capacity of local hospitals, improving patient-provider communication, and fostering a patient-centred approach in care delivery. By prioritizing these aspects, healthcare systems can enhance patient confidence and ensure better engagement with locally available health services.\u003c/p\u003e \u003cp\u003ePatients with diabetic foot disease, particularly chronic foot wounds demand more frequent follow-up for foot care and wound dressing than what is typically provided for glycaemic control at most clinics. Therefore, rural patients who attend a distant tertiary care diabetic clinic tend to neglect of foot disease due to inconsistency of attending foot care. The lack of specialized diabetic foot care at local healthcare facilities leads to delayed diagnoses, worsening foot complications, and higher amputation risks \u003csup\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/sup\u003e. Long-distance travel, particularly over extended durations to attend clinic at a distant tertiary care hospital, can significantly increase the risk of developing callosities and foot wounds, especially in financially strained individuals who have limited access to specialized footwear. Diabetic patients living in rural areas have shown to be more likely to develop foot ulcers due to the lack of proper footwear and limited access to specialized care \u003csup\u003e(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe overall glycaemic control evidenced by HbA1c and management of diabetic complications was slightly more optimal among those who had their diabetic follow up in close proximity to home, indicating the positive impact of resourceful healthcare facility closer to home. The convenience of travel reduced missed appointments and facilitated consistent monitoring and adjustments to therapy. Geographic barriers, including distance from the healthcare facility have shown to negatively impact chronic disease management, with longer travel distances correlating with poorer glycaemic outcomes \u003csup\u003e(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAddressing these disparities requires robust policies to improve drug supply chains, equitable resource distribution, and strengthening the capacity of local hospitals to meet the healthcare needs of their communities. Implementing a more decentralized approach can facilitate comprehensive diabetes management by strengthening primary healthcare facilities, and expanding community health programs in rural areas.\u003c/p\u003e\n\u003ch3\u003ePotential steps to implement decentralization of Diabetes care in Sri Lanka\u003c/h3\u003e\n\u003cp\u003eRural patients should receive routine clinic follow-up for diabetes at local healthcare centres, with referrals to tertiary centres for specialized care as and when indicated. This system ensures continuity of care, efficient resource use, and patient convenience by reducing travel and costs. Standardized referral protocols and communication between care providers should be established to streamline the process. Steps need to be taken to optimise healthcare at primary care local hospitals and to build trust in the patients about its care. Health care personals should be trained in optimal diabetes management with adherence to guidelines, addressing patients concerns with professionalism, expanding community health programmes in rural areas, providing continuous access to medications and investigations including diagnostic tools. By empowering local healthcare centres with resources, training, and technology, early detection and preventive measures for diabetes and related complications can be implemented more effectively.\u003c/p\u003e \u003cp\u003eAdopting a general practitioner (GP) system in Sri Lanka could transform primary care by enabling GPs to provide holistic care, manage a range of medical issues, and ensure early diagnosis of both chronic and acute conditions. Acting as gatekeepers, GPs would coordinate referrals, directing patients to specialists when needed, and foster patient trust through continuity of care. This system would be particularly beneficial in rural health centres, bridging the gap between local communities and tertiary healthcare services. GP-based diabetes care is associated with better glycaemic control, increased patient satisfaction, and reduced diabetes-related complications \u003csup\u003e[34]\u003c/sup\u003e. Additionally, GP-centred models often include integrated care pathways that combine lifestyle modification guidance, pharmacological interventions, and screening for complications, which are essential for comprehensive diabetes care. Furthermore, the GP approach can reduce the burden on tertiary care centres. When diabetes care is managed effectively at the primary care level, hospital admissions for preventable complications, such as diabetic ketoacidosis or foot ulcers, decrease significantly \u003csup\u003e[35]\u003c/sup\u003e. A systematic review revealed that integrating diabetes care into primary care settings resulted in fewer referrals to specialists and improved utilization of healthcare resources \u003csup\u003e[36]\u003c/sup\u003e. Implementing such a system in Sri Lanka could alleviate the strain on tertiary care facilities, enhance early diagnosis, and foster better long-term outcomes for patients.