title: The Perspectives of Patients on Health-Care for Co-Morbid Diabetes and Chronic Kidney Disease: A Qualitative Study.
abstract: BACKGROUND
  Multi-morbidity due to diabetes and chronic kidney disease (CKD) remains challenging for current health-systems, which focus on single diseases. As a first step toward health-care improvement, we explored the perspectives of patients and their carers on factors influencing the health-care of those with co-morbid diabetes and CKD.
  
  
  METHODS
  In this qualitative study participants with co-morbid diabetes and CKD were purposively recruited using maximal variation sampling from 4 major tertiary health-services from 2 of Australia's largest cities. Separate focus groups were conducted for patients with CKD stages 3, 4 and 5. Findings were triangulated with semi-structured interviews of carers of patients. Discussions were transcribed verbatim and thematically analysed.
  
  
  RESULTS
  Twelve focus groups with 58 participants and 8 semi-structured interviews of carers were conducted. Factors influencing health-care of co-morbid diabetes and CKD grouped into patient and health service level factors. Key patient level factors identified were patient self-management, socio-economic situation, and adverse experiences related to co-morbid diabetes and CKD and its treatment. Key health service level factors were prevention and awareness of co-morbid diabetes and CKD, poor continuity and coordination of care, patient and carer empowerment, access and poor recognition of psychological co-morbidity. Health-service level factors varied according to CKD stage with poor continuity and coordination of care and patient and carer empowerment emphasized by participants with CKD stage 4 and 5, and access and poor recognition of psychological co-morbidity emphasised by participants with CKD stage 5 and carers.
  
  
  CONCLUSIONS
  According to patients and their carers the health-care of co-morbid diabetes and CKD may be improved via a preventive, patient-centred health-care model which promotes self-management and that has good access, continuity and coordination of care and identifies and manages psychological morbidity.
authors.affiliation: Diabetes and Vascular Research Program, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.|Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia.
authors.forename: Clement
authors.initials: C
authors.lastname: Lo
authors.affiliation: Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, Australia.
authors.forename: Dragan
authors.initials: D
authors.lastname: Ilic
authors.affiliation: Diabetes and Vascular Research Program, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.|Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia.
authors.forename: Helena
authors.initials: H
authors.lastname: Teede
authors.affiliation: Menzies School of Health Research, Casuarina, Northern Territory, Australia.|The George Institute for Global Health, Camperdown, New South Wales, Australia.
authors.forename: Alan
authors.initials: A
authors.lastname: Cass
authors.affiliation: Department of Diabetes and Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
authors.forename: Greg
authors.initials: G
authors.lastname: Fulcher
authors.affiliation: The George Institute for Global Health, Camperdown, New South Wales, Australia.|Department of Nephrology, Concord Hospital, Concord, New South Wales, Australia.
authors.forename: Martin
authors.initials: M
authors.lastname: Gallagher
authors.affiliation: Diabetes Australia, Canberra, Australian Capital Territory, Australia.
authors.forename: Greg
authors.initials: G
authors.lastname: Johnson
authors.affiliation: Department of Nephrology, Monash Health, Clayton, Victoria, Australia.
authors.forename: Peter G
authors.initials: PG
authors.lastname: Kerr
authors.affiliation: Kidney Health Australia, Adelaide, South Australia, Australia.
authors.forename: Tim
authors.initials: T
authors.lastname: Mathew
authors.affiliation: Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, Australia.
authors.forename: Kerry
authors.initials: K
authors.lastname: Murphy
authors.affiliation: Department of Nephrology, Monash Health, Clayton, Victoria, Australia.
authors.forename: Kevan
authors.initials: K
authors.lastname: Polkinghorne
authors.affiliation: Department of Renal Medicine, Alfred Health, Prahran, Victoria, Australia.
authors.forename: Rowan
authors.initials: R
authors.lastname: Walker
authors.affiliation: Diabetes and Vascular Research Program, Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.|Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia.|The George Institute for Global Health, Camperdown, New South Wales, Australia.
authors.forename: Sophia
authors.initials: S
authors.lastname: Zoungas
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001315:Australia / Q000453:epidemiology; D017028:Caregivers / Q000706:statistics & numerical data; D002947:Cities; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000453:epidemiology / Q000628:therapy*; D005260:Female; D017144:Focus Groups; D019538:Health Care Surveys / Q000379:methods* / Q000706:statistics & numerical data; D006296:Health Services / Q000706:statistics & numerical data; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D036301:Qualitative Research; D051436:Renal Insufficiency, Chronic / Q000453:epidemiology / Q000628:therapy*; D012648:Self Care / Q000379:methods / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D062606:Tertiary Care Centers / Q000706:statistics & numerical data