title: Identifying health service barriers in the management of co-morbid diabetes and chronic kidney disease in primary care: a mixed-methods exploration.
abstract: Co-morbid diabetes and chronic kidney disease (CKD) are common in primary care but health care can be suboptimal.
  
  
  
  In this multi-centre mixed-methods study, we investigated GPs' perspectives on health service barriers in managing diabetes and CKD as an initial step towards health care improvement.
  
  
  
  Four focus groups were conducted among GPs in Australia's two largest cities. Transcripts underwent content analysis to inform development of a survey exploring health service barriers. This survey was then emailed/mailed to 840 GPs. Statistical analyses were performed using STATA v2.1.
  
  
  
  Responses were received from 13.7% of GPs (n = 115), mean (±SD) age 55.3 (10.1) years and mean duration of practice 26.6 (10.6). The majority (88.4%) reported wanting to manage diabetes and CKD in primary care with specialist assistance. However, 34.8% were unclear about the definition of CKD with 73.2% wanting more education. Access to specialist services was problematic with 39.3% and 28.2% reporting the process of referring patients to diabetes or CKD services, respectively, as hard. Coordination of care was also a problem with 35.6% unclear about each health care provider's role, 50.5% believing patients faced difficulties due to poor coordination across providers and 51.6% reporting duplication of tests.
  
  
  
  GPs expressed a clear interest in being the principal health care providers for patients with co-morbid diabetes and CKD. Supporting GPs and health care improvement focusing on overcoming reported barriers such as inadequate knowledge about CKD, access to specialist services and coordination of care may improve outcomes for people with co-morbid diabetes and CKD.
authors.affiliation: 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: 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: 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: School of Primary Health Care, Monash University, Clayton, Victoria, Australia.
authors.forename: Grant
authors.initials: G
authors.lastname: Russell
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 General Practice, Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia and.
authors.forename: Timothy
authors.initials: T
authors.lastname: Usherwood
authors.affiliation: Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.
authors.forename: Sanjeeva
authors.initials: S
authors.lastname: Ranasinha
authors.affiliation: 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, University of Sydney, Sydney, New South Wales, Australia. sophia.zoungas@monash.edu.
authors.forename: Sophia
authors.initials: S
authors.lastname: Zoungas
mesh_terms: D000368:Aged; D001315:Australia; D015897:Comorbidity; D003920:Diabetes Mellitus / Q000453:epidemiology / Q000628:therapy*; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006296:Health Services / Q000592:standards* / Q000706:statistics & numerical data; D006301:Health Services Needs and Demand; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D012017:Referral and Consultation; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000453:epidemiology / Q000628:therapy*; D011795:Surveys and Questionnaires
keywords: Chronic kidney disease; co-morbidity; diabetes; health care delivery; primary health care.