Patients’ Future Expectations for Diabetes and Hypertension Treatments: “Through the Diet… I Think This is Going to Go Away.”
Patients' Future Expectations for Diabetes and Hypertension Treatments: BThrough the Diet… I Think This is Going to Go Away.^
Paige C. Fairchild 1
Aviva G. Nathan 0
Michael Quinn 0
Elbert S. Huang 0
0 Department of Medicine, Section of General Internal Medicine, University of Chicago , Chicago, IL , USA
1 Feinberg School of Medicine, Northwestern University , Chicago, IL , USA
BACKGROUND: Diabetes and hypertension are chronic conditions for which over 90 % of patients require medication regimens that must be intensified over time. However, delays in intensification are common, and may be partially due to unrealistic patient expectations. OBJECTIVE: To explore whether patient expectations regarding their diabetes and hypertension are congruent with the natural history of these conditions. DESIGN: Qualitative analysis of semi-structured interviews. PARTICIPANTS: Sixty adults from an urban academic primary care clinic taking oral medications for both diabetes (duration <10 years) and hypertension (any duration) MAIN MEASURES: (1) Expectations for their a) current diabetes and hypertension medications, b) need for additional medications, c) likelihood of cure (not requiring medications); (2) preferences for receiving information on expected duration of treatments KEY RESULTS: The average patient age was 60 years, and 65 % were women. Nearly half (48 %) of participants expected to discontinue current diabetes medications in 6 years or less, whereas only one-fifth (22 %) expected to take medications for life. For blood pressure medications, one-third (37 %) expected to stop medicines in 6 years or less, and one-third expected to take medicines for life. The vast majority did not expect that they would need additional medications in the future (oral diabetes medications: 85 %; insulin: 87 %; hypertension medications: 93 %). A majority expected that their diabetes (65 %) and hypertension (58 %) would be cured. Most participants believed that intensifying lifestyle changes would allow them to discontinue medications, avoid additional medications, or cure their diabetes and hypertension. Nearly all participants (97 %) wanted to hear information on the expected duration of their diabetes and hypertension treatments from their healthcare provider. CONCLUSIONS: Providers should educate patients on the natural history of diabetes and hypertension in order to manage patient expectations for current and future medications. Future research should assess whether education can increase the adoption of and adherence to medications, without diminishing enthusiasm for lifestyle changes.
diabetes; hypertension; patients' expectations; clinical inertia; J Gen Intern Med 32(1); 49-55 DOI; 10; 1007/s11606-016-3871-3 © Society of General Internal Medicine 2016
While many studies have described patient knowledge of
diabetes and hypertension and its impact on treatment
adherence,14–18 few studies have explored patient expectations for
treating their conditions in the future. One study of African
American patients with high blood pressure found that 38 %
believed they would not need to take medication for life,19 and a
study of low-income African American and Latino patients with
diabetes found that almost one-third believed a doctor would
cure them of diabetes.20 These studies paint a general picture of
unrealistic patient expectations and suggest that these
expectations contribute to poor treatment compliance and poor
outcomes; however, these studies do not provide a systematic
understanding of beliefs about time-sensitive decisions that
patients may face regarding their current and future medications.
Since patient expectations are an important driver of patient
behavior,21 we used qualitative methods to understand
patients’ expectations for the future of their 1) current diabetes
and hypertension medications, 2) need for additional
treatments, and 3) possibility of remission (not needing
medications) in the future.
In this qualitative exploratory study, we conducted
semistructured interviews with individuals diagnosed with both
diabetes and hypertension to assess their expectations. This
is part of a larger study22 (The On Time Diabetes and
Hypertension Study) focusing on patient decision-making in relation
to information about the time requirements for diabetes and
hypertension treatment. This study was approved by the
University of Chicago Biological Sciences Division Institutional
All interviews took place between January and September
2014 at a primary care clinic in an urban academic medical
center. All interviews were conducted in private patient rooms
within the clinic.
The flow of participant selection is outlined in
Supplementary Appendix Figure 1. As previously described,22
using the Clinical Research Data Warehouse maintained
by the Center for Research Informatics at the University
of Chicago, we identified 1158 eligible adults who had
been seen in the primary care clinic between August 2012
and August 2013. We required participants to have had
diabetes for less than 10 years. We intended to study
individuals with type 2 diabetes, so we limited the
population to those 40 years and older. To minimize issues with
cognitive impairment and/or limited life expectancy, we
limited the population to those less than 70 years of age.
