1. Treatment perceptions and
misunderstandings with clinicians
in people with diabetes
30-10-2015 1
Peter Schwarz
Anne-Marie Felton
Michael Cobble
Ayeza Bonilla Islas
Johan Wens

2. Aims
30-10-2015 2
understand in more detail similarities and differences
between clinicians’ and patients’ perceptions
regarding the treatment for T2DM
Research questions
• How do patients and clinicians perceive the need for treatments that manage
challenges beyond hyperglycemia, including obesity, lipids, hypertension, … ?
• How perceive clinicians and patients meaningful weight loss?
• How perceive clinicians and patients weight management as a motivator to patient
self-management?
• How to characterize the disconnect between patients and clinicians regarding the
above?

3. Methods
30-10-2015 3
online survey
10 minute structured online questionnaire
across 13 countries
stepwise design:
- originally drafted by HCP focussing on the main objectives
- developed by an iterative Delphi type approach
- mirrored questions for clinicians and PWD (“people with diabetes”)
- reviewed by international T2DM experts
- reviewed by clinicians from external steering committee
- piloted by some PWDs
- tested in small number of PWD from English speaking country

4. Methods
30-10-2015 4
After pilot testing
- data reviewed to ensure good understanding of scripts
2nd pilot of PWD questionnaire
- as further check for language, length, flow and clarity
Final survey
- translated in local languages
- back-translated in English
to confirm language and face validity

5. Methods
30-10-2015 5
Data collection
- baseline demographics
- mix of question types
- 4 and 5 point semantic (Likert) scales
- frequency counts of 1st, 2nd or 3rd ranks
- pre-coded / dichotomous questions
Analysis
primarily conducted to show percentage distributions of ranks
across the samples as applicable at a global/country level

6. Participants
30-10-2015 6
Clinicians
identified in response of answers to questions about the healthcare
they provided and the medical conditions they treated
People with T2DM (PWD)
recruited from
- online communities
- social media
- affiliated partners
- web-based sources
selected their condition from a list of different conditions without
being informed about qualifying condition for the survey

7. Participants
30-10-2015 7
PWD Clinicians
France
Germany
Italy
Spain
UK
US
Canada
PWD Clinicians
China
Japan
Brazil
Mexico
Australia
South Africa
TOTAL

8. Participants
30-10-2015 8
PWD Clinicians
France
Germany
Italy
Spain
UK
US
Canada
PWD Clinicians
China
Japan
Brazil
Mexico
Australia
South Africa
TOTAL 2140 1406

9. Participants
30-10-2015 9
PWD Clinicians
France 177 100
Germany 179 103
Italy 175 100
Spain 150 101
UK 175 100
US 331 200
Canada 128 102
PWD Clinicians
China 226 100
Japan 150 100
Brazil 100 100
Mexico 101 101
Australia 101 97
South Africa 147 100
TOTAL 2140 1406

10. Participants
30-10-2015 10
n
PWD
%
obese
%
overweight
France 177 48 27
Germany 179 58 30
Italy 175 29 40
Spain 150 33 44
UK 175 51 24
US 331 61 20
Canada 128 61 16
n
PWD
%
obese
%
overweight
China 226 42 20
Japan 150 49 25
Brazil 100 42 35
Mexico 101 35 40
Australia 101 56 28
South Africa 147 39 38
TOTAL 2140 50 30
using country specific BMI definitions

11. Type of Healthcare practitioner
30-10-2015 11
PCPs/GPs Nurses Specialists**
China 100 - -
Japan 100 - -
Brazil 50 - 50
Mexico 51 - 50
Australia 70 29 -
South
Africa
100 - -
TOTAL 1035 171 200
PCPs/GPs Nurses Specialists**
France 100 - -
Germany 71 32 -
Italy - - 100
Spain 101 - -
UK 70 30 -
US 150 50 -
Canada 72 30 -
**Includes diabetologists/ endrocrinologists (Italy/LatAm);
cardiologists (LatAm); specialist Internists (LatAm)

12. Participants - demographics
30-10-2015 12
13 15 26 31 16
<35 35-44 45-54 55-64 >65
58 42
Male Female
Gender Age
50 27 10 11 2
Employed Retired
Unable to work Unemployed
5 13 25 19 38
1 2 3 4 5
Second
stage of
tertiary
education
First stage
of basic
education
Education level Employment status
(Upper)
secondary
education
Lower
secondary
education
Post-
secondary
(vocational)
education

