Barriers and Facilitators for Sodium-Glucose Cotransporter-2 Inhibitor Uptake and Implementation in Australia – Perspectives From Clinicians and Patients: An Interview Study

Abstract

Background

While sodium-glucose cotransporter-2 (SGLT2) inhibitors provide major benefits across multiple chronic diseases, clinician prescription and patient adherence rates remain low.

Objective

To explore perspectives of clinician and patient stakeholders regarding barriers and facilitators for SGLT2 inhibitor use.

Design

Semi-structured interviews, conducted as part of a larger project examining the type 2 diabetes mellitus (T2DM) standard of care.

Setting

Australia.

Participants

Clinicians involved in the care of people with T2DM, including primary care clinicians, endocrinologists, nephrologists, cardiologists, diabetes educators, and pharmacists; and adults with T2DM.

Methods

Barriers and facilitators of SGLT2 inhibitor implementation were explored through the Consolidated Framework for Implementation Research. Analysis of interview transcripts was conducted in duplicate using a combination of framework and thematic analysis.

Results

A total of 24 clinicians, and four people with T2DM, were interviewed between November 2021 and August 2023, including four primary care clinicians, four endocrinologists, four nephrologists, four cardiologists, four diabetes educators, and four pharmacists. Key findings included that clinicians miss opportunities to prescribe due to competing priorities and therapeutic inertia, and may find it difficult to educate and engage patients about SGLT2 inhibitor use. Patients require detailed education to understand benefits and adverse effect prevention, ideally with multimodal resources and staggered over time, and would benefit from general adherence coaching. Some clinicians were concerned about the risk of urinary tract infections despite reassuring safety data, and few provided genital hygiene advice to reduce SGLT2 inhibitor-associated genital mycotic infections. Better health system support could be achieved through additional cost reimbursement and support for multidisciplinary care access.

Limitations

Most participants were from a single Australian state, New South Wales, which may not fully reflect experiences across Australia. Participation bias may under-represent those less engaged in SGLT2 inhibitor use.

Conclusions

Clinicians are convinced about SGLT2 inhibitor benefits but require support to deliver evidence-based care, including effective patient education and engagement. These insights can help inform the design of interventions to maximise societal benefit from these effective medications.

Keywords

SGLT2 inhibitors uptake adherence qualitative research interviews

Introduction

In recent years, a series of landmark clinical trials have established the role of sodium-glucose cotransporter-2 (SGLT2) inhibitors in reducing the risk of cardiovascular death or kidney disease in people with type 2 diabetes mellitus (T2DM), the risk of kidney failure in chronic kidney disease (CKD), and the risk of heart failure hospitalisation, alongside other metabolic benefits.¹ Unfortunately, while prescription rates are steadily increasing, only a small subset of people who are likely to benefit are receiving these medications. For example, an Australian study found 44.2% of adults with CKD would meet reimbursement criteria, but only 4.1% were using these medications.² Increasing uptake to 75% across Australia for three years could prevent 3644 kidney or cardiovascular events and 1312 kidney failure events.²

In addition, there are major shortcomings of patient medication adherence. A meta-analysis of international observational studies found only 59.5% of people maintained a consistent active supply of their SGLT2 inhibitor over six months, falling to 49.0% over 12 months.³

These implementation challenges highlight the need for detailed qualitative research with multidisciplinary stakeholders to explore barriers to SGLT2 inhibitor implementation, and facilitators to enhance their effective use. We have previously conducted a qualitative study of SGLT2 implementation in British Columbia, Canada,⁴ and have now conducted an investigation in Australia to examine barriers and facilitators in an Australian context. The study extends beyond the scope of the previously published British Columbia study by incorporating direct insights from people living with type 2 diabetes, perspectives from both public and private healthcare sectors, and the views of multidisciplinary healthcare providers. The study poses the research question: What are the barriers and facilitators of SGLT2 inhibitor implementation in Australia according to multidisciplinary stakeholders?

