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Contextual Factors Affecting SGLT2 Inhibitors and GLP-1 Receptor Agonists Prescribing in Primary Care: An Application
Teresa M Salgado1,2, Rana Amayreh1, Mona Alshahawey1,3
1Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA.
Background:
Despite strong evidence supporting cardiovascular and kidney benefits of sodium-glucose co-transporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) in patients with type 2 diabetes, prescribing rates remain suboptimal. The aim of this study was to assess clinicians' knowledge and comfort prescribing SGLT2i and GLP-1 RA in clinical practice and factors influencing prescribing of these agents.
Methods:
This multi-methods study used questionnaires to assess self-reported knowledge and comfort prescribing SGLT2i and GLP-1 RA, and semi-structured interviews based on the Consolidated Framework for Implementation Research (CFIR) to assess factors affecting prescribing decisions among 21 clinicians (12 primary care physicians, 4 pharmacists, 5 nurse practitioners) at a large community-based health system in Virginia. Questionnaire results were analyzed using descriptive statistics, and interviews used a two-phase analytic approach combining inductive and deductive coding.
Results:
Clinicians self-reported high knowledge (7.9/10) and comfort (8.1 and 8.4/10) prescribing SGLT2i and GLP-1 RA but identified multiple implementation barriers. The most significant barriers were insurance coverage and out-of-pocket costs, with prior authorization requirements delaying therapy initiation. Medicare beneficiaries faced particularly challenging access due to coverage gaps and ineligibility for manufacturer assistance programs. Organizational factors, including high workload, limited appointment time, and the absence of automated patient identification systems, hindered consistent prescribing. Medication burden, side effects, and aversion to injectable medications emerged as patient-related barriers. Facilitators included strong clinical evidence supporting these agents, organizational culture supportive of innovation, and access to pharmacist support.
Conclusion:
Despite high self-reported knowledge and comfort prescribing SGLT2i and GLP-1 RA, clinicians identified barriers to their use in clinical practice at the patient, clinician, organizational, and medication access levels. Future work should identify the best implementation strategies to address these barriers.
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