We required participants to have both diabetes and
hypertension, because the larger study was among patients with
both conditions. We required that patients were prescribed
oral medications for both conditions and not prescribed
insulin, because we wanted to minimize general
preferences against taking chronic disease medications and insulin.
We reviewed the electronic medical record (EMR) for
eligible subjects and excluded individuals who were
currently pregnant, on dialysis, or had active cancer, liver
failure, severe visual impairment, deafness, or cognitive
impairment. We then contacted eligible individuals by
phone to screen for cognitive impairment and to verify
chart review data.23 Eligible individuals were invited to
participate in an hour-long in-person interview. Eligible
individuals who declined to participate did not differ
significantly in sex, race/ethnicity, or age from those
who consented. We used stratified purposeful sampling24
to reach a minimum of 30 % white participants and to
ensure racial/ethnic diversity in respondents. We recruited
and interviewed individuals until we achieved the a priori
sample size of 60 participants, at which point we expected
to reach theme saturation.
The interview guide (Supplementary Appendix) was created
through an iterative process with the research team and
contained scaled-response and open-response questions. For
scaled-response questions (e.g., 1–10 scale), visual aids
depicting response options were created and provided to
participants. The interview guide was pilot-tested with
nonpatient volunteers by the internal research team. The interview
was administered in English for all participants.
Two interviewers (AN and PF) obtained informed consent,
then conducted and audio-recorded the interviews. Interviews
ranged from 30 to 60 min. All interviews took place 1 h before
scheduled appointments. In gratitude for their participation,
participants received their choice of a parking pass or public
transit voucher, as well as a $20 mailed check.
We asked participants the following open-ended questions: 1)
BHow much longer do you think you’ll take your current
medicines?^ 2) BDo you think that you’ll have to take more
medicines in the future?^ 3) BDo you think your conditions can
be cured?^ and 4) BBefore starting a new medicine for your
diabetes and high blood pressure, would you like your doctor to
tell you how long you’ll be on the medication?^ We did not
define the term Bcure^ for the participants, leaving it open to
their interpretation. Participants gave free responses, and
interviewers probed for further explanations. Interviewers also
asked participants to report when they had been diagnosed with
hypertension, when they began taking medications for
hypertension and diabetes, their current self-rated health status,
smoking history, marital status, race, ethnicity, education, and income
range. We used EMR data to document each participant’s
duration of diabetes, most recent A1C value and blood pressure
reading, and current diabetes and hypertension medications.
Study data were collected and managed using REDCap
electronic data capture tools hosted at the University of Chicago.25
Interviews were transcribed, and a modified template
approach was used to qualitatively analyze participant
responses.26 The initial codebook was aligned with the
interview guide and was amended throughout the coding process to
capture new information and themes. Each interview transcript
was reviewed and coded by two or more trained coders (PF,
AN, NL, NS, CL, DG), and codes were discussed and agreed
upon by consensus. Codes were then compared across
transcripts and grouped into high-order themes. Representative
quotes were chosen to illustrate major themes. Responses to
some questions such as BHow much longer do you think you’ll
need to take your current medications?^ favored participant
responses that could be categorized. We used the software
ATLAS.ti (version 7.5) to manage the qualitative data and
SAS (version 9.3) to conduct quantitative analysis.
The average age of participants was 60 years, and 65 % were
women. In line with our purposeful sampling design, 35
participants self-identified as non-Hispanic black (58 %), 19
(32 %) as non-Hispanic white, 4 (7 %) as Hispanic, and 2
(3 %) as Asian/Pacific Islander. The majority of participants
reported at least some college education (83 %); however,
40 % reported an annual income of $50,000 or less. The
median duration of diabetes was 4 years (interquartile range
[IQR] 3.5), and participants reported taking diabetes
medications for a median of 4 years (IQR 3.0). The median duration
of hypertension was 9 years (IQR 7.5), and participants
reported taking hypertension medications for a median of
8 years (IQR 7.8). The average A1C value was 6.9 %
(standard deviation [SD] 1.1 %) and blood pressure was 134/
76 mmHg (SD 17/11 mmHg).
