This study assessed the reasons reported by a sample of UK GPs for not initiating antihyperglycaemic therapy in younger (< 65 years) and older (≥65 years) patients with newly diagnosed type 2 diabetes mellitus who remained untreated for at least six months following the initial diagnosis. In patients whose HbA1c was well controlled at the time of the survey, the GPs reason for not initiating treatment was often that the patients had only Mild hyperglycaemia, whereas for less well-controlled patients, other reasons were more prominent. Interestingly, 29% of patients had an HbA1c ≥7% despite their GP's selection of the first-ranked reason being Mild hyperglycaemia. In a cross-sectional survey study of US-based practices, physicians provided reasons of "improving/doing well" for over 50% of the patients who had an HbA1c ≥7% and no action taken on therapy (i.e., lifestyle and/or medication) after a recent office visit . These findings represent an important gap between treatment guidelines and the current clinical practice.
GPs were also requested to provide an HbA1c threshold for initiating antihyperglycaemic therapy for individual patients included in this study. The mean for the GP-reported HbA1c threshold for initiating antihyperglycaemic therapy was lower for younger patients than for older patients (7.3% vs. 7.5%). This lower threshold for younger patients may explain why a higher proportion of younger patients (14%) had their most recent HbA1c value exceed their GP-defined individualized threshold for initiating treatment than that of the older patients (10%). Interestingly, the GP-reported thresholds on average were near the HbA1c value of 7.5%, which was recently associated with the lowest incidence of all-cause mortality and progression to macrovascular events . NICE recommends treatment targets between 6.5% and 7.5% depending on the extent of pre-existing comorbid conditions and agreement with the patient . However, GPs actually applied an HbA1c threshold ≥7.5% for initiating antihyperglycaemic therapy in about half of these older patients.
Reasons within the categories of Factors related to antihyperglycaemic agents and Comorbidities and polypharmacy were selected more frequently by GPs as reasons for non-treatment of older patients. The individual reasons with significant between-group differences appeared to be focused on issues related to safety (e.g., risk of side effects or drug-drug interactions), disease or medication burdens for patients and cognitive or physical function of the patient. Although not assessed for age-related differences, similar reasons have been provided by physicians for their patients not receiving action in diabetes treatment despite having elevated HbA1c . Diabetes therapies that have demonstrated efficacy and safety in patients, especially older patients, may allay some of these concerns raised by GPs. Furthermore, GPs in the present study set a higher HbA1c threshold for initiating treatment in older patients. These results are consistent with previous studies that have shown that older patients with newly diagnosed type 2 diabetes mellitus were less likely to receive antihyperglycaemic therapy [8, 9]. The reasons identified in the present study may help explain the clinical inertia or inequality of health care observed in previous studies. It is understandable to focus on issues related to safety and functional capacity when considering diabetes treatments and management in older patients, especially frail patients . However, in the present study, a majority of older patients lived independently. Furthermore, given that older patients have higher prevalence of comorbidities, failure to treat or delays in diabetes treatment for this population may have greater health implications than for younger patients.
There are many factors that influence the treatment of patients with type 2 diabetes mellitus. In a focus group setting with family physicians, Brown et al.  identified patient-, physician- and systemic-related factors that were considered barriers and facilitators to the management of patients with type 2 diabetes mellitus. For patient factors, physicians felt that many patients with type 2 diabetes mellitus failed to recognise the seriousness of their disease due its asymptomatic nature. Education was seen as both a barrier and facilitator to disease management. Physicians indicated that early education led to better outcomes for their patients. Conversely, physicians felt overwhelmed with all of the different treatment guidelines for their diabetic patients and associated comorbid conditions . In another study, reasons of GPs for not prescribing lipid-lowering agents in patients with type 2 diabetes mellitus were divided into patient- and physician-related factors . Patient-related factors included compliance or refusal to take prescribed medication due to expected or perceived side effects. Physician reasons were related to proximity to treatment targets, perceived lack of benefits in patients with short life expectancy and expected compliance problems with their patients . In the present study, risk of non-compliance was selected by up to 13% of GPs as a reason for non-treatment. Overall, these and the present results demonstrate that diverse factors influence the GP's decision to initiate treatment in patients with type 2 diabetes mellitus.
The following limitations should be considered when interpreting the results of this study. Observed trends pertain to GPs and might not be generalisable to endocrinologists, diabetes, or GPs who do not treat many patients with type 2 diabetes mellitus. A selection bias may have occurred as the GPs needed to meet specific criteria in order to be eligible to participate, which may have limited the participating GPs to those who had a greater focus on diabetes care. Other reasons not identified may influence GPs for not initiating therapy (e.g., life expectancy, overall quality of life, or recent clinical findings). All physician-reported laboratory measures closest to diagnosis were included in the analysis regardless of the timing of measurement. Although GPs provided the clinical data of patients who met specific criteria, the GPs self selected the patients from their practices. GPs entered select patient data in the online form and completeness of the form was assessed. Validation of data extraction was confirmed using built-in logical checks of the data (e.g., edit checks).