Barriers and Facilitators to Diabetes Self-Management in a Primary Care Setting – Patient and Physician Perspectives
OBJECTIVES: To identify patient- and physician-perceived barriers to self-management of type-2 diabetes (T2DM) and explore the challenges physicians face in managing these patients. METHODS: This cross-sectional study of T2DM patients and their physicians used a mixed-methods approach (combination of patient survey and electronic medical record (EMR) database). A random stratified sample of 2,100 patients (age≥18 years) with a recorded diagnosis of T2DM (ICD-9 code: 250.xx) and having ≥2 physician visits was selected from a large physician group’s EMR database, and based on HbA1c level, was categorized into three groups: HbA1c<7, 7–9, and >9. Patients were administered a survey containing standardized instruments to collect information on demographics and diabetes self-care behaviors. Physician survey measured physician perceptions of patient barriers to self-management and their challenges in managing uncontrolled T2DM patients. RESULTS: 210 responses were received (10% response rate). Mean age was 63.68 years (+/-11.79), 102 (48.6%) were females, 197 were Caucasian (93.8%). Univariate analysis revealed that age (X2=15.73, p<0.01), insurance status (X2=12.03, p<0.05), referral to an endocrinologist (X2=6.17, p<0.05), level of self-management (X2=12.01, p<0.05), and willingness to take insulin (X2=9.8, p<0.01) were associated with HbA1c control. Older age, lower willingness to take insulin, and less than graduate level education were significant determinants of glycemic control. Of the 21 physicians who responded (53.8% response rate), 71.2% were over the age of 50 years, 54.16% had ≥25 years of clinical experience, and 50% practiced in an urban setting. Barriers leading to clinical inertia as identified by the physicians include cost of medications, non-compliance with diet and medications, polypharmacy, lack of patient motivation, knowledge, time, and social support. CONCLUSIONS: Self-management behavior of T2DM patients is strongly associated with HbA1c control. Interventions directed towards improving self-management in T2DM population that take both physician and patient perspectives in to consideration may result in improved clinical outcomes.