Expectations for Current Diabetes and Hypertension Medications
Nearly half of the participants (48 %; n = 29) expected to
discontinue their diabetes medications in six or fewer years;
about one-third (37 %; n = 22) expected to discontinue their
hypertension medications in six or fewer years. These
participants expressed plans to improve their lifestyle and control
their glucose or blood pressure levels (Table 1). For diabetes,
participants also mentioned that good social support, including
support from their physician, would help them to discontinue
their medications in the near future.
Nearly one-third of participants (30 %; n = 18) thought
that they might be able to discontinue diabetes medicines
someday, while slightly fewer participants (25 %; n = 15)
thought that they might be able to discontinue hypertension
medications someday. These participants also stated that
they could stop taking medications if they changed their
lifestyles or controlled their glucose or blood pressure
levels, but expressed less confidence in their ability to
make changes. More importantly, external factors affected
their expectations regarding continuation of medications,
specifically that their doctors would tell them if they could
stop taking medications, that life stressors may prevent
them from stopping medications, and that scientific
advancements may allow them to stop taking medications.
About one-fifth of participants (22 %; n = 13) expected
to take diabetes medications for the rest of their lives, and
37 % of participants (n = 22) expected to take their
hypertension medications for the rest of their lives. These
participants expressed low self-efficacy in the ability to
change their lifestyles, and believed that their diseases
BI lost a lot of weight in the last months so I was thinking maybe
that’s enough to get me off the [high blood pressure] pills.^ -#1307
BAbout 3 years…I’ve been doing it right and I check it every day.^ -#331
BI have a very good physician that’s helping and directing me.^ -#716
BWell, as long as I do good I figure I will be off of it, but if I don’t,
I’m going to take it for the rest of my life.^ -#619
B[Diabetes] can be controlled. I know as long as I get it under control
I will be okay.^ -#2025
BI heard that you can get off the pills…I would have to discuss that
with the doctor to see when.^ -#882
BWhenever all these crazy folks in my family quit stressing me out.^
BI think I would probably say as soon as they find a cure.^ -#453
BI was told that type 2 is not curable.^ -#920
BEveryone tells me if I get under 200 lbs I can stop taking [the high
blood pressure medicine]. I’ve been trying for 10 years to get under
200 lbs.^ -#624
BMy mother has been taking [high blood pressure pills] for a long time…my
sister did the same thing, so I don’t think there [are] any changes
for me.^ -#841
BBecause my doctor told me about the benefits of lisinopril for kidney
were not curable in general, and pointed to their family
histories of diabetes and hypertension as evidence that
their own diseases were not curable.
Expectations for Future Treatment
About 85 % of participants (n = 51) expected that they
would not need additional oral diabetes medications or
insulin (n = 52) in the future. Similarly, 93 % of
participants (n = 56) expected that they would not need
additional hypertension medications in the future. These
participants explained that improving their lifestyle and
adopting healthier behaviors would prevent them from
needing additional medications, and stated that the
diseases were currently under good control (Table 2).
Fewer than three participants each were unsure whether
they would need additional diabetes or hypertension
medications in the future (oral diabetes medications: n = 2,
insulin: n = 1, hypertension medications: n = 1). They
expressed uncertainty as to their ability to improve their
lifestyles and considered external factors like the
possibility of scientific advancements and their doctors’ opinions.
Some participants (oral diabetes medication: n = 7,
insulin n = 7, hypertension medication: n = 3) believed that
they would need additional diabetes or hypertension
medications in the future. They stated that their current level
of control was poor and that they doubted their ability to
improve their lifestyles, and thus expected their diseases
to worsen in the future.
Expectations for Being Cured of Diabetes and Hypertension
Nearly two-thirds of participants (65 %; n = 39) believed that
their diabetes could be cured, compared to 58 % of participants
(n = 35) who believed that their hypertension could be cured.
These participants were confident in their ability to improve
their lifestyles and also attributed their expectations to
scientific advancements, good social and physician support, and
stress reduction (Table 3).
Over one-third of participants (35 %; n = 21) believed that
their diabetes could not be cured; 40 % of participants (n = 24)
believed that their hypertension could not be cured. These
participants emphasized that their conditions were chronic,
and thus could be successfully managed or controlled, but
not necessarily cured. In addition, they commented that their
family histories suggested that they could not be cured, and
that science may not find a cure in their lifetimes.
