A comprehensive exploration of barriers to attaining treatment targets in diabetes and CKD: a mixed-methods study — ASN Events
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A comprehensive exploration of barriers to attaining treatment targets in diabetes and CKD: a mixed-methods study (#320)

Clement Lo 1 2 , Helena J Teede 1 2 , Alan Cass 3 , Greg Fulcher 4 , Martin Gallagher 5 6 , Greg Johnson 7 , Peter Kerr 8 , Tim Mathew 9 , Kevan Polkinghorne 8 , Sanjeeva Ranasinha 2 , Rowan Walker 10 , Sophia Zoungas 1 2 6
  1. Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Victoria, Australia
  2. Diabetes and Vascular Research Program, Monash Centre for Health Research and Implementation, Monash University, Melbourne, Victoria, Australia
  3. Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
  4. Department of Diabetes and Endocrinology, The Royal North Shore Hospital, Sydney, New South Wales, Australia
  5. Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
  6. The George Institute of Global Health, Sydney, New South Wales, Australia
  7. Diabetes Australia, Canberra, ACT, Australia
  8. Department of Nephrology, Monash Health, Melbourne, Victoria, Australia
  9. Kidney Health Australia, Adelaide, South Australia, Australia
  10. Department of Renal Medicine, Alfred Health, Melbourne, Victoria, Australia

Guidelines exist for management of diabetes and chronic kidney disease (CKD) yet treatment targets are often not achieved. The underpinnings of this evidence–practice gap are unclear.  Limited data from patients is available to identify barriers and inform health-care improvement.  In this large multi-centre study we identify the most significant barriers to patients attaining treatment targets.

 Patients with diabetes and CKD (eGFR < 60 ml/min/1.73 m2) from clinics and dialysis units in Melbourne and Sydney were surveyed.  Each patient completed a questionnaire examining diabetes self-care, health-care usage and common barriers (derived from thematic analysis of 12 patient focus groups) limiting management.  Analyses were completed with STATA v12.1.

308 patients, mean age 67 (SD 11) years, were studied. Patients were mostly male (70%) and had type 2 diabetes (88%). 49% had stage 3, 25% stage 4 and 26% stage 5 CKD, with 19% receiving dialysis. Treatment gaps were evident for patients with CKD stages 3, 4 and 5 with 35%, 34% and 25% having HbA1c levels ≥8%; 31%, 40% and 54% having  BP levels  ≥140/90 mmHg; and 18%, 19% and 21% of those aged 40 and above not being prescribed a statin respectively.  Overall, the commonest barriers reported were poor continuity of care (49%), inadequate understanding/education about CKD (44%) and feeling unwell (43%). On analysis by CKD stage, additional barriers reported included difficulty maintaining dietary and fluid restrictions (47% of CKD stage 4) and difficulty adjusting to the personal and social impact of diabetes and CKD (48% of CKD stage 4 and 43% of CKD stage 5). 

Implementation of a model of care individualised to CKD stage for patients with diabetes and CKD and focusing on continuity of care, disease understanding, optimal symptom control and psychological support, may promote greater attainment of treatment targets and improve outcomes.