title: Gaps and barriers in health-care provision for co-morbid diabetes and chronic kidney disease: a cross-sectional study.
abstract: BACKGROUND
  Patients with diabetes and chronic kidney disease (CKD) are a complex subset of the growing number of patients with diabetes, due to multi-morbidity. Gaps between recommended and received care for diabetes and chronic kidney disease (CKD) are evident despite promulgation of guidelines. Here, we document gaps in tertiary health-care, and the commonest patient-reported barriers to health-care, before exploring the association between these gaps and barriers.
  
  
  METHODS
  This cross-sectional study recruited patients with diabetes and CKD (eGFR < 60 mL/min/1.73 m2) across 4 large hospitals. For each patient, questionnaires were completed examining clinical data, recommended care, and patient-reported barriers limiting health-care. Descriptive statistics, subgroup analyses by CKD stage and hospital, and analyses examining the relationship between health-care gaps and barriers were performed.
  
  
  RESULTS
  308 patients, of mean age 66.9 (SD 11.0) years, and mostly male (69.5%) and having type 2 diabetes (88.0%), participated. 49.1% had stage 3, 24.7% stage 4 and 26.3% stage 5 CKD. Gaps between recommended versus received care were evident: 31.9% of patients had an HbA1c ≥ 8%, and 39.3% had a measured blood pressure ≥ 140/90 mmHg. The commonest barriers were poor continuity of care (49.3%), inadequate understanding/education about CKD (43.5%), and feeling unwell (42.6%). However, barriers associated with a failure to receive items of recommended care were inadequate support from family and friends, conflicting advice from and poor communication amongst specialists, the effect of co-morbidities on self-management and feeling unmotivated (all p < 0.05).
  
  
  CONCLUSIONS
  Barriers to health-care varied across CKD stages and hospitals. Barriers associated with a deviation from recommended care were different for different items of care, suggesting that specific interventions targeting each item of care are required.
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: C
authors.initials: C
authors.lastname: Lo
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: H
authors.initials: H
authors.lastname: Teede
authors.affiliation: Department of Diabetes and Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
authors.forename: G
authors.initials: G
authors.lastname: Fulcher
authors.affiliation: Department of Nephrology, Concord Hospital, Concord, New South Wales, Australia.|The George Institute for Global Health, Sydney, New South Wales, Australia.
authors.forename: M
authors.initials: M
authors.lastname: Gallagher
authors.affiliation: Department of Nephrology, Monash Health, Clayton, Victoria, Australia.
authors.forename: P G
authors.initials: PG
authors.lastname: Kerr
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.
authors.forename: S
authors.initials: S
authors.lastname: Ranasinha
authors.affiliation: School of Primary Health Care, Monash University, Notting Hill, Victoria, Australia.
authors.forename: G
authors.initials: G
authors.lastname: Russell
authors.affiliation: Department of Renal Medicine, Alfred Health, Prahran, Victoria, Australia.
authors.forename: R
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. sophia.zoungas@monash.edu.|Diabetes and Vascular Medicine Unit, Monash Health, Clayton, Victoria, Australia. sophia.zoungas@monash.edu.|Department of Diabetes and Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia. sophia.zoungas@monash.edu.
authors.forename: S
authors.initials: S
authors.lastname: Zoungas
mesh_terms: D000368:Aged; D001315:Australia; D003266:Continuity of Patient Care; D003430:Cross-Sectional Studies; D048909:Diabetes Complications / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000628:therapy*; D005260:Female; D019538:Health Care Surveys; D057220:Health Literacy / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D010353:Patient Education as Topic / Q000706:statistics & numerical data*; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*
keywords: Barriers; Chronic kidney disease; Diabetes; Health-care; Multi-morbidity; Tertiary health-care; Treatment gaps