Facilitators and barriers to SGLT2i and GLP1a prescribing in Northern Ontario: a qualitative interview study

Background One in three adults in Ontario, Canada has type 2 diabetes, obesity, heart failure, or chronic kidney disease, and the prevalence is even higher in Northern Ontario. Sodium glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 analogues (GLP1a) are highly effective medications to treat these conditions, but prescribing rates in Northern Ontario are low. This study aimed to explore the facilitators and barriers to SGLT2i and GLP1a prescribing for adults living with and without diabetes in Northern Ontario.

We conducted virtual, semistructured interviews of clinicians (i.e., physicians, nurse practitioners, resident physicians) working in Northern Ontario, Canada between July 2024 and November 2024. Interview transcripts were thematically coded into categories based on the Theoretical Domains Framework (TDF). Findings were classified as either barriers or facilitators, and then grouped to identify major subthemes within the data. Subthemes were then further aggregated into themes and mapped onto the Capability, Opportunity, Motivation-Behaviour (COM-B) model for behaviour change.

We interviewed 25 clinicians, including eight physicians, eight resident physicians, and nine nurse practitioners caring for adults in Northern Ontario. Twenty-two of the interviews were held one-on-one and one was held as a co-interview with three participants. We identified five main barriers and five main facilitators to SGLT2i and GLP1a prescribing. The major barriers included: limited access to medications, patient challenges and competing demands, lack of familiarity, clinical identity, and prescribing inertia. Limited access to medications was a prominent theme with nested subthemes of high cost of medications for patients and insufficient compassionate drug programs to cover these costs. The major facilitators included: role as a clinician that follows the data, belief that SGLT2i/GLP1a use will improve patient outcomes, clinicians’ perceptions of patient openness to these drugs, comfort prescribing, and system and colleague supports.

Our findings provide useful insights to inform knowledge translation initiatives aimed at increasing the uptake of SGLT2i and GLP1a in Northern Ontario. Competing Interest Statement MF was a consultant for ProofDx, a start up company creating a point of care diagnostic test for COVID-19; is an advisor for SIGNAL1, a start-up company deploying machine learned models to improve inpatient care; and has been an expert witness on content unrelated to this work. He also holds a provisional patent for a model that predicts acute dialysis needs. He received salary support from the PSI Foundation to support this work. PO, CSG, TVB and JB have no disclosures or conflicts of interest to declare. Funding Statement This study was supported by funding from the PSI Foundation, the Sinai Health Department of Medicine Research Fund, and the Banting and Best Diabetes Centre Charles Hollenberg Summer Studentship. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Mount Sinai Hospital Research Ethics Board of Sinai Health System gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability An aggregate summary of the data generated during this study is presented in this published manuscript. Individual data transcripts cannot be publicly shared due to confidentiality.