Glucose-lowering medication initiation in people with newly diagnosed type 2 diabetes in Scotland: a mixed-methods study
Item statusRestricted Access
Embargo end date30/11/2021
Carrillo Balam, Genny Gabriela
Background: Worldwide, clinical guidelines recommend the reduction of glucose levels in people with type 2 diabetes mellitus (T2DM) as necessary in order to reduce risk of complications. In Scotland, the national guidelines suggest a target of glycated haemoglobin (HbA1c) of 53 mmol/mol (7.0%) and recommend an individualised treatment approach that may include lifestyle and/or pharmacological interventions. For most patients, the initial treatment is recommended to be lifestyle changes: diet and physical activity. However, when glycaemic targets are not achieved by lifestyle changes, pharmacological treatment should be added, drug choices should be based on patient characteristics and preferences. The literature review showed that the period after diagnosis is one of the critical points for optimal management for T2DM. However, it also showed that there is a lack of studies, which have focused on the initiation of pharmacological treatment in people with newly diagnosed T2DM. Thus, this study aimed to describe factors associated with the initiation of glucose-lowering medication (GLM) in people with newly diagnosed T2DM and the underlying reasons for starting pharmacological treatment in a Scottish primary healthcare context. Methods: This study employed a convergent parallel mixed-methods design, comprising two strands: one quantitative and one qualitative. The quantitative strand comprised a retrospective cohort study design; participants were drawn from an extract of the SCI-Diabetes dataset, which included people who had been diagnosed with T2DM in Scotland between 2004 and 2012 and were followed up for at least two years after diagnosis. This strand explored factors associated with time to initiation of GLM amongst people with newly diagnosed T2DM. For the qualitative strand, interviews were undertaken with 16 healthcare professionals (HCPs) recruited from 12 practices in Scotland to identify and explore factors and considerations that might influence clinical decision-making in relation to initiation of GLM in people with T2DM in a Scottish primary healthcare context, data were analysed thematically.Results: The cohort, for the quantitative strand, consisted of 154,660 people with newly diagnosed T2DM. More than half of people (54.9%) received GLM prescription within two years after T2DM diagnosis. The results indicated that increased age, male sex, the least deprived Scottish Index of Multiple Deprivation (SIMD) quintiles and receiving antihypertensive medication were associated with longer time to drug treatment. Conversely, HbA1c >53 mmol/mol, body mass index (BMI) >30 Kg/m2 and receiving antihypertensive medication were associated with shorter time to drug treatment. The findings from the qualitative strand revealed that a variety of interwoven factors and considerations influenced HCPs’ decision-making about initiating medication to lower blood glucose. These fell into three main categories: individual-patient related considerations, HCP-patient related factors, and contextual factors. Individual patient-related considerations included physiological aspects such as patient’s age and HbA1c, and psychological aspects, for instance, whether they were perceived to be motivated, their needs and expectations and cultural/ethnic background. HCP-patient related factors included historical contact with patients and, negotiation with patients. Contextual factors included time resources, division of labour within their practices, clinical guidelines (including the recent decommissioning of the Quality and Outcomes Framework; QOF), and HCPs’ perceptions of how their own roles fitted in with those of other colleagues involved in delivering diabetes care.Conclusions: The cohort showed that patients’ baseline HbA1c, age, sex, and SIMD quintile were among the factors associated with the timing of GLM initiation in Scotland from 2004 to 2012. However, the interviews with HCPs highlighted the complex factors, which can influence and inform HCPs’ decision-making. Thus, offering important insights into why prescription patterns for treatment of early type 2 diabetes vary across patients, practices and over time.