Study Design

We conducted a qualitative interview study. The study has been developed and reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ, Supplemental Appendix).⁵

Setting and Participants

We conducted interviews among patients and multidisciplinary clinician stakeholders involved in T2DM care in Australia, as part of a larger project exploring T2DM care improvements. At the time of project initiation, T2DM was the sole government-subsidised indication for SGLT2 inhibitors, although these indications have since expanded to heart failure and proteinuric CKD.^6,7 Stakeholders included primary care clinicians, nephrologists, endocrinologists, cardiologists, pharmacists, diabetes educators, and people with T2DM. To seek highest-yield insights, initial purposive recruitment focused upon leading experts through email contact. Recruitment was expanded through clinical networks of the research team and snowball recruitment, in New South Wales, Queensland and Victoria, Australia. Recruitment continued until data saturation, where the final two interviews did not yield new additional data. A similar, parallel study was conducted in Canada, with results published separately.⁴

Interviews

The initial draft semi-structured interview questions were broad questions to identify key barriers and existing or potential facilitators of SGLT2 inhibitor implementation. To expand into a comprehensive approach, the questions were adapted and mapped to the Consolidated Framework for Implementation Research (CFIR, Figure 1 and Supplemental Appendix).⁸ An update to this framework was published during the conduct of the study, but was not used. Supplementary questions were included to seek opinions on two specific initiatives being considered by the research team – a text message program to educate and remind patients about SGLT2 inhibitors, and a decision aid incorporated into the electronic medical record (EMR). General strategies to improve the standard of care in T2DM were also sought, to be published separately.

Figure 1.

Study themes mapped to the dominant contributing codes from the consolidated framework of implementation research (CFIR)*

After informed consent, interviews were conducted one-on-one via Zoom (San Jose, California) by DVO, a male nephrologist who was a PhD candidate, and who was not responsible for the care of patient participants.

Analytical Approach

Audio transcriptions of the interviews were analysed using NVIVO software (Burlington, Massachusetts) through a combination of framework analysis,⁹ involving mapping the data across pre-set CFIR codes,⁸ and thematic analysis using inductive and deductive approaches to identify additional insights and to better synthesise diverse opinions.¹⁰ The coding tree is provided in Figure 1. All transcripts were coded in duplicate by DVO and by TWY, another nephrologist. Additional method details are provided in the Supplemental Appendix.

Results

A total of 28 semi-structured interviews (lasting 25-50 minutes) were performed between November 2021 and August 2023, including four people in each of the following categories: primary care clinicians, nephrologists, endocrinologists, cardiologists, pharmacists, diabetes educators, and adults with T2DM. A further 23 participants declined participation or did not respond to directed email contact. Of the 28 included participants, 17 were females and 11 were males, and 21 lived in metropolitan areas while seven lived in regional areas in Australia. Among clinicians, 12 were qualified in their speciality for fewer than five years. Clinicians represented a spread of public hospital practice, private practice, clinical research, and mixed practice. None of the patients were taking an SGLT2 inhibitor but all required long-term medications and multidisciplinary care for T2DM management.

The findings were grouped into barriers and facilitators at the medication, patient, clinician and health system levels (Table 1 and Figure 1). A broad range of practical strategies to improve SGLT2 inhibitor implementation were proposed (Figure 2).

Table 1.

