Why physicians do not initiate dual therapy as recommended by AACE guidelines: A survey of clinicians in the United States

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.

Keywords: Clinical practice guidelines; Dual therapy; Patient factors; Physician factors; Type 2 diabetes mellitus.