title: How doctors choose medications to treat type 2 diabetes: a national survey of specialists and academic generalists.
abstract: OBJECTIVE
  Glycemic control remains suboptimal 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. We sought to study the means by which physicians choose medications for type 2 diabetic patients.
  
  
  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, response rate 23%) currently managing patients with type 2 diabetes. Respondents weighed the importance of 15 patient, physician, and nonclinical factors when deciding which medications to prescribe for type 2 diabetic subjects at each of three management stages (initiation, use of second-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, A1C 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 noninsulin 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., A1C, age, weight) with mean aggregate scores of 7.3 vs. 6.9 on a scale of 0-10, 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.
authors.affiliation: General Medicine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. rgrant@partners.org
authors.forename: Richard W
authors.initials: RW
authors.lastname: Grant
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Wexler
authors.forename: Alice J
authors.initials: AJ
authors.lastname: Watson
authors.forename: William T
authors.initials: WT
authors.lastname: Lester
authors.forename: Enrico
authors.initials: E
authors.lastname: Cagliero
authors.forename: Eric G
authors.initials: EG
authors.lastname: Campbell
authors.forename: David M
authors.initials: DM
authors.lastname: Nathan
mesh_terms: D000328:Adult; D002755:Choice Behavior; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D005194:Family Practice; D006442:Glycated Hemoglobin / Q000378:metabolism; D006306:Health Surveys; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use; D008511:Medicine; D010821:Physicians, Family / Q000523:psychology; D012955:Societies, Medical; D013038:Specialization; D045162:Thiazolidinediones / Q000627:therapeutic use; D014481:United States
chemical_list: D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin; D045162:Thiazolidinediones