Themes and Illustrative Quotes

Theme	Illustrative quote
Medication-Level Barriers to SGLT2 Inhibitor Use
Adverse Effects	Endocrinologist 4 “The one area that I see discontinuation is problems with urinary tract infections or genital thrush…fortunately, it’s only a small group.”
Challenges of Perioperative Use	Endocrinologist 4: “They’ve already taken their SGLT2 inhibitor that morning or the night before…but then what happens if the person ends up being ketoacidotic post op[eratively] and then…they spend 24 or 48 hours in intensive care.”
Difficulty Prioritising Heart Failure Interventions	Cardiologist 2: “I have sort of more experience with [heart failure medications such as a] beta blocker, ACE [angiotensin-converting enzyme inhibitor], ARNI [angiotensin receptor/neprilysin inhibitor], spironolactone, and I kind of have my wish list, definitely beta blockers and the ARNIs would be higher than say spironolactone. I am not quite sure where the SGLT2 [inhibitor] fits in that hierarchy.”
Medication-Level Facilitators of SGLT2 Inhibitor Use
Advantages over Other Agents	Diabetes Educator 2: “This is actually so good for protecting your kidneys and your heart, that in fact, it’s almost become superior to the glycaemic benefit.”
Benefits of Adverse Effect Counselling	Pharmacist 3: “We can educate people on the more common sort of stuff like recurrent UTIs [urinary tract infections] and fungal infections…the patients will be more aware and then they know what to do.”
Patient-Level Barriers to SGLT2 Inhibitor Use
Struggling with Polypharmacy	Nephrologist 1: “There’s usually a resistance to go on to an extra tablet.”
Forgetting to Take Tablets	Patient 1: “It’s just a forgetting sort of situation or sometimes it’s a can’t be bothered situation or sometimes they don’t have it with them… It takes a lot of concentration I guess, to know you’re taking tablets.”
Difficulty Understanding Benefits	Endocrinologist 4 “Telling someone that they might have a cardiac event within the next five years and by taking this medication they will reduce that chance by 10%, is a hard concept”.
Lack of Written Information Provision	Primary Care Clinician 4: “If you’ve ever read the product information for these medications, it’s all very scientific language…lists every single side effect they found in the clinical trials…sometimes that might be enough just to scare people away from starting”.
Patient-Level Facilitators of SGLT2 Inhibitor Use
Benefits of Careful Patient Selection	Endocrinologist 3: “I’m less inclined to use it as my first choice in a patient who is over 80 years old. Or if they have a [dose administration aid] and aren’t going to be able to easily identify which tablet is the SGLT2 inhibitor.”
Simplifying Medication Regimens	Nephrologist 3: “We need to be looking at their polypharmacy and prioritising the list for them and the SGLT2 inhibitors would have to be very high up the list when I talk to my patients.”
Effective Education	Pharmacist 4: “If they understand why it’s important, I do think, generally, they might be more likely to take it.”
Teaching Practical Adherence Strategies	Patient 1: “When I get up in the morning to go and have breakfast, I put all the tablets on the counter, on the bench, so that they’re there… if I was going out tonight, I would go and put a tablet on the bench where I keep the keys, because otherwise I’ll forget them”.
Clinician-Level Barriers to SGLT2 Inhibitor Use
Delays in Adopting Evidence-Based Care	Nephrologist 2: “I think there is probably a large group of people that should still be on it that maybe it just doesn’t cross your mind…So I should imagine if we audited people’s practice, there’d still be a big group of people that are not getting it.”
Difficulty Keeping Up with Rapidly Evolving Evidence Base	Endocrinologist 1:“That’s again an educational impasse that these drugs provide on the person who is prescribing them.”
Time Pressures	Nephrologist 2: “You have a very limited time in your consultation with the patient to be thinking about the interactions and the complications and that kind of thing.”
Clinician-Level Facilitators of SGLT2 Inhibitor Use
Robust Efficacy Evidence	Endocrinologist 4:“The advent of these medications and the real evidence that pharmacologically we can reduce things like renal disease and cardiovascular disease using diabetic medication has been a real game changer.”
Encouragement from Prescription by Colleagues	Cardiologist 4: “…others want to get some general feedback from their peers and cardiac communities and guideline writing authorities before they start prescribing.”
Clinician Education Resources	Endocrinologist 2: “Something that’s concise, straight to the point and easily accessible even when you’re with a patient for example, would be the way to improve delivery of evidence-based care.”
Shared Responsibility	Endocrinologist 3: “Any doctor who is comfortable with the risks and benefits should be able to prescribe SGLT2 inhibitors.”
Multidisciplinary Care Co-Ordination	Cardiologist 1: “Sessions with the diabetes educators I think help, and they help improve confidence of the patients in giving themselves medications…just the multidisciplinary approach kind of helps with adherence.”
Healthcare System-Level Barriers to SGLT2 Inhibitor Use
Limitations of Prescription Reimbursement Criteria	Pharmacist 2: “PBS [Pharmaceutical Benefits Scheme] need to update themselves in terms of the use of both drugs [SGLT2 inhibitors and GLP1 receptor agonists]. Because why would you make the patient choose between the two if they can benefit from both of them anyway?”
Lack of Access to Multidisciplinary Healthcare	Patient 4 [discussing services in a peri-urban region]: “There’s not enough doctors, there’s not enough medical centres, there’s not enough [primary care clinicians], there’s not enough nurse educators to educate you, to teach you what to do and not to do, when to start and how to take the medications”.
Healthcare System-Level Facilitators of SGLT2 Inhibitor Use
Benefits of Medication Subsidisation	Nephrologist 2: “…if those kind of restrictions were reduced so that [patients] could be on it regardless of what they were on for diabetes then there may be a higher uptake.”
Clinical Decision Aids	Primary Care Clinician 4: “A popup would be helpful because you may be having a chat about other things and that little popup can be a reminder in the back of your head…”

Figure 2.

