The impact of national chronic kidney disease management guidelines in the United Kingdom on referral patterns for South Asian and european patients with type 2 diabetes mellitus

Abstract

Background: South Asian patients with type 2 diabetes mellitus in the United Kingdom are over 10 times more likely to progress to end-stage renal disease than European patients. It is unclear whether this is due to late interaction with primary care, late referral to secondary care, suboptimal treatment with protective therapies or increased rates of progression among South Asian patients. This study investigated the demographic and clinical status of South Asian and European patients at the time of referral to renal service, before and after the introduction of national CKD management guidelines. The study also sought to understand patient experiences. Method: A mixed-methods approach was undertaken combining audit and patient interviews. The audit consisted of a retrospective, observational study comparing all South Asian and European patients with type 2 diabetes referred to 4 specialist renal services in the United Kingdom in 2004 and in 2007. Univariate and multivariate analyses were performed. For the patient interviews, newly referred South Asian and White European patients with diabetes over 16 years were recruited from nephrology outpatient clinics in three UK centres - Luton, West London and Leicester. A semi-structured qualitative interview was conducted with 48 patients and a thematic analysis of the data produced is reported. Results: The national audit shows that South Asian patients were younger than European patients at the time of referral (2004: European (E) 70.1±10.5 vs South Asian (SA) 63.0±12.1 years, p<0.001) with less advanced renal disease (2004: eGFR E 40.7±19.6 vs SA 47.3±24.8 ml/min, p=0.006). Following introduction of national CKD guidelines, patients were referred with more advanced renal disease although the decrease in mean eGFR was less pronounced for South Asian patients (2007: eGFR E 32.7±12.4 (- 8.0) vs SA 42.8±23.1 (-4.5) ml/min, p=0.001). These differences were not accounted for by prevalence of social deprivation. There was no difference in prescription of cardioprotective or renoprotective therapies or blood pressure control between ethnic groups. The patient interviews show that despite having familiarity and first hand experience of living with diabetes there was varying levels of understanding and knowledge about diabetes and low levels of awareness of renal complications of diabetes. For many patients referral to renal services was confusing and this was associated with a lack of information reported at the time of referral but also for some with reflections of a lack of information earlier on. Access to information seems to be moderated by a number of factors: language barriers; comorbidities; individual attitudes and expectations of health care providers, some of which relate to the individual patient's cultural context. Conclusion: There is not a delay in referral of South Asian patients with type 2 diabetes to specialist renal care in the United Kingdom or reduced prescription of protective therapies prior to referral to account for the increased progression to end stage renal disease. Patients with diabetes who have been referred for specialist renal care and found the referral process confusing have poor of awareness of kidney complications of diabetes. This reflects poor access to information at referral and during the previous period they have been managing their diabetes. In order to improve patient experience of the diabetic renal disease care pathway service, healthcare providers should be more aware of the ongoing information needs of people with diabetes as well as the context of any information exchange.