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.

Keywords: Barriers; Chronic kidney disease; Diabetes; Health-care; Multi-morbidity; Tertiary health-care; Treatment gaps.

Fig. 1

Patient recruitment

Fig. 2

Deviation from optimal care according to CKD stage.  For all items of recommended care according to guidelines, comparisons between CKD stages were not statistically significant at the 5% level for Chi square or Fisher exact tests and for linear trends

Fig. 3

Significant barriers to health-care identified by patients