Proposed approaches to improve SGLT2 inhibitor use

Medication-Level Barriers to SGLT2 Inhibitor Use

Adverse Effects

According to most participants, potential adverse effects of SGLT2 inhibitors could limit their use. The most commonly cited were recurrent genital mycotic infections, hypovolemia and polyuria, with several clinicians raising concerns about urinary tract infection risk and diabetic ketoacidosis. Monitoring symptoms was seen as a challenge for non-primary care clinicians who reviewed each patient less frequently. Some clinicians noted that adverse effect counselling can be time-consuming, and it can be difficult to provide adequate information without creating undue concern for adverse effects with relatively low incidence rates.

Challenges of Perioperative Use

Several clinicians discussed challenges posed by the need to pause SGLT2 inhibitor therapy perioperatively to reduce the risk of diabetic ketoacidosis,^11-13 which could result in delayed procedures. No clinicians identified this as a reason for not prescribing SGLT2 inhibitors. Safe perioperative use was seen as most effective when the patient and multiple team members considered it in advance.

Difficulty Prioritising Heart Failure Interventions

All four cardiologists expressed difficulty prioritising which medication to use in people with heart failure, with evidence supporting the use of beta blockers, renin-angiotensin aldosterone system blockers, angiotensin receptor-neprilysin inhibitors, spironolactone, and SGLT2 inhibitors, all of which could lower blood pressure.

Medication-Level Facilitators of SGLT2 Inhibitor Use

Advantages Over Other Agents

Most clinicians expressed SGLT2 inhibitors had distinct advantages over other agents, including their effect in reducing kidney and cardiovascular disease, the glycaemic efficacy “across all levels of insulin resistance and insulin sensitivity” (Endocrinologist 1), and weight and blood pressure reduction. Endocrinologist 4 discussed that while the weight loss was modest, it could provide motivation and positive feedback for a greater weight loss trajectory.

Compared to glucagon-like peptide-1 (GLP-1) receptor agonists, SGLT2 inhibitors were seen as having more definitive heart failure and kidney benefits, similar benefits for cardiovascular events, inferior weight loss benefits, a more favourable route of administration by avoiding injections, and lower likelihood of gastrointestinal adverse effects.

Benefits of Adverse Effect Counselling

Most clinicians discussed SGLT2 inhibitors have a broadly favourable side effect profile provided careful medication counselling was conducted, and expressed that medication counselling would help support their use. Many clinicians described counselling about genital mycotic infections, but few mentioned providing specific genital hygiene advice. Most clinicians provided sick day advice including guidance to stop SGLT2 inhibitors when unwell or before a procedure requiring fasting. Two nephrologists mentioned patients also require careful counselling about the acute reversible drop in kidney function after initiation, to prevent alarm and medication discontinuation.

Patient-Level Barriers to SGLT2 Inhibitor Use

Struggling With Polypharmacy

Several participants discussed polypharmacy (commonly defined as using more than five concomitant medications) as an adherence obstacle faced by people with T2DM, particularly as T2DM commonly coincides with other chronic health conditions requiring additional medications. Challenges included difficulty keeping track of medications, the need to regularly refill multiple prescriptions, and increasing out-of-pocket costs.

Forgetting to Take Medications

All four patients, and several clinicians, raised the difficulty of remembering to take medications regularly. This included challenges with consistent use, consistent timing, and planning use when away from the home. Patients stated it could take months to years to establish regular medication habits.

