The Disconnect Between Patient and Provider Perceptions of Medications in Type 2 Diabetes: A Cross-Sectional Analysis of Health Narratives Shared in Social Media Forums Discussing Cardioprotective GLP-1RAs and SGLT-2is (Preprint)
Authors: Lambert Natalie , Clark Callhan , McCoy Rozalina G , Wong Alyssa , Cook David 
Published: September 2022

BACKGROUND

Gaps exist between type 2 diabetes (T2D) clinical guideline recommendations for the use of cardioprotective glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT-2is) and their observed real-world utilization and persistence. This discrepancy may be partly attributed to differences between patient and clinical mental models for risks and benefits of GLP-1RAs and SGLT-2is.

OBJECTIVE

We aimed to evaluate patient-reported perceptions of GLP-1RAs and SGLT-2is by analyzing health narratives collected from publicly available social media data and assess for differences between patient-defined and clinically-defined risks and benefits as approximations of mental models.

METHODS

We extracted all health narratives mentioning cardioprotective GLP-1RAs and SGLT-2is from posts (N=250) in public T2D Facebook groups (N=14) from January 1, 2019 to November 20, 2021. We used open coding to categorize all mentions of risks and benefits of these drugs as defined by the 2021 American Diabetes Association Standards of Care (SOC) to represent the clinically-defined perspective. We coded risks and benefits not explicitly mentioned in the SOC, but described in the health narratives, to represent the patient-defined perspective.

RESULTS

Of posts containing narratives, 70.8% referenced GLP-1RAs and 29.2% referenced SGLT-2is. Overall, 43.6% of posts mentioned 41 risks and 6 benefits not discussed in the SOC, such as difficulty eating, positive and negative emotions, general side effects, injection pen experiences, and diabetes remission. A total of 19 SOC-defined features were reported. Patient-defined mental models often focused on near-term concerns, such as daily quality of life, glucose control, or side effect management. In contrast, posts mapping to SOC-defined mental models emphasized disease management endpoints, like glucose and weight benefits. Posts rarely (<2.5%) mentioned cardiovascular or renal benefits. GLP-1RA discussion was distributed evenly through reports of both effective and ineffective glucose lowering, weight loss, and side effects like difficulty eating, nausea, vomiting, and diarrhea. Discussion of SGLT-2is tended to emphasize effective glucose lowering, with additional attention to high cost, ketoacidosis, and weight loss.

CONCLUSIONS

People with T2D express a range of concerns and perceptions regarding the risks and benefits of GLP-1RAs and SGLT-2is. Many represent nearer-term and more precise, individual-level concerns than what is represented in clinical guidelines. While cardiovascular and renal outcomes strongly inform T2D clinical guidelines, these are of lower awareness and priority in patient-defined mental models relative to tangible risks and benefits, indicating gaps between mental models for these medications. There is a need to develop strategies to reduce barriers to GLP-1RA and SGLT-2i utilization, initiation, and persistence that are attuned to patients’ mental models of the perceived risks and benefits of these medications. Understanding and bridging the gap between patient and provider perspectives has implications beyond these drug classes to achieving real-world effectiveness in therapeutic decision-making.