Factors Associated With Transition of Care in Patients With Chronic Non-Communicable Diseases: Cross-Sectional Study

Abstract

Aim: To assess the relationship between sociodemographic and clinical characteristics and the quality of care transitions among individuals with chronic non-communicable diseases after hospital discharge. Design: Cross-sectional, single-centre study. Method: Participants were people with chronic diseases who underwent clinical or surgical treatment and were discharged from a hospital in southern Brazil. Data were collected from March to July 2021. The study used clinical and sociodemographic characterisation instruments at the bedside; after hospital discharge, the care transitions measure-15 (CTM-15) was conducted by telephone. Descriptive and inferential statistical analyses were applied. Results: A total of 487 participants were included, with a mean age of 60.6 years; 67.4% were classified as having satisfactory care transitions. In the adjusted model, a higher likelihood of satisfactory transitions was observed among individuals who underwent surgical treatment (OR = 2.974; p < 0.001), those without family income (OR = 2.546; p < 0.001), White individuals (OR = 1.705; p = 0.027), and women (OR = 1.589; p = 0.042). Discharge with clinical devices was also associated with satisfactory transitions (OR = 1.245; p = 0.043). Conversely, individuals with family income between R$1100 and R$3299 showed a lower likelihood of satisfactory transitions, although this association was not statistically significant (OR = 0.724; p = 0.066). Conclusion: Clinical and sociodemographic characteristics significantly influence the quality of care transitions. The results highlight social and contextual factors and show that effective transitions require strategies that integrate clinical needs with the social determinants shaping the care experience. Transition practices that are sensitive to patients' social, cultural and economic contexts may help strengthen equity and safety in post-discharge continuity of care. Implications for the Profession and/or Patient Care: These findings reinforce the need for individualised discharge planning, clear interprofessional communication and health education adapted to patients' literacy levels and social conditions. Such measures can improve safety, autonomy and treatment continuity for patients with chronic conditions and support professionals in developing context-responsive care transition strategies. Reporting Method: This study followed the STROBE checklist for cross-sectional studies. Patient or Public Contribution: Patients participated in the data collection by answering the care transitions measure-15 after hospital discharge, directly contributing to the interpretation of the care transitions data.