Difficulty Understanding Benefits

Several clinicians raised that it could be difficult to convey the kidney and/or cardiovascular benefits of SGLT2 inhibitors. Educating patients about benefits was noted to be more challenging among those with lower health or numerical literacy, in particular conveying concepts about small but significant relative risk reductions. Pharmacist 4 also raised that patient cognitive impairment may be under-diagnosed and this further complicates education efforts.

Lack of Written Information Provision

Most participating clinicians did not regularly use written patient education materials when prescribing SGLT2 inhibitors. Of those that did, many used pharmaceutical company information sheets, although these were noted to contain substantial jargon. Some clinicians and patients discussed that consumer medical information handouts were often provided with the first dispensation of a new medication, but the technical language and focus on adverse effects could be discouraging. Several clinicians had developed their own written materials about SGLT2 inhibitors to meet the need for patient-friendly resources. A range of online patient-facing resources are now available.^14,15,16

Patient-Level Facilitators of SGLT2 Inhibitor Use

Benefits of Careful Patient Selection

Many clinicians discussed the role of patient selection in reducing the likelihood of adverse effects. Benefits were anticipated for a broad range of individuals including people with T2DM, proteinuric CKD, and/or heart failure. Cited reasons to have considered avoiding SGLT2 inhibitor use included recurrent mycotic infections or urinary tract infections, baseline polyuria, those with reduced oral intake or who practice fasting, those who may have difficulty identifying and stopping the agent when unwell, and in the frail or elderly.

Simplifying Medication Regimens

Several participants discussed that reducing tablet burden with active de-prescribing could help facilitate adherence. SGLT2 inhibitors were identified as a priority medication for continuation. Combination tablets of SGLT2 inhibitors and metformin were seen as helpful in reducing tablet burden.

Effective Education

Many participants discussed that good patient education about SGLT2 inhibitor benefits could improve engagement, uptake and long-term adherence, particularly since these medications do not produce symptomatic benefits. A variety of modalities were suggested, including one-page infographic-based information sheets, short booklets/pamphlets, short videos, social media posts, group education nights, and a card to carry in the wallet about sick day advice. Patients and clinicians discussed that different patients might like different depths of information, from “quick and easy” resources to “lots of text” (Primary Care Clinician 1), but with a focus upon frequently asked questions and clinically important information. Staggering the education over time was recommended to improve knowledge retention.

Most participants, including all patient participants, agreed a text message-based education and reminder system could be helpful. There was considerable variation in opinion about how often messages should be sent, from “every time [the SGLT2 inhibitor] is due” (Patient 1) to “a few times in the first week and then tapering off gradually over weeks to months” (Diabetes Educator 2). Concerns were raised about the possibility of messages feeling “intrusive” (Primary Care Clinician 1) or “annoying” (Pharmacist 4).

Teaching Practical Adherence Strategies

Other practical strategies to improve medication adherence included the use of dispensation aids, incorporating tablets into routines such as when eating breakfast or brushing teeth, repeated clinician reviews for encouragement and adverse effect monitoring, clinician surveillance of script filling, involvement of family members or carers, carrying spare medications when leaving home, phone timers or calendar alerts, and pharmacist home medication reviews. Patients expressed that being taught about such strategies could improve medication use.

Clinician-Level Barriers to SGLT2 Inhibitor Use

Delays in Adopting Evidence-Based Care

Most clinicians agreed clinician uptake of SGLT2 inhibitors lags behind the clinical need, while several noted rising prescription rates. Some clinicians suggested uptake may be slower in regional areas and private clinics, where clinicians may be less exposed to the evolving prescribing habits of colleagues, and among senior clinicians who may have established prescribing habits and less familiarity with newer therapies.

A component of the under-utilisation was therapeutic inertia, or the failure to adjust treatments when indicated. Several clinicians discussed that prescribers may not think about SGLT2 inhibitor initiation when patients are clinically stable. Several participants noted that late consideration of initiation could represent a missed opportunity, particularly if the kidney function becomes too low to safely initiate. Three clinicians highlighted some confusion about the minimum threshold of kidney function for safe use.

Difficulty Keeping Up With a Rapidly Evolving Evidence Base

Some clinicians expressed it could be difficult to stay abreast of the evolving SGLT2 inhibitor evidence, including new clinical trial data, evolving guideline recommendations, and changing patient reimbursement criteria in the Pharmaceutical Benefits Scheme (PBS).

