Why physicians do not initiate dual therapy as recommended by AACE guidelines: A survey of clinicians in the United States. Issue 3 (June 2015)

• Record Type: Journal Article
• Authors: Qiu, Ying; Li, Qiong; Tang, Jackson; Fan, Chun-Po Steve; Li, Zhiyi; Apecechea, Mercedes; Hegar, Ruth; Shankar, Ravi; Kurtyka, Karen M.; Engel, Samuel S.
• Is Part Of: Diabetes research and clinical practice. Volume 108:Issue 3(2015)
• Page Start: 456
• Page End: 465
• Publication Date: 2015-06
• Subjects: Clinical practice guidelines -- Physician factors -- Patient factors -- Dual therapy -- Type 2 diabetes mellitus; Diabetes -- Periodicals; Diabetes Mellitus -- Periodicals; 616.462
• DOI: 10.1016/j.diabres.2015.02.027
• Languages: English
• ISSNs: 0168-8227

Abstract

Highlights: We survey physicians on reasons for not initiating dual therapy per AACE algorithm. Four of five top reasons are related to physician beliefs about therapy. One top reason is patient-related. Relevance of each reason varies by physician specialty and patient age. Abstract: Aims: The American Association of Clinical Endocrinologists (AACE) recommends initiating dual therapy with antihyperglycemic agents in untreated patients with type 2 diabetes mellitus and HbA1c between 7.6% (60 mmol/mol) and 9.0% (75 mmol/mol). In practice physicians do not always follow guidelines. This study assessed why physicians do not prescribe dual therapy when treating eligible patients. Methods: 1235 primary care physicians (PCPs) and 290 specialists in the United States reviewed medical charts for 5995 patients whose HbA1c was between 7.6% (60 mmol/mol) and 9.0% (75 mmol/mol) at diagnosis and were being treated with metformin monotherapy. In an online survey physicians rated the relevance of 22 reasons for not initiating dual therapy using a 5-point Likert scale. Relevant reasons were compared between PCPs vs. specialists, and younger vs. older patients, using multivariate general linear regression and mixed-effect models. Results: Four relevant reasons for not following AACE guidelines were physician-related: (1) "Metformin monotherapy is sufficient to improve glycemic control"; (2) "Monotherapy is easier to handle than dual therapy"; (3) "I believe that monotherapy and changes in lifestyle are enough for hyperglycemia control"; and (4) "I recommend monotherapy before considering dual therapy." One relevant reason was patient-related: (5) "Patient has mild hyperglycemia." Regression analysis demonstrated that PCPs rated each physician-related reason as significantly more relevant than specialists. Three physician-related reasons were significantly more relevant for younger patients than older patients. Conclusions: Physicians do not follow AACE guidelines due to physicians' beliefs toward therapy and the perception of mild hyperglycemia in patients.