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How Doctors Choose Medications to Treat Type 2 Diabetes: A National Survey of Specialists and Academic Generalists

¹General Medicine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA
²Diabetes Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA
³Partners Telemedicine Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA
⁴Laboratory of Computer Science, Massachusetts General Hospital and Harvard Medical School, Boston, MA
⁵Institute for Health Policy, Massachusetts General Hospital and Harvard Medical School, Boston, MA

Rgrant{at}partners.org

ABSTRACT

Background:: Glycemic control remains sub-optimal despite the wide range of available medications. More effective medication prescription might result in better control. However, the process by which physicians choose glucose-lowering medicines is poorly understood.

Methods:: We surveyed 886 physician members of either the Society of General Internal Medicine ("academic generalists", response rate 30%) or the American Diabetes Association ("specialists", 23%) currently managing patients with type 2 diabetes. Respondents weighed the importance of 15 patient, physician, and non-clinical factors when deciding which medications to prescribe for type 2 diabetes at each of three management stages (initiation, use of 2^nd line oral agents, and insulin).

Results:: Respondents reported using a median of five major considerations (Interquartile range: 4-6) at each stage. Frequently cited major considerations included: overall assessment of the patient's health/comorbidity, HbA1c level, and patient's adherence behavior, but not expert guidelines/hospital algorithms or patient age. For insulin initiation, academic generalists placed greater emphasis on patient adherence (76% vs. 60% of specialists, p <0.001). These generalists also identified patient fear of injections (68%) and patient desire to prolong non-insulin therapy (68%) as major insulin barriers. Overall, qualitative factors (e.g. adherence, motivation, overall health assessment) were somewhat more highly considered than quantitative factors (e.g. HbA1c, age, weight) with mean aggregate scores of 7.3 vs. 6.9 on a scale of 0 to 10, p < 0.001.

Conclusions:: The physicians in our survey considered a wide range of qualitative and quantitative factors when making medication choices for hyperglycemia management. The apparent complexity of the medication choice process contrasts with current evidence-based treatment guidelines.

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