OBJECTIVES

To better understand how physicians decide what second-line therapy to prescribe for T2DM patients not meeting HbA1c targets with monotherapy metformin.

METHODS

This was a qualitative focus group study of physicians treating T2DM patients and prescribing metformin and second-line antidiabetic medications in 2016. The HealthCore Integrated Research Database was used to identify primary care physicians (PCPs) and endocrinologists from submitted claims. Physicians in NYC and LA were invited to participate in four 90-minute focus groups (five physicians per group) conducted by an experienced moderator. The focus group proceedings were audio/video recorded. Physicians’ insights regarding decision triggers, second-line therapy selection factors, and patient profiles for specific treatment choices were grouped into common themes to provide a deeper understanding of the criteria physicians consider when choosing second-line therapies for their T2DM patients.

RESULTS

Of 20 invited physicians, 18 participated (10 NYC/8 LA); 56% PCPs and 44% endocrinologists; 22% female; 89% in practice >15 years; 56% in group practice. PCPs and endocrinologists agreed that HbA1c and blood glucose levels were key factors that motivated them to add/change therapy. Cost, medication burden, diet and exercise, lifestyle, weight and co-morbidities were all factors considered to determine what medication to use. GLP1-RA medications were often considered for obese patients; SGLT2 inhibitors were frequently used in combination with other drugs; sulfonylureas were preferred for patients with cost concerns; DPP4 inhibitors were not considered as effective as other drugs but easy to use with few complications; both PCPs and endocrinologists considered insulin as 3^rd or 4^th line therapy after failing other options.

CONCLUSIONS

While physicians’ decision heuristics were generally consistent with the American Diabetes Association clinical practice guidelines, insurance coverage was also found to be a key treatment decision factor, especially among PCPs. Endocrinologists tended to consider multiple factors before reaching a treatment decision.