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Diabetes Educ. 2011 Jan-Feb;37(1):78-84. doi: 10.1177/0145721710388427. Epub 2010 Nov 29.

Diabetes oral medication initiation and intensification: patient views compared with current treatment guidelines.

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The Division of General Medicine, Boston, Massachusetts (Dr Grant, Dr Pabon-Nau, Ms Pandiscio)
Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts (Dr Grant, Dr Pabon-Nau, Dr Park)
The Mongan Institute for Health Policy, Boston, Massachusetts (Ms Ross, Ms Youatt, Ms Pandiscio, Dr Park),



The purpose of this study was to compare patient perceptions about medication management with principles underlying American Diabetes Association (ADA) published treatment algorithms.


Six focus groups (4 English and 2 Spanish) were conducted with 50 patients with type 2 diabetes. Patients were asked about their prior experiences with initiating and changing oral medicines. They were also shown a medication plan for a hypothetical patient depicting future potential changes to achieve glycemic control. Coded responses were mapped to 3 concepts implicit in the ADA recommended treatment algorithm: (1) prescribing medicines to achieve A1c goal is beneficial, (2) medical regimens are generally intensified, and (3) intensification should be timely.


Patient perceptions contrasted markedly with the treatment algorithm: (1) most patients had negative perceptions of medication initiation, viewing this event as evidence of personal failure and an increased burden; (2) patients equated medication intensification with increased risk for diabetes-related complications (rather than a step to reduce future risk) and viewed de-escalation as a primary goal; and (3) no patients expressed concerns about delays in medication intensification. Patients responded very favorably to an individualized medication plan depicting future potential changes.


Patients in this study described a conceptual model for medication therapy that contrasted in critical ways from the principles of current treatment guidelines. Underscoring the key role of patient-provider communication, the results suggest that effective counseling should also include an informed discussion of future medication intensification.

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