13. Participants
30-10-2015 13
Time since T2D diagnosis
PCP / internist 52%
Diabetes specialist 37%
Diabetes nurse 4%
Primary care nurse 1%
Pharmacist 1%
Other specialist 4%
Country variations:
PCP: US = 77%; Canada = 72%; Australia = 67%
Diabetes specialist: China = 79%; Italy = 65%; Brazil = 62%
Diabetes nurse = UK = 29%
Main T2D treater

14. Participants – co-morbidities
30-10-2015 14
Fr Ger It Sp UK US Can Bra Mex Chn Jpn Aus SA
11
13
9 6 8
11 10
7
11 9
15
12
Co-morbidities
High blood pressure
High cholesterol
Vision problems
(due to diabetes)
Circulation problems
Kidney problems
Heart attack
Heart surgery
angioplasty, stent, CABC,
Stroke
None of these
% with Each Co-morbidity by Country
17
27
21 18 15
19 22
31
7 9 15
24
15
27
17 13 13
16
29 28 27
13 12
29
42
68 66
45
69
76 68 70
38
68
42
65 67
51
63 50
65 66
65 52 46 48 38
63
33
16 11
21 14 9
14 10
21
11
31
13 12
6 4 5 5 5 10
5
2
8
3 2
7
9 5
2
6
12
7 8
1 3
6
17
4
11
13
9 6 8
11 10
7
11 9
15
12

15. Participants – current treatment
30-10-2015 15
15
4
5
28
9
24
15
Diet and exercise & Oral & injectable
medication
Injectable medicine & Oral
medication
Diet and exercise & Injectable
medication
Diet and exercise & Oral medication
Injectable medication only
Oral medication only
Diet and exercise only
Patients receiving injectable = 33%
Patients on oral therapy = 72%
%
Of whom

16. Participants – current treatment
30-10-2015 16
46
77
73
84
77
38
25
20
63
23
Oral Injectable
72
71
76
71
67
67
70
74
23
28
32
23
29
37
34
24
*Source: Decision Resources “Type 2 Diabetes in China,” May 2008 and AZ Global Diabetes Forecasting with IMS MIDAS data
France
Germany
Italy
Spain
UK
US
Canada
Brazil
Mexico
China
Japan
Australia
South Africa

17. Challenges for clinicians…
30-10-2015 17
2
2
1
1
11
9
9
7
3
56
63
65
59
44
31
26
25
33
52
Indifferent Not at all challenging Challenging Very challenging%
Weight
Microvascular
Complications
Glycemic Control
Managing CV Risk
Patient Compliance
96%
92%
90%
89%
87%
Top 2 Boxes Score
(Challenging /
Very challenging
4
3
2
4
2
33
31
25
21
22
54
52
60
59
61
10
14
13
16
15BP Control
Delay progression to
insulin
Cholesterol Control
Minimize episodes of
hypos
Managing side effects
of T2D treatment
76%
75%
73%
66%
64%

18. Concerns of PWD…
30-10-2015 18
0 10 20 30 40 50 60 70
achieve/maintain target BP
achieve/maintain target cholesterol
managing side-effects of treatment
regularly forgetting to take tablets
minimising hypoglycemic episodes
suffering from microvasc. complications
increased risk of CV complications
achieve/maintain glycaemic control
achieve/maintain target weight
PWD (n = 2140) HCP (n = 1406)

19. Concerns of PWD and HCP
30-10-2015 19
0 10 20 30 40 50 60 70
achieve/maintain target BP
achieve/maintain target cholesterol
managing side-effects of treatment
regularly forgetting to take tablets
minimising hypoglycemic episodes
suffering from microvasc. complications
increased risk of CV complications
achieve/maintain glycaemic control
achieve/maintain target weight
PWD (n = 2140) HCP (n = 1406)

20. Differences in feelings on …
30-10-2015 20
16%
15%
7%
6%
2%
-5%
-5%
-8%
-12%
-20%
-21%
-30% -20% -10% 0% 10% 20% 30%
Forget to take tablets
Cholesterol control
Forget to inject*
BP control
Side effects
Manage weight
Diabetes complications*
CV event (e.g., MI/stroke)
Manage blood sugar
Having to inject in future***
Having to inject self now*
Percentage of PwD minus Clinicians Saying Consideration
“Makes Patients Moderately / severely Anxious” (Top 2 Box)
+/-10% was judged
to be threshold of
clinically
meaningful
differences
between patients
and clinicians
Patients less
concerned in
relation to what
Clinicians
perceive
Patients
similarly
concerned in
relation to what
Clinicians
perceive
Patients more
concerned in
relation to what
Clinicians
perceive
* Such as retinopathy kidney failure, neuropathic symptoms, diabetic foot.
•**Asked only to patients currently injecting
•***Asked only to patients currently not injecting
All differences between Clinicians & patients are statistically significant at 95% CI