\u003c/p\u003e \u003cp\u003eFor patients requiring specialized input, a system of \"SOS reviews\" can be implemented. This would include scheduled infrequent consultations at tertiary care centres, telemedicine for remote consultations with a tertiary care facility, and multidisciplinary teams for comprehensive evaluations and patient centred care. \"SOS reviews\" or similar systems have shown to improve patient outcomes, reduce hospital stays, and enhance patient satisfaction. For example, the \"Advice and Guidance\" system in the UK National Health Service (NHS) allows primary care providers to seek advice from specialists electronically, reducing unnecessary referrals and expediting critical consultation \u003csup\u003e(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/sup\u003e. By integrating these components, a proper referral system, the introduction of a GP model, and SOS reviews, Sri Lanka can achieve a more equitable and efficient healthcare system, ensuring that patients in rural areas receive timely and appropriate care while optimizing resources at tertiary care centres.\u003c/p\u003e \u003cp\u003eTelemedicine and telehealth solutions can significantly reduce costs and time spent on travel by minimizing the need for patients to physically visit tertiary care centres. Sri Lanka's success with mobile-based consultations during the COVID-19 pandemic underscores the feasibility of adopting such systems for SOS reviews \u003csup\u003e(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/sup\u003e. Patients receiving telehealth intervention were found to have better HbA1c control than those routinely attending clinic visits \u003csup\u003e(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis approach not only enhances accessibility but also alleviates the burden on patients and healthcare providers, creating a more sustainable and patient-centred healthcare system. Decentralization of Diabetes care in Sri Lanka by shifting routine clinic follow up to primary care local hospitals relieves the cost burden to both individual patient and the health sector on the whole. Decentralization strengthens primary healthcare systems by promoting investments in local infrastructure and workforce development. It also ensures equity in healthcare delivery, expanding diabetes care to marginalized and rural communities, not just urban populations.\u003c/p\u003e \u003cp\u003eDecentralization of DM healthcare is a timely and necessary solution for enhancing the welfare of both patients and the overall health sector. This approach involves shifting the focus of diabetes care delivery from centralized, urban-based tertiary care hospitals to more accessible primary and secondary healthcare facilities in rural and underserved areas. By doing so, it addresses critical challenges such as limited access, overburdened healthcare systems, and inequities in service delivery which is timely need in Diabetes care in Sri Lanka.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRecommendations for channeling patient care based on their tertiary care requirement and proximity to a tertiary care facility\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThose who require tertiary care follow for diabetes will need to attend the diabetic clinic at the specialist lead tertiary care hospital irrespective if they bypass a primary care local hospital close to home (T-K and T-NK).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThose who do not require tertiary care follow up for diabetes, but have no other local hospital other than the tertiary care hospital close to home (P-K) can follow up at a non-specialist lead primary care clinic by trained medical officers either at the same tertiary care hospital or at a separate medical centre with access to specialized diabetic clinic referral if and when the need arises only.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThose whose closest hospital from home is a primary care local hospital and do not require tertiary care follow up for diabetes (P-NK) can follow up at the closest primary care local hospital with improved healthcare services and a good referral system to a tertiary care diabetic service if and when the need arises only.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNHK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Hospital Kandy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDEUK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiabetes and Endocrinology Unit Kandy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLKR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSri Lankan rupees\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited States of American dollars\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatients who require tertiary care follow up for diabetes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatients who do not require tertiary care follow up for diabetes, and can be followed up at a primary care facility\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRTC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe criteria considered to classify patients as requiring tertiary care follow up\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatients whose closest hospital from home was NHK\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatients who bypassed another hospital close to home to attend NHK\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eK-Those who did not require tertiary care follow up for diabetes and whose closest hospital from home was NHK\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNK-Those who did not require tertiary care follow up for diabetes and bypassed another primary care hospital close to home\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eK-Those who require tertiary care follow up for diabetes and whose closest hospital from home was NHK\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNK-Those who require tertiary care follow up for diabetes and bypassed another primary care hospital close to home\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCost