Patients' and Providers' Perspectives on Metformin for Diabetes Prevention

Evidence-based, cost-effective interventions that can prevent progression from pre-diabetes to type 2 diabetes mellitus (T2DM) are available; however these interventions are underutilized in primary care settings. Clinical trials have demonstrated that intensive lifestyle intervention or metformin therapy can substantially reduce T2DM incidence. Clinical guidelines recommend that adults with pre-diabetes be treated with intensive lifestyle intervention aimed at 7% weight reduction and 150 minutes of moderate intensity physical activity per week. Despite proven benefits, it has been difficult to apply intensive lifestyle interventions in primary care settings and, to achieve results similar to those in clinical trials, because of the difficulty of delivering the frequent and long-term support that is needed to achieve and maintain weight loss. As an adjunct to lifestyle intervention, guidelines also recommend metformin therapy for T2DM prevention in individuals at highest risk for T2DM and in those who may be failing lifestyle intervention. However, key questions remain that could significantly impede the implementation of these recommendations in primary care. First, the acceptability of metformin therapy for T2DM prevention among primary care providers and patients with pre-diabetes is not well understood. Second, long-term adherence to metformin therapy for T2DM prevention has not been studied in primary care. Third, there have been no randomized trials comparing the effectiveness of these evidence-based treatments in primary care settings. The proposed study aims to address critical knowledge gaps about patient-clinician perspectives on T2DM prevention strategies, in preparation for a larger study comparing the effectiveness of lifestyle and metformin for T2DM prevention in high-risk primary care patients. To date, no studies have examined patients’ or primary care providers’ perspectives on lifestyle intervention and metfomin treatment for pre-diabetes; furthermore, T2DM prevention guidelines have largely been developed with little or no patient engagement. During the proposed 12-month study, we will work with a practice-based research network to recruit 30 patients with pre-diabetes for semi-structured interviews and 20 primary care providers for focus groups. This study uses an integrative model of shared-decision making in the primary care encounter as the framework. Semi-structured interviews and focus groups will be used to investigate the feasibility, acceptability, and perceived benefits and harms of intensive lifestyle interventions and metformin therapy in T2DM prevention from patient and provider perspectives. We will also elicit patient and provider values, preferences, and outcome expectations. Our results will provide important insights into the dynamics of decision-making in diabetes prevention in primary care, which is a critical first-step