Primary Care Physicians' Perceptions of Diabetes Treatment Protocols Texas Medicine January 2014

Primary Care Physicians' Perceptions of Diabetes Treatment Protocols

Texas Medicine Logo

The Journal — January 2014

Tex Med. 2014;110(1):e1.

By Samuel N. Forjuoh, MD, MPH, DrPH, FGCP1,2,4; Jane N. Bolin, PhD, JD, RN3; Ann M. Vuong, DrPH, MPH, CPH2; Janet W. Helduser, MA3; Darcy K. McMaughan, PhD3; and Marcia G. Ory, PhD, MPH4.

1Department of Family & Community Medicine, Scott & White Healthcare, College of Medicine, Texas A&M Health Science Center, Temple, TX
2Department of Epidemiology & Biostatistics, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX
3Department of Health Policy & Management, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX
4Department of Health Promotion & Community Health Sciences, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX

Send correspondence to Ann M. Vuong, DrPH, MPH, CPH, Texas A&M Health Science Center, School of Rural Public Health, 364B SRPH Administration Building, College Station, TX 77843-1266; email: avuong[at]srph[dot]tamhsc[dot]edu.


Primary care physicians' perceptions of diabetes treatment protocols (DTPs) in the management of type 2 diabetes mellitus (T2DM) were examined at the individual and organizational levels. A 27-item electronic survey was administered to primary care physicians from an integrated multispecialty health care system in Texas. Information was collected on various aspects of DTPs, including attitudes toward these protocols, perceived barriers, and knowledge, as well as utilization of diabetes self-management programs. Besides quality of care, the primary care physicians surveyed generally had mixed feelings regarding DTPs' ability to contribute positively to other aspects of health care; in addition, only a small percentage were familiar with some currently available self-management programs. Given that implementation of DTPs depends on primary care physicians, we should address physicians' attitudes and perceptions toward DTPs so as to increase utilization of these helpful protocols.  


Diabetes mellitus is an increasingly prevalent chronic condition associated with multiple comorbidities such as heart disease, hypertension, kidney disease, and blindness.1,2 According to the Centers for Disease Control and Prevention, 25.8 million people in the United States are affected by diabetes, with an overwhelming majority of all adult cases diagnosed as type 2 diabetes mellitus (T2DM).3 Further, medical expenses for persons with diabetes are estimated to be two times greater than for those without diabetes.4 Recent estimates for 2012 indicate that the total annual cost of diagnosed diabetes in the United States has risen to nearly 250 billion, up from $174 billion in 2007.3,5

Current treatment guidelines recommend early and aggressive control of glycemia to achieve a glycated hemoglobin A1c (HbA1c) of less than 7%.6 Glycemic control has been reported to effectively reduce cardiovascular disease and microvascular complications among those with T2DM.7 Providing a comprehensive approach, such as those recommended in diabetes treatment protocols (DTPs), may assist in attaining the target HbA1c among patients with T2DM.8,9 DTPs include self-management, lifestyle interventions, monitoring for complications, and prescribing of medicines as recommended by the Texas Diabetes Council.

Rather than seeking specialty care, most patients with diabetes receive their care from a primary care physician.10 In addition, the primary care setting is the conduit to the health care system. As such, information about DTPs has been targeted toward primary care physicians, including family physicians, although little is known regarding their knowledge and attitudes toward these protocols. Although DTPs are in place, implementation depends upon the primary care physician. This paper assessed primary care physicians' familiarity with, as well as their attitudes toward and recommendations of, DTPs.    


Primary care physicians at a large integrated health care system in Texas were invited via email to complete a Healthcare Provider Survey, a 27-item electronic survey designed to capture information regarding diabetes-related case loads as well as physician knowledge and use of current diabetes management protocols. The survey consisted of short answer, multiple choice, and Likert-scale questions. Participants were asked about diabetes diagnostic procedures, attitudes toward clinical treatments, perceived barriers to their implementation, diabetes-related case loads, diabetes-related patient health behaviors, knowledge and use of diabetes self-management programs (Stanford University's Chronic Disease Self-Management Program [CDSMP] and Texas A&M AgriLife Extension Service's "Do Well, Be Well"), and additional specialized training related to diabetes. 

A survey was considered complete if the participant clicked on the submit button at the end of the survey and answered more than 80% of the questions. Survey data were collected using SNAP, a web-based software (v.9.0, 2008, Mercator Research Group, Portsmouth, NH), and converted to a Stata format (v.12, 2012, StataCorp LP, College Station, TX) using Stat/Transfer (v.10, 2009, Circle Systems, Seattle, WA). Reported percentages are based on the total number of nonmissing responses from completed surveys. The study protocol was approved by the Institutional Review Boards of Scott & White Healthcare and the Texas A&M Health Science Center. 