21. Differences in which feels the worst…
30-10-2015 21
0 10 20 30 40 50 60 70
Risk of Diabetic Complications
Side Effects of Treatment
Hypoglycemia
Managing Weight
Managing Blood Sugar
Risk of Heart Attack / Stroke
Managing Blood Presure
Maintaining Cholesterol Levels
Forgetting to Take Tablets
% of Respondents Indicating “Top 3 Box” Level of Concern
Situation/Challenge
Differences in Level of Patients Concern vs. What Clinicians Perceive
Patients
Clinicians
*Statistically comparable or statistically
different (95% CI)
Patients
equally
concerned as
clinicians*
Patients more
concerned
than clinicians*
Patients less
concerned
than clinicians*

22. Differences in feelings on…
30-10-2015 22
Talking about diabetes
& treatment
Discussing worries/concerns
Maintaining blood sugar
Having enough time to talk
about lifestyle changes 32
27
32
43
37
54
44
44
46
43
50
43
43
40
3
10
5
1
7
1
6
21
17
19
6
12
1
10
Very positive Positive Indifferent Anxious

23. Differences in feelings on ideal drug…
30-10-2015 23
18%
5%
2%
1%
0%
-3%
-8%
-10%
-15%
-19%
-30% -20% -10% 0% 10% 20% 30%
Injectable by you/physician*
Treats several conditions*
Minimal negative side effects
Helps manage blood pressure
Taken by mouth
Maintains normal cholesterol levels
Promotes weight loss that is meaningful*
Once a Day*
Promotes consistent weight loss*
Helps manage blood sugar*
Percentage of Patients minus Clinicians Saying Medication Attribute is
“Very Important” or “Extremely Important” (Top 2 Box)
+/-10% was judged
to be threshold of
clinically
meaningful
differences
between patients
and clinicians
Patients rate
more
important
than do
clinicians
*Differences statistically significant at 95% CI
Patients rate
less important
than do
clinicians
Patients rate
similarly
important as
do clinicians

24. Differences in meaningful weight loss
30-10-2015 24
*Differences statistically significant at 95% CI
1%
5%
10%
31%
52%
2%
11%
38% 39%
10%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1-2% 2-3% 4-5% 6-10% >10%
PWD Clinicians
PercentageofRespondents
PWD 5x more
likely than
Clinicians to say
>10%
PWD similarly
likely as
Clinicians to
say 6-10%
Neither PWD
nor Clinicians
likely to say 1-
2%
PWD half as likely to say 2-3%;
one-quarter as likely to say 4-5%
In 6 months…

25. 26%
30%
12%
31%
12%
40%
23% 25%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
6 Mos. 12 Mos. 2 Yrs. > 2 Yrs.
PWD (n=1819) Clinicians (n=1406)
Differences in meaningful weight loss
30-10-2015 25
*Differences statistically significant at 95% CI
time to keep the weight off
PercentageofRespondents
PWD similarly
likely as
clinicians to say
>2 Yrs.
PWD half as
likely as
clinicians to
say 2 Yrs.
PWD twice as
likely as
clinicians to say
6 Mos.
PWD similarly likely
as clinicians to say
12 Mos.

26. Discussion
30-10-2015 26
Limitations:
• statistical comparison of differences is not possible
• similar versus identical questions
• inclusion of T1DM could not be ruled out
• conclusions on causality are not possible
• respondents drawn from online surveys
• respondents seem to be more educated than average
• sensitivity analyses confirmed valid survey results
• country level differences most likely based on:
• demographics
• availability of medicines
• standards of care

27. Conclusions
30-10-2015 27
• differences between perceptions of HCP and PWD regarding
T2DM disease management
• for HCP managing weight is most challenging, not so for PWD
• less concerned for modifiable risk factors
• unaware of relationship with long-term complications
• HCP overestimate PWD’s anxiety with self injection
• HCP underestimate PWD’s concerns about adherence
• more than half PWD consider only weight loss > 10 % as
meaningful and stresses on short-term goals
• Ineffective communication perhaps contribute in these
differences of perceptions
 Need for further education and better communication

28. Acknowledgements
30-10-2015 28
Peter Schwarz
Anne-Marie Felton
Michael Cobble
Ayeza Bonilla Islas
Johan Wens