Factors Influencing Primary Care Physicians' Adjustment of Oral Anti-Diabetic Drugs in Patients with Type 2 Diabetes Mellitus: A Qualitative Research Study.

Abstract

Background: Primary care physicians' (PCPs) prescription of oral anti-diabetic drugs (OADs) is pivotal to optimise glycaemic control of patients with type 2 diabetes mellitus (T2DM). Their decision-making process is not well-understood and is postulated to be multi-factorial. The study aimed to explore the factors influencing the prescribing behaviour of PCPs managing patients with T2DM in an urban setting.

Methods: A qualitative methodology using a descriptive-interpretive approach was employed for this study. Qualitative data from 23 PCPs was collected via 3 focus group discussions and 10 in-depth interviews using a semi-structured topic guide. PCPs with various experiences, qualifications and backgrounds were purposively recruited from public and private primary care clinics in Singapore. The audio-recorded interviews were transcribed verbatim and audited for accuracy. Thematic analysis was conducted and the emergent themes were grouped under the domains of the 'Generalist Wheel of Knowledge, Understanding and Inquiry' framework. The data was managed using Nvivo qualitative management software.

Results: The 4 main themes identified were clinician experience and knowledge, patient clinical risk stratification and preference, diabetes severity and drug factors, and healthcare system. PCPs' prior experience with OADs, years of practice, academic roles and knowledge resources influenced their decision-making when prescribing OADs. Their prescription was guided by patient preferences and comorbidities, such as selecting sodium-glucose cotransporter-2 inhibitors for patients with proteinuria. Disease severity, OADs safety profile, efficacy, stipulations in the drug formulary, cost and availability of OADs in their pharmacy, and social worker support were other factors affecting PCPs' prescribing habits of OADs. Clinical decision support functionality in the electronic medical record (EMR) system prompted PCPs to select the type of OADs during the consultation.

Conclusions: The study highlights the multifaceted factors influencing PCPs' prescribing of OADs, including clinical experience, patient preferences, drug formulary limitations, medication costs and EMR utilisation. To enhance prescribing habits, interventions should focus on continuous education for PCPs, expanding drug formularies, addressing patients' preferences, cost and access barriers through subsidies and promoting the adoption of EMRs with clinical decision support systems in both public and private sectors.