The Decision to Intensify Therapy in Patients with Type 2 Diabetes: Results from an Experiment Using a Clinical Case Vignette

Richard W. Grant; Karen E. Lutfey; Eric Gerstenberger; Carol L. Link; Lisa D. Marceau; John B. McKinlay

doi:10.3122/jabfm.2009.05.080232

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Table 1.

Symptoms, Patient Behavior, and Clinical Data Embedded in the Diabetes Vignette “Diagnosed Diabetes with Complications”

Patient Symptoms	Patient Behaviors	Clinical Data
Burning sensation at bottoms of feet and up one ankle Foot pain is intermittent and hard to localize Patient otherwise feeling “quite good”	Regularly tests glucose Concerned about high blood pressure Adherence to blood pressure medicine less than ideal	Patient is overweight Last hemoglobin A1c level was 6.9% Single high blood pressure reading (145/98)

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Table 2.

Associations Between Patient, Physician, and Practice Characteristics and the Study Physician's Decision to Intensify Therapy to Treat Blood Pressure, Glycemia, Lipids, or Any of These Three Conditions After Viewing the Patient Vignette (n = 192)*

Medication Changes	Intensified According to Vignette Patient Characteristics (%)
Medication Changes	Male	Female	P	35 years old	65 years old	P
Blood pressure	52	46	.44	44	54	.20
Glycemia	24	25	.88	22	27	.46
Lipids	18	13	.32	14	17	.55
Any of the 3	55	50	.52	48	57	.24

	Higher SES^†	Lower SES^†	P	White	Black	Hispanic	P
Blood pressure	51	47	.61	48	52	47	.89
Glycemia	29	20	.18	28	27	19	.51
Lipids	20	10	.08	17	17	11	.53
Any of 3	55	50	.52	55	52	52	.94

	Intensified According to Physician Characteristics (%)^‡
	Male	Female	P	Less Experienced	More Experienced	P
Blood pressure	46	52	.44	51	47	.61
Glycemia	23	26	.66	26	23	.66
Lipids	14	17	.55	13	18	.32
Any of 3	49	56	.36	52	53	.90

	Intensified According to Practice Factors (%)^§
	For profit (n = 135)	Other (n = 57)	P	Solo (n = 65)	Small (n = 105)	Large (n = 22)	P
Blood pressure	47	53	.42	45	52	46	.58
Glycemia	24	25	.68	25	27	14	.39
Lipids	14	18	.15	20	12	14	.68
Any of 3	50	58	.30	49	56	46	.47

* Numbers are proportions of respondents indicating that they would prescribe medications for each or any of the three diabetes-related risk factors; Numbers of physicians per practice variables are indicated in the table. Due to the factorial experimental design, numbers within each patient and physician variable category are equal.
† Socioeconomic status (SES) depicted by occupation of lawyer versus janitor.
‡ Physician experience groups divided as ≤12 years vs ≥22 years of clinical experience.
§ Practice sizes defined by number of physicians (1, ≤10, or >10).

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Table 3.

Differences in Medication-Related Treatment Concerns Between Physicians Who Would or Would Not Prescribe Therapy for Vignette (n = 173)*

Treatment Concerns (%)	Would Study Physician Prescribe a Medicine for Vignette Patient to Treat:
	Glycemia?		Blood Pressure?		Anything Related to Diabetes?
	Yes (n = 45)	No (n = 128)	Yes (n = 85)	No (n = 88)	Yes (n = 92)	No (n = 81)
Financial barriers	89^†	49	75^†	44	74^†	43
Medication adherence	71^†	52	65^†	49	63	49
Need more clinical data	11	14	8	18	10	17
Long-term risk for complications	38	25	37^†	20	34	22

* Numbers are proportions of study physicians who discussed each of the 4 treatment concerns, categorized by whether the study physician would prescribe medications for the indicated diabetes-related conditions. “Anything related to diabetes” defined as medicines to treat hypertension, hyperglycemia, or hyperlipidemia.
† Difference between yes and no responses statistically significant (P < .05).