Sample Descriptive Statistics
A total of 458 physicians in the UK (n = 225) and USA (n = 233) completed the survey. GPs comprised 58.5% of the sample (n = 268), while specialists accounted for 41.5% of the sample (n = 190). Sample descriptive statistics are presented in Table 1.
Table 1 Physician and practice setting descriptive statistics
Healthcare Resource Use and Time to Intensification
Physician reports on the healthcare resource use and time needed for intensification of “example” T2D patients from basal insulin to basal–bolus and to basal with GLP-1 regimens are presented in Table 2. On average, the intensification process to a basal–bolus regimen required 7.0 HCP visits (SD 3.7), including visits needed for patients to agree or refuse to intensify, to train patients to intensify, and to titrate patients to their optimal dose after the initial intensification visit. As shown in Table 2, UK physicians reported a significantly greater number of HCP visits for patient training (2.4 visits), on average, compared to US physicians (1.8 visits, p < 0.001). Country differences in average HCP visits needed for patients to agree or refuse to intensify and for titration to an optimal dose were not statistically significant.
Table 2 Average healthcare resource use and time needed to intensify T2D patients treated with basal insulin to basal–bolus and to basal in combination with GLP-1 regimens
Average time needed for the entire intensification process to basal–bolus was 30.1 weeks (SD 17.4). UK physicians reported greater patient training time for intensification (8.3 weeks) compared to US physicians (6.4 weeks, p = 0.005), on average. Country differences were not significant for time patients take to agree or refuse to intensify or for the titration process.
For intensification from basal insulin to basal in combination with GLP-1, physicians reported that the intensification process for T2D patients required an average of 5.7 HCP visits (SD 3.8), including visits needed for patients to agree or refuse to intensify, for intensification training, and for titration to an optimal dose after initial intensification. Average HCP visits needed for patients to agree or refuse to intensify and for patient training when intensifying to basal with GLP-1 were similar among physicians in the UK and USA. For titration to an optimal dose, UK physicians reported a slightly lower average number of HCP visits (1.8 visits) compared to US physicians (2.0 visits, p = 0.046).
The average total time for the intensification process to basal combined with GLP-1 was 23.5 weeks (SD 15.2). US physicians reported greater time for patients to agree or refuse to intensify (9.3 weeks) compared to UK physicians (7.4 weeks, p = 0.004). Country differences in average time for training or titration were not significant.
Referral Process for Intensification in Uncontrolled T2D
GPs
On average, GPs reported referring 22.6% of their uncontrolled (based on HbA1c values) T2D patients to specialists for intensification (SD 25.4). Reported referrals for intensification did not differ significantly by country. The most frequently reported reasons for referring T2D patients to specialists for intensification were being unsuccessful intensifying the patient themselves (70.8%), patient requesting the referral (61.5%), patient having too many comorbidities (52.5%), and complications during treatment (39.3%). Following referral, GPs indicated that the average patient wait time before being intensified by a specialist was 8.4 weeks (SD 5.4). Country differences in reasons for referring patients to specialists for intensification are shown in Fig. 1.
After referral to specialists for intensification, GPs reported that 24.6% of referred patients do not return to the GP’s practice for ongoing diabetes care (SD 28.1), while 23.2% of referred patients return to their practice without having been successfully intensified (SD 21.5), on average. Differences by country were not statistically significant. The most frequently reported issues (occurring “regularly” or “always”) when patients return to the GP’s practice after intensification were that patient is not confident that they are following the regimen properly (23.4%), patient still requires additional training/information about intensification (22.2%), and patient has difficulty titrating on new regimen (22.2%). GPs in the UK were significantly more likely to indicate “Patient is not confident that they are following the regimen properly” as an issue (30.4%) compared to GPs in the USA (15.6%, p = 0.018).
Among GPs who refer at least some uncontrolled T2D patients to specialists for intensification (n = 257), the average time spent on the overall referral process for intensification of T2D patients was 36.7 min (SD 24.8), including time spent discussing the referral with the patient, following up with the specialist after referral, following up with the patient after referral, and/or reviewing/assessing a new care plan from the specialist. GPs in the UK reported spending significantly greater time on the referral process (42.3 min) compared to those in the USA (30.5 min, p < 0.001).
Specialists
On average, specialists reported that 68.7% of their T2D patients were referred to them by GPs for treatment intensification (SD 25.9). UK specialists reported a greater percentage of referred T2D patients (73.7%) compared with specialists in the USA (64.4%, p = 0.013). Average patient wait time for non-urgent appointments with specialists following referral was 8.2 weeks (SD 5.4). Reported wait time was greater among UK specialists (9.3 weeks) compared to specialists in the USA (7.2 weeks, p = 0.008). On average, specialists indicated that they received notes or care plans from the referring GPs for 70.1% of referred patients (SD 31.6). UK specialists reported receiving notes/care plans from referring GPs for more referred patients (76.8%) compared to specialists in the USA (64.3%, p = 0.006).