Time Pressures

Several clinicians discussed the difficulty of commencing SGLT2 inhibitors during busy clinics, and half of all participants stated clinicians were under significant time pressure in general. Clinicians expressed that time constraints limited clinicians’ ability to learn about the current evidence, to consider their initiation during brief patient consultations, and to provide thorough medication counselling.

Clinician-Level Facilitators of SGLT2 Inhibitor Use

Robust Efficacy Evidence

All clinicians expressed high confidence in SGLT2 inhibitor efficacy for a wide range of patient outcomes, such that they were described as a “real game changer” (Endocrinologist 4). No participants expressed concerns about their efficacy.

Encouragement From Prescription by Colleagues

Many clinicians expressed seeing other clinicians endorsing and prescribing SGLT2 inhibitors encouraged their prescribing practice, including discussions during departmental meetings and journal clubs, and shared patient care between different clinicians.

Clinician Education Resources

Most clinicians described using a wide variety of information sources, with the Australian Diabetes Society guidelines¹⁷ being cited most often. Other sources included departmental meetings and journal clubs, resources from specialty societies (in particular the “Management of Type 2 Diabetes: A Handbook for General Practice” from the Royal Australian College of General Practitioners and Diabetes Australia¹⁸), speciality society meetings, conferences, webinars, review articles, and clinical trial papers.

The majority of clinicians expressed interest in additional clinician education resources for SGLT2 inhibitors. Requested information included guidance on adverse effect counselling, strategies to better convey the benefits, summaries of clinical indications and Australian PBS prescribing restrictions, and easy to follow decision matrices. Several clinicians discussed the need for regularly updated clinical guidelines. The Australian Diabetes Society (ADS) subsequently launched living guidelines for T2DM, which promote the use of SGLT2 inhibitors among people with diabetes and elevated risk of kidney or cardiovascular disease.¹⁹

Shared Responsibility

Most clinicians agreed any clinician who felt comfortable could initiate an SGLT2 inhibitor. Several clinicians stated that if an endocrinologist were involved in the patient’s care they would defer to the endocrinologist to initiate, to avoid “stepping on their toes” (Primary Care Clinician 2). Some clinicians raised concerns that deferring prescription to another care provider may result in the medication not being started, or being started after a long delay. Two nephrologists noted proactive early initiation would help maximise long-term benefits.

Multidisciplinary Care Co-Ordination

Several clinicians expressed a desire for more multidisciplinary collaboration to optimise care, including input from pharmacists, diabetes educators, pharmaceutical company representatives, shared endocrinology and nephrology clinics for people with diabetes, and additional support from dietitians and exercise physiologists. Many clinicians highlighted the potential role for expanding pharmacist provision of medication counselling.

Healthcare System-Level Barriers to SGLT2 Inhibitor Use

Limitations of Prescription Reimbursement Criteria

Approximately half of clinicians mentioned the indications for prescription from the PBS could be limiting. At the start of our study period, SGLT2 inhibitors were only listed for use in T2DM in the context of inadequate glycaemic control and in combination with another glucose-lowering agent.^7,20 Further indications have since been added for symptomatic heart failure, albuminuric and non-albuminuric CKD, and T2DM with elevated cardiovascular risk, supporting broader prescribing without high out-of-pocket costs.^7,20,21 An ongoing limitation discussed by clinicians was that when SGLT2 inhibitors and GLP-1 receptor agonists were prescribed together, reimbursement was only available for one of the agents at a time, despite emerging evidence that some patients would benefit from dual therapy.^22,23

Lack of Access to Multidisciplinary Healthcare

Nearly all clinicians discussed access issues for multidisciplinary care, most notably in regional areas, that could affect implementation of therapies like SGLT2 inhibitors. People in regional areas often travelled several hours to larger centres for reviews, and those with diabetes had very limited access to reviews with diabetes educators, and up to six month wait times to see endocrinologists.