Of the 128 family physicians invited to complete the Healthcare Provider Survey, 61 physicians responded, resulting in a response rate of 47.7%. Forty-five surveys were deemed complete (completion rate=35.2%). The characteristics of the physicians who completed the survey are presented in Table 1. Three-quarters of the physicians were male. Most of the physicians reported practicing for 10 years or longer, with 46.7% stating that they had been practicing for at least 20 years. The average length of practice was 18.4±8.9 years. In terms of years of practice at the health care system, 44.4% of the physicians indicated that they had been in service for fewer than 10 years, while 55.5% had at least 10 years of practice at this location. 

Most of the physicians reported that more than 10% of their patients carried the diagnosis of diabetes. Approximately 31.8%, 27.3%, and 20.5%, respectively, reported that 11%-20%, 21%-30%, and more than 30% of their patients were diagnosed with T2DM. Furthermore, physicians reported that an average of 23.0% of their patients' visits pertained to diabetes per month. Comparing the average percentage of T2DM-related visits per month with the number of patients diagnosed with T2DM provided a rough estimate of T2DM case loads. For example, physicians who reported that 11%-20% of their patients had T2DM would spend approximately 18% of their patient visits on T2DM-related issues. In addition, a case-load average of 28% was observed among physicians who reported that 21%-30% of their patients had T2DM. 

Table 2 summarizes physicians' attitudes toward the use of DTPs. Three-quarters or more of the physicians agreed (responding either "a great deal" or "much") that DTPs contribute to patients' quality of care (75.0%), clinical units' quality of care (75.0%), and the institution's quality initiative (84.1%), and that the protocols provide measures for quality indicators (86.1%). Financial benefits from using DTPs varied, as only 29.3% of physicians agreed that clinical units benefit financially whereas more physicians (41%) felt that the health system benefits. More than half further indicated that DTPs capture information that could increase reimbursement.

Overall, more physicians responded that the benefits for the health system, e.g., professional resources being used more efficiently and reducing liability exposure, were greater than those for the physicians themselves. Only 40.9% and 32.5% of the respondents indicated that using DTPs saves time and assists in gaining and retaining medical certification, respectively. And less than half felt that their patients' satisfaction with care would increase with the use of DTPs. Physicians generally had a favorable opinion toward advantages of DTPs in terms of addressing aspects of the health system and quality of care. However, more skepticism was observed in terms of DTPs' capability in assisting financially, benefiting physicians themselves, and improving patient satisfaction with care. 

Despite DTPs' perceived benefits, some evident concerns regarding implementation were reported (Table 3). While physicians did not report limits on physicians' individual practice autonomy and lack of access to best treatment protocols as factors hindering implementation, approximately 85% of physicians considered time and competing demands as barriers to implementing formal DTPs. In addition, more than 70% agreed patient noncompliance is a formidable obstacle. Physicians were asked what percentage of their patients effectively managed their medications and diets. Only 42.3% reported that more than 60% of their diabetic patients managed their medications effectively; in terms of their diet, 6.7% was noted. Even lower percentages were observed among diabetic patients who also had other comorbidities, with only 31.9% of physicians indicating that more than 60% effectively managed their medications and only 4.6% with regard to their diet. However, a higher percentage of respondents indicated that less than one-fifth of their diabetic patients (90%) and diabetic patients with comorbidities (70%) required either hospitalization or emergency department care for their condition.

Regarding physicians' familiarity with a number of selected T2DM interventions (Table 4), only one-third reported being familiar with the CDSMP, the "Do Well, Be Well" program, and the use of self-management software on hand-held electronic devices. Two-thirds were aware of written materials, including self-management literature. Of those familiar with the programs, approximately 88% indicated that they would recommend the American Diabetes Association's diabetes self-management education. A higher percentage (92.9%) of those familiar with written materials recommended using this type of management strategy. And to a somewhat lesser extent, nearly 70% of physicians who reported being familiar with CDSMP and "Do Well, Be Well" specified that they would recommend these programs. Furthermore, 62.2% of the physicians made referrals to a formal disease management program for diabetes, but only 35.6% followed suit for other comorbidities. 