for travel to attend a visit to the diabetic clinic\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePICV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProportion of monthly family income spent on travel to attend the clinic visit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTotal both ways time taken to travel to hospital to attend a visit to the diabetic clinic\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral practitioner\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003e \u003cb\u003eEthics approval and consent to participate\u003c/b\u003e \u0026ndash;\u003c/strong\u003e \u003cp\u003e The study is adhered to the Declaration of Helsinki and it was approved by local Ethics Committee of the National Hospital, Kandy on 09/12/2024 ( Reference: NHK/ERC/85/2024). Informed written consent was obtained from all patients prior to recruiting to the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cb\u003eConsent for publication\u003c/b\u003e \u0026ndash;\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interest:\u003c/h2\u003e \u003cp\u003eThe authors have declared that they have no competing interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding -\u003c/h2\u003e \u003cp\u003eNo funding was received for this study\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCNA, LRBD, KPJ, and HKL contributed to the research planning and formulation of the study. DB, MDMSBD, KGRLBW, KPJ, and LRBD were responsible for data collection. ST, LRBD, and KPJ performed the data analysis. KPJ and LRBD drafted the manuscript under the guidance of CNA. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to acknowledge Dr. Dhulashiha Jegavanthan, Consultant Endocrinologist at the District General Hospital, Vavuniya, Sri Lanka, and Dr. Sonali Gunathilaka, Consultant Endocrinologist at the National Hospital, Kandy, Sri Lanka, for generously contributing their time, knowledge, and expertise to this article. We are also grateful to all the patients who participated in this study, as well as the nurses and staff of the Diabetes and Endocrinology Unit, National Hospital, Kandy, Sri Lanka, for their invaluable support.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhou B, Rayner AW, Gregg EW, Sheffer KE, Carrillo-Larco RM, Bennett JE et al. Worldwide Trends in Diabetes Prevalence and Treatment from 1990 to 2022: a Pooled Analysis of 1108 population-representative Studies with 141 Million Participants. Lancet. 2024;404(10467).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSun H, Saeedi P, Karuranga S, Pinkepank M, Ogurtsova K, Duncan BB et al. 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[cited 2023 Dec 27];.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Decentralization, Primary care, Tertiary care, Diabetes, Referral system","lastPublishedDoi":"10.21203/rs.3.rs-8212044/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8212044/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePatients 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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA 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).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 429 patients, 56.3% (n\u0026thinsp;=\u0026thinsp;242) did not require tertiary care follow up for diabetes (P), among which 36.9% (n\u0026thinsp;=\u0026thinsp;89) P-K and 63.1% (n\u0026thinsp;=\u0026thinsp;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\u0026thinsp;=\u0026thinsp;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\u0026thinsp;=\u0026thinsp;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\u0026thinsp;=\u0026thinsp;0.000). P-NK spent a higher proportion of their MFI on TCV compared to P-K (p\u0026thinsp;=\u0026thinsp;0.002). Among 9 patients who spent\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;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 \u0026ndash; 3 hours vs. median 1.5 hours; range 15 minutes \u0026ndash; 11 hours) (p\u0026thinsp;=\u0026thinsp;0.000). 2 patients among NK required overnight stay. neither of them required tertiary care follow up for diabetes (P-NK).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThere 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.\u003c/p\u003e","manuscriptTitle":"Time and Cost Burden of Non-essential Tertiary Care Follow-up for Diabetes in Rural Patients: Implications for Decentralizing Diabetes Healthcare","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-06 10:54:59","doi":"10.21203/rs.3.rs-8212044/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-17T02:40:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"245575743071293207766373416253193140306","date":"2026-01-11T15:28:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"316822874644960602228429951430357004565","date":"2026-01-11T09:20:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"40066240301409931829908816016658295256","date":"2026-01-04T13:42:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-02T09:17:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-29T16:54:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-10T04:51:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-09T16:48:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-12-09T16:38:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"953eb672-8c52-4148-865a-54d0a70187bb","owner":[],"postedDate":"January 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-06T10:55:00+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-06 10:54:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8212044","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8212044","identity":"rs-8212044","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}