Healthcare System-Level Facilitators of SGLT2 Inhibitor Use

Benefits of Medication Subsidisation

Most clinicians had not encountered cost as a barrier to SGLT2 inhibitors use, prescribing SGLT2 inhibitors as subsidised on the PBS. For those of limited financial means “most people are on a pension or healthcare [concession] card” (Nephrologist 3) where the co-payment per script is further reduced. Several clinicians noted, however, working in areas with higher socioeconomic demographics where cost may be less impactful. No clinicians discussed providing informed financial consent for SGLT2 inhibitor initiation,²⁴ and many did not know the co-payment required, which currently averages AUD$25 per month when prescribed through the PBS without a concession card.^7,20 It was raised that patients may hesitate to discuss financial concerns, so financial barriers may be under-recognised. Three patients raised that costs of diabetes care in general could be a challenge, including “multiplying medicine costs” (Patient 3). Further subsidisation for cardiovascular indications and co-prescription with GLP1 receptor agonists, as discussed above, was raised as potentially helpful.

Clinical Decision Aids

Most clinicians felt SGLT2 inhibitor initiation prompts in the EMR tailored to individual patient indications could be useful, but many felt they could also be annoying or distracting. Several clinicians felt prompts to consider withholding SGLT2 inhibitors during hospital admissions might be helpful to help prevent ketoacidosis.

Discussion

The present study yielded a wealth of insights from a diverse group of stakeholders to examine barriers and facilitators of SGLT2 inhibitor implementation into routine care. SGLT2 inhibitor use was limited by barriers such as medication adverse effects, the patient challenges of remembering medications and managing polypharmacy, the difficulty time-poor clinicians face in keeping up-to-date with an evolving evidence base and incorporating this knowledge into prescription practices, indication restrictions for medication subsidies, and lack of access to multidisciplinary care in regional areas. A wealth of recommendations have been proposed, including a need to develop patient education programs to better explain kidney and cardiovascular benefits, adverse effect prevention strategies, and practical tips to support adherence; the use of patient medication reminder systems, multidisciplinary care co-ordination, concise reference materials for prescribing clinicians, and prompt updates to medication subsidisation schemes to reflect new evidence.

Several results differed from what might be expected from existing SGLT2 inhibitor and adherence literature. Eight clinicians mentioned concerns about urinary tract infections, while meta-analysis of clinical trials,²⁵ and cohort studies,²⁶ have not shown increased risk. Few mentioned providing genital hygiene advice, while provision of this advice is recommended,²⁷ and could reduce genital mycotic infections and thereby improve adherence.²⁸ Most clinicians did not provide written patient education materials for SGLT2 inhibitors, despite most also agreeing such materials were helpful, and with adherence literature also supporting the role of written patient-friendly resources.²⁹ Lastly, while some participants discussed that SGLT2 inhibitor uptake may be slower in regional areas, a study in New South Wales, Australia, demonstrated greater uptake of SGLT2 inhibitors among people with T2DM living in outer regional and remote areas compared to those living in major cities or inner regional areas.³⁰ This finding highlights the importance of an evidence-based approach to identifying and targeting implementation gaps.

The results were broadly comparable to our parallel qualitative research project conducted in British Columbia, Canada, among 21 clinicians across four specialties – family physicians, nephrologists, endocrinologists and cardiologists.⁴ Common themes included adverse effect challenges, variable clinician comfort prescribing SGLT2 inhibitors, therapeutic inertia, and restrictive reimbursement criteria. The addition of pharmacist, diabetes educator, and patient participants in our present study provided valuable additional insights, including the challenge of remembering tablets, the importance of multi-disciplinary care, and the need for improved patient education.

An Australian qualitative study explored primary care clinician and endocrinologist perspectives surrounding SGLT2 inhibitor initiation without focusing on a full profile of barriers and facilitators.³¹ It also raised the impact of adverse effects, a need for better clinician education around SGLT2 inhibitor use, and for collaborative care. This study identified an under-appreciation of the kidney and cardiovascular benefits of SGLT2 inhibitors, which was not a key theme in our study, although some of the present study’s participants described difficulty keeping up with evolving evidence. This may relate to the interviews being conducted approximately one to three years earlier than the present study, with active dissemination of SGLT2 inhibitor evidence in the intervening time. A subsequent study by the same research group interviewing cardiologists and nephrologists again identified some themes in common with the present study.³² These included concern about adverse effects, the need for clinicians to gain prescribing experience and confidence, uncertainty prescribing in those with low kidney function, and difficulties with government reimbursement.³²