This study explored primary care physicians' familiarity with, as well as their attitudes and recommendations for, DTPs. DTPs' perceived ability to contribute to various areas is interesting to note as physicians' perceptions of DTPs differed across several aspects of health care. Most of the physicians indicated that using DTPs would positively contribute to quality of care, ranging from the patients' and clinical units' quality of care to the institution's quality care initiative. However, few felt that DTPs would be beneficial financially for the clinical unit and the institution. Physicians were even more uncertain of DTPs' ability to assist on the individual level as less than half agreed that it would save time for physicians and improve patients' satisfaction with care. And although DTPs were viewed as potentially promising, implementation was a concern with the two most cited barriers as time/competing demands and patient noncompliance. These two factors have also been observed by other investigators as barriers to diabetes management and guidelines.11-14

With regard to T2DM interventions, most physicians were familiar with written materials, which include self-management literature, but for the most part, a large proportion were not aware of the CDSMP or the "Do Well, Be Well" program. The CDSMP equips participants with the education and skill sets needed to take a more proactive approach in managing their chronic condition(s) and related symptoms.15 With the goal of increasing self-efficacy to ultimately decrease chronic disease-related symptoms and avoidable health care utilization, CDSMP teaches techniques to facilitate enhanced decision making, action planning, and effective communication. The CDSMP has been documented to produce positive results on clinical outcomes (blood pressure and serum cholesterol) and behavioral activities (monitoring blood glucose and following a healthy diet).16 The "Do Well, Be Well" program helps persons with diabetes learn skills to achieve successful disease management. The class consists of 9 self-care and nutrition topics with the primary purpose of improving blood glucose management. In 2011, approximately 65% of 1044 enrollees completed the 5-week series of classes.17

Both self-management interventions had merely one-third of physicians indicating that they had some familiarity, whether it was knowledge of or experience with these two programs. However, approximately 70% of physicians who were familiar with these programs recommended or prescribed them to their patients with T2DM. These results indicate that the availability of self-management strategies, such as CDSMP and "Do Well, Be Well," are not common knowledge among primary care physicians within this health care system. It may be prudent for diabetes self-management educators to promote the programs so that physicians become aware of their availability and benefits. Although studies have reported that physicians do not see self-management as a core of their responsibility,18,19 our results indicate that primary care physicians are not resistant to self-management interventions, as most physicians who were familiar with self-management interventions have recommended these programs and, hence, were adherent to this core element of the chronic care model.20  

This study had several limitations, with the first being its small sample size (n=45). The low number of respondents prevented more in-depth analyses as models generated were unstable. However, our response rate is excellent for physician surveys,21-24 and we were able to report on primary care physicians' attitudes and perceptions of, and familiarity with, DTPs, adding to the sparse literature in this area. The importance of primary care physicians' perceptions of DTPs cannot be negated as they provide the bulk of diabetes care.10 Secondly, nonresponse bias is always a research concern (our response rate was 47.7%, and completion rate even lower). Because we did not have data on physicians who chose not to complete the survey, we were unable to determine whether respondents were different from the target population. However, our response rate is in line with what has been reported by national surveys of physicians that ranged from 25.6% to 70%.21,25,26

Little has been published regarding primary care physicians' attitudes and perceptions on DTPs, although a large percentage of patients with T2DM are treated in primary care settings. Because of the relative scarcity of literature in this regard, the attitudes and perceptions of primary care physicians toward DTPs as uncovered in this study is very timely. With the Affordable Care Act legislation signaling an increasingly prominent role of primary care providers in the US health care system, their thoughts and opinions on DTPs will influence whether evidence-based protocols are being implemented. A comprehensive total patient care approach may be beneficial for DTP implementation, with involvement from the patient, the practitioner, and the organization.27 Providing options for self-care support to the patient, offering training in DTPs to primary care physicians, and increasing the availability of DTP training by the organization to other practitioners may assist in the use of DTPs in clinical practice. Given that implementation of DTPs depends on primary care physicians, their attitudes and perceptions toward DTPs should be addressed to increase utilization of these important treatment protocols.  

Conflict of Interest

There is no financial conflict of interest by any author of this paper. 


This research was supported by Award Number #1P20MD002295 from the National Institutes of Health's National Institute on Minority Health and Health Disparities Program for the Study of Rural & Minority Health Disparities. 

Sponsors of Research

This research was supported by Award Number #1P20MD002295 from the National Institutes of Health's National Institute on Minority Health and Health Disparities Program for the Study of Rural & Minority Health Disparities.  


