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

Published:February 26, 2015DOI:https://doi.org/10.1016/j.diabres.2015.02.027


      • 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.



      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.


      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.


      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.


      Physicians do not follow AACE guidelines due to physicians’ beliefs toward therapy and the perception of mild hyperglycemia in patients.


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