Determinants of referral for diabetic wound care from primary care: A mixed-methods study in Indonesia

Abstract Background: Diabetic foot ulcers are a major complication of diabetes that often require complex care. Although primary care is expected to manage most diabetic wounds, high referral rates to hospitals in Indonesia suggest inefficiencies in frontline service capacity under the National Health Insurance Scheme. This study aimed to identify the factors associated with decisions regarding referrals for diabetic wound care from primary care to hospitals in Indonesia. Methods: We applied a parallel explanatory mixed-methods design. The quantitative analysis used cross-sectional 2023 claims data comprising 286,253 visits by 54,904 patients with diabetes across Indonesia. Multivariate logistic regression was used to identify the predictors of referral. Qualitative data were obtained through 39 in-depth interviews with health workers and patients across 22 primary care facilities in 11 provinces and were analysed thematically using the Andersen behavioural model and health system framework. Results: Of all visits for diabetic wounds, 132,927 (46.4%) resulted in hospital referrals. Factors that were significantly associated with higher odds of referral included younger age (18–39 vs.40–59 years: adjusted odds ratio [aOR] 1.27, 95% CI 1.22–1.36), underweight BMI (aOR 1.05, 95% CI 1.03–1.08), enrolment in informal sector worker membership (aOR 1.46, 95% CI 1.43–1.49), and residing in districts with available specialists (aOR 1.03, 95% CI 1.01–1.04). Lower odds of referral were observed in private facilities (aOR 0.85, 95% CI 0.84–0.87) and in the outer Java and Bali island regions of Sumatera (aOR 1.72, 95% CI 1.40-2.10), Kalimantan (aOR 1.66, 95% CI 1.19-2.33), Sulawesi (aOR 2.08, 95% CI 1.56-2.78), and Nusa Tenggara, Maluku, and Papua (aOR 1.79, 95% CI 1.27-2.52). Qualitative insights reinforced these findings and highlighted clinical severity, infrastructure gaps, and limited clinical capacity of providers as the key drivers of referrals. Conclusions: Improving diabetic wound care at the primary level requires targeted investment in nurse training, referral protocols, clinical practice guidelines (standard procedures for diabetic wounds in primary care), and equitable distribution of resources. These reforms may reduce unnecessary referrals and improve the delivery of chronic care in Indonesia.