  1. Avitabile NA, Banka A, Fonseca VA. Glucose control and cardiovascular outcomes in individuals with diabetes mellitus: lessons learned from the megatrials. Heart Fail Clin. 2012;8(4):513-522. doi: 10.1016/j.hfc.2012.06.009.
  2. Forbes JM, Cooper ME. Mechanisms of diabetic complications. Physiol Rev. 2013;93(1):137-188. doi: 10.1152/physrev.00045.2011.
  3. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Accessed Jan 28, 2013. 
  4. Centers for Disease Control and Prevention. Diabetes report card: national and state profile of diabetes and its complications, 2012. Accessed March 11, 2013. 
  5. American Diabetes Association. The cost of diabetes. Accessed March 10, 2013. 
  6. American Diabetes Association. Standards of medical care in diabetes – 2009. Diabetes Care. 2006;32(Suppl 1):S13-S61.
  7. Stratton IM, Adler AI, Neil HA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;321(7258):405-412. 
  8. Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association of the study of diabetes. Diabetes Care. 2009;32(1):193-203.
  9. Prochaska JD, Mier N, Bolin JN, Hora KL, Clark HR, Ory MG. Assessing diabetes practices in clinical settings: precursor to building community partnerships around disease management. J Community Health. 2009;34(6):493-499.
  10. Freeman JS. The increasing epidemiology of diabetes and review of current treatment algorithms. J Am Osteopath Assoc. 2010;110(7 Suppl 7):eS2-6.
  11. Chesover D, Tudor-Miles P, Hilton S. Survey and audit of diabetes care in general practice in south London. Br J Gen Pract. 1991;41(348):282-285.
  12. Clement S. Diabetes self-management education. Diabetes Care. 1995;18(8):1204-1214.
  13. Glasgow RE, Eakin EG. Dealing with complexity: the case of diabetes self-management. In: Anderson BJ, Rubin RR, eds. Practical Psychology for Diabetes Clinicians. Alexandria, VA: American Diabetes Association; 1996:53-62.
  14. Kim MY, Suh S, Jin SM, et al. Education as prescription for patients with type 2 diabetes mellitus: compliance and efficacy in clinical practice. Diabetes Metab J. 2012;36(6):452-459.
  15. Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999;37(1):5-14.
  16. Tang TS, Funnell MM, Brown MB, Kurlander JE. Self-management support in "real world" settings: an empowerment-based intervention. Patient Educ Couns. 2010;79(2):178-184.
  17. Texas A&M AgriLife Extension. Do well, be well with diabetes. Accessed on February 15, 2013.
  18. Blakeman T, Macdonald W, Bower P, Gately C, Chew-Graham C. A qualitative study of GPs' attitudes to self-management of chronic disease. Br J Gen Pract. 2006;56(527):407-414.
  19. Macdonald W, Rogers A, Blakeman T, Bower P. Practice nurses and the facilitation of self-management in primary care. J Adv Nurs. 2008;62(2):191-199.
  20. Wagner EH. Academia, chronic care, and the future of primary care. J Gen Intern Med. 2010;25(Suppl 4):S636-S638.
  21. Bleich SN, Gudzune KA, Bennett WL, Cooper LA. Do physician beliefs about causes of obesity translate into actionable issues on which physicians counsel their patients? Prev Med. 2013;56(5):326-328. Published online February 8, 2013. doi: 10.1016/j.ypmed.2013.01.012. 
  22. Elkin Z, Cohen EJ, Goldberg JD, et al. Studying physician knowledge, attitudes, and practices regarding the herpes zoster vaccine to address perceived barriers to vaccination. Cornea. 2013;32(7):976-981. Published online February 26, 2013. doi: 10.1097/ICO.0b013e318283453a.
  23. Kondrad E, Reid A. Colorado family physicians' attitudes toward medical marijuana. J Am Board Fam Med. 2013;26(1):52-60.
  24. Thyrian JR, Hoffmann W. Dementia care and general physicians – a survey on prevalence, means, attitudes, and recommendations. Cent Eur J Public Health. 2012;20(4):270-275.
  25. Kasprzyk D, Montano DE, St. Lawrence JS, Phillips WR. The effects of variations in mode of delivery and monetary incentive on physicians' responses to a mailed survey assessing STD practice patterns. Eval Health Prof. 2001;24(1):3-17.
  26. VanGeest JB, Wynia MK, Cummins DS, Wilson IB. Effects of different monetary incentives on the return rate of a national mail survey of physicians. Med Care. 2001;39(2):197-201.
  27. Appiah B, Hong Y, Ory MG, et al. Challenges and opportunities for implementing diabetes self-management guidelines. J Am Board Fam Med. 2013;26(1):90-92.  


January 2014 Texas Medicine Contents
Texas Medicine Main Page



Last Updated On

July 29, 2019

Originally Published On

December 19, 2013