Specialists reported that 57.7% of patients referred for basal–bolus intensification continue to see both their referring GP and the specialist (SD 36.6), on average. Specialists in the USA reported a greater percentage of these patients continuing to see both their GP and specialist (71.2%) compared to specialists in the UK (42.0%, p < 0.001). For referrals for basal in combination with GLP-1 intensification, specialists indicated that 54.0% of patients continue to see both their GP and specialist (SD 37.4), on average. Specialists in the USA were also more likely to report that these patients continue to see both their GP and specialist (69.8%) compared to specialists in the UK (35.7%, p < 0.001). Most specialists (87.9%) reported spending at least some time preparing notes/care plans for GPs after patients return to their referring GPs, and time spent preparing notes/care plans for GPs did not differ significantly by country.
Specialists indicated that they spend an average of 28.4 min (SD 21.5) on the overall referral process, including time reviewing notes or care plans from the referring GP and time preparing notes or care plans for the referring GP. Average time specialists spent on the overall referral process did not differ significantly by country.
Patient Experiences With Intensification Process
Physicians reported on their perspectives of the intensification process for patients treated with basal insulin who require intensification. As described above, physicians were asked to think about more typical or “example” patients when responding to these questions. On average, physicians reported that the target HbA1c value for “example” patients would be 6.9% (SD 0.5) and that they would consider intensification necessary at an HbA1c value of 7.8% (SD 0.6).
Among physicians who would intensify at least some “example” patients to basal–bolus, physicians reported that an average of 25.4% (SD 19.2) of “example” patients refuse to intensify to a basal–bolus regimen, while another 13.9% (SD 15.4) initially agree but then change their minds (n = 438). Likewise, physicians who indicated that they would intensify at least some “example” patients to basal with GLP-1 estimated that an average of 17.6% (SD 15.2) of “example” patients refuse to intensify to a basal combined with GLP-1 regimen, while another 12.5% (SD 16.4) initially agree but then change their minds (n = 444). Physician-reported reasons that patients refuse to intensify to basal–bolus are shown in Fig. 2, while reported reasons that patients refuse to intensify to basal combined with GLP-1 are displayed in Fig. 3. The frequency of injections required, not wanting to add even one more injection to the current regimen, and feeling that the intensified regimen is too complicated were the most frequently reported reasons for refusal to intensify to basal–bolus. For the basal combined with GLP-1 regimen, physicians reported that not wanting to add even one more injection to the current regimen, negative side effects, and concerns/fear about taking medication after reading package insert were the most frequently reported reasons for patient refusal to intensify to basal insulin in combination with GLP-1.
Physicians also reported on “example” patients’ most frequent concerns once intensified. The most frequent concerns of patients intensified to basal–bolus are depicted in Fig. 4, and the most frequent concerns of patients intensified to basal combined with GLP-1 are shown in Fig. 5. For patients intensified to basal–bolus, physicians reported that weight gain was the most frequent concern, followed by experiencing hypoglycemia, and difficulty adhering to the intensified regimen. For patients intensified to basal combined with GLP-1, physicians indicated that insurance coverage/cost, weight loss, and negative side effects were the most frequently expressed concerns.
Among physicians who reported that they would intensify at least some “example” patients to a basal–bolus regimen (n = 438), physicians estimated that about 30.3% of intensified “example” patients report adherence problems (SD 20.2). Physicians were most likely to indicate that patient adherence problems to the basal–bolus regimen were due to the frequency of additional injections (65.7%), difficulty remembering to take doses (53.5%), and feeling that the intensified regimen is too complicated (53.3%) (n = 458). Following intensification training for basal–bolus, physicians reported that an average of 57.0% of “example” patients intensified to basal–bolus reach their target HbA1c levels (SD 19.5) and that 37.8% of “example” patients discontinue the basal–bolus regimen (SD 29.8), on average. Among physicians who reported that at least some “example” patients discontinue their basal–bolus regimen after intensification (n = 428), the most frequently reported reasons for patient discontinuation of their basal–bolus regimen were the frequency of additional injections (53.0%), difficulty adhering to the intensified regimen (50.0%), and feeling that the intensified regimen is too complicated (47.0%).
Among physicians who indicated that they would intensify at least some “example” patients to a basal combined with GLP-1 regimen (n = 444), physicians indicated that about 18.6% of patients report adherence problems (SD 14.3). Physicians most frequently reported that adherence problems to the basal combined with GLP-1 regimen were due to negative side effects (47.8%), insurance coverage/cost (38.4%), and concerns/fears about the medication after reading the package insert (37.8%) (n = 458). Following intensification training for basal insulin in combination with GLP-1, physicians indicated that 58.5% of “example” patients reach their target HbA1c levels (SD 20.1) and that 36.7% of “example” patients discontinue the regimen (SD 30.2), on average. Among physicians who indicated that at least some “example” patients discontinue their basal combined with GLP-1 regimen (n = 427), the most frequently reported reasons for patients discontinuing the regimen were negative side effects (55.3%), followed by patient does not see a response/does not feel that the regimen is working (36.1%), and insurance coverage/cost (34.2%).