Strengths and Limitations

Study strengths include diverse participant backgrounds and perspectives, including the lived experience of patients managing T2DM. The CFIR framework enabled a systematic approach, while the semi-structured interview style facilitated discussion of many unanticipated insights. Study limitations included the potential for participation bias, and a predominance of New South Wales-based participants that may not fully reflect experiences across Australia. As the study was part of a larger project exploring the standard of care in T2DM, the research was largely focused on the use of SGLT2 inhibitors in the context of T2DM care, which may not represent their use in other health conditions.

Conclusions

While there are several medication, patient, clinician and healthcare system barriers to the widespread adoption of SGLT2 inhibitors, there are also many existing and potential strategies for better implementation. Efforts to educate and support patients to take medications regularly and to understand the nuanced benefits of SGLT2 inhibitor therapy, as well as education and multidisciplinary support for busy clinicians, and updates to government reimbursement criteria, could help to improve uptake of these effective agents and produce major benefits for individuals and the health system.

Supplemental Material

Supplemental material - Barriers and Facilitators for Sodium-Glucose Cotransporter-2 Inhibitor Uptake and Implementation in Australia – Perspectives From Clinicians and Patients: An Interview Study

Supplemental material for Barriers and Facilitators for Sodium-Glucose Cotransporter-2 Inhibitor Uptake and Implementation in Australia – Perspectives From Clinicians and Patients: An Interview Study by Daniel V. O’Hara, Tae Won Yi, Meg J. Jardine, Rachael L Morton in Canadian Journal of Kidney Health and Disease

Supplemental Material

Supplemental material - Barriers and Facilitators for Sodium-Glucose Cotransporter-2 Inhibitor Uptake and Implementation in Australia – Perspectives From Clinicians and Patients: An Interview Study

Footnotes

Acknowledgements

The research team is very grateful to the patient and clinician participants for their time, expertise and honesty, including Mr Geoff Rossiter, Ms Carmela Santisteban, Ms Louise Vaughan, Ms Lauren Kirby, Dr Lisa Raven and Dr Hsien Loo. DVO received support through an Australian Government Research Training Program Scholarship, the Royal Australian Society of Nephrology Jacquot Research Entry Scholarship, and the NHMRC Clinical Trials Centre Postgraduate Research Scholarship. MJJ is supported by an NHMRC Investigator Grant. RLM is supported by an Australian NHMRC Investigator grant #1194703.

ORCID iDs

Daniel V. O’Hara

Tae Won Yi

Ethical Considerations

The study received approval from the Sydney Local Health District Human Research Ethics Committee (ID 2021/PID00101).

Consent to Participate

All participants provided written informed consent.

Consent for Publication

Participants named in the Acknowledgements section provided written informed consent to be named.

Author Contributions

All authors contributed to study conceptualisation, methodology, investigation, formal analysis, validation and reviewing and editing. DVO also contributed to data curation, visualisation, and writing the original draft. TWY also contributed to data curation. MJJ and RLM also contributed to supervision.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MJJ is responsible for research projects that have received unrestricted funding from Amgen, Baxter, CSL, Eli Lilly, Gambro, and MSD; has served on advisory boards sponsored by Akebia, Astra Zeneca, Baxter, Bayer, Boehringer Ingelheim, Merck Sharp & Dohme, Occuryx and Vifor; serves/has served on Steering Committee for trials sponsored by Chinook, CSL, Janssen and Boehringer Ingelheim; received funding support for an investigator-initiated trial from Dimerix, Kensana; spoken at scientific meetings sponsored by Amgen, Boehringer Ingelheim, Janssen, NovoNordisk, Roche and Vifor; has received fees for educational activities from Cesas Medical, Medcon International PACE CME and Medscape; with any consultancy, honoraria or travel support directed to her institution. DVO is the Medical Fellow on a trial funded by Boehringer Ingelheim and has received speaking fees from Boehringer Ingelheim and Astra Zeneca. TWY and RLM declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request, and after approval from the Sydney Local Health District Human Research Ethics Committee.*

Supplemental Material

Supplemental material for this article is available online.

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