Preferences for Information About the Duration
of New Medications for Diabetes and
Nearly all participants (97 %; n = 58) stated that they would
want their provider to tell them how long they might need to
be on a new medication for diabetes or hypertension (Table 4).
Participants reported that this information would be Bgood to
know^ and that it would help them Bknow what to expect^
with regard to managing their condition. However, some
participants doubted that their doctors would have that kind
BI’m planning not to [need additional diabetes medications].
Because it’s a goal for me to control my weight and what
I eat.^ -#481
BBecause I don’t plan to take anymore. Well I’m not going to
take anymore. This is it. I’m never taking more.^ -#836
BI just need to improve my health overall.^ -#631
BI read a lot of scientific literature like a newsletter on diabetes
studies. As soon as there’s something that can get me off the
medication I will be first in line for it.^ -#728
BAs long as I have a reasonable doctor we’re okay.^ -#328
BAnd meditation, which may be more important than anything
else in my opinion.^ -#728
BI’m one of the early adopters of a new drug that’s had a
drug dramatic effect for me.^ -#728
BIt’s not been a good 6 months. The blood sugars and
A1Cs, instead of going down…they’re creeping.^ -#1648
BMy brother did this. Now he’s on insulin.^ -#624
BYes, because they started me on 500 mg. They upped me to
1000 mg, so if I don’t change my way I think yeah, I would
have to take more.^ -#624
B[My diabetes can be cured] through the diet… That’s why I think this
is going to go away.^ -#897
BIn the future they might find something to cure diabetes.^ -#152
BA good doctor tells you what you’re facing and he tells you good or
bad what’s going to happen.^ -#716
BWhen I had that motorcycle accident and lost that weight, it was cured.^ -#331
BNo stress. That’s the cure right there, no stress, no headaches, that’s all.^ -#518
BIf it’s caught early it can be undone…^ -#406
BI don’t think [high blood pressure] can be cured. It may get better, but it
might not get cured.^ -#502
BI’ve never known anyone that had it cured.^ -#741
BIt would be nice to think it would be cured in my lifetime, but I don’t believe
it will.^ -#661
BProbably not because my mother, my brothers and sisters has it. I mean
it’s like genetic.^ -#841
BAs I get older, you know, I know it takes longer and longer…to feel better,
so the same thing with high blood pressure.^ -#481
In this study of patients with diabetes for less than 10 years and
with hypertension, the majority expected that they would be
able to discontinue their diabetes and hypertension medications
in about 5 years, nearly all expected not needing additional
diabetes and hypertension medications, and the majority
thought that their conditions could be cured. Participants’
expectations were closely related to how certain they were that
they could achieve significant lifestyle changes. The minority of
participants who were less certain that they could stop
medications in the future were more likely to mention the influence of
external factors such as the opinions of their doctors, scientific
advancements, life stressors, and family history. Participants
also expressed a strong desire to know how long they would
need to take new diabetes and hypertension medications in
order to help them manage their expectations for these diseases.
Participant expectations for their diabetes and
hypertension were very inconsistent with the natural history of
diabetes and hypertension. Participants attributed their
beliefs to expectations that they could achieve significant
lifestyle changes. However, multiple studies3–5 suggest that
remission is rare and that the majority of patients with
diabetes and hypertension need to intensify medications
over time. An epidemiologic study of adults with type 2
diabetes found that less than 2 % achieved partial remission
(defined as two or more consecutive normoglycemic A1C
measurements over a period of at least 12 months) and less
than 1 % achieved prolonged remission (two or more
consecutive normoglycemic A1C measurements over a period
of at least 5 years) of diabetes.4 Higher rates of remission
were found in the Look AHEAD [Action for Health in
Diabetes] trial, which compared an intensive lifestyle
intervention to support and education (11.5 % at year 1 and
7.4 % at year 4 for the intervention arm, compared to
2.0 % at years 1 and 4 for the control arm).3 Similarly, for
hypertension, less than 10 % of participants in the
Framingham Heart Study discontinued their antihypertensive
medications and were normotensive after 2 years.5 Thus, while
remission of diabetes and hypertension is possible with
lifestyle changes, a large discrepancy remains between our
participants’ expectations and the clinical evidence.
Table 4 Themes and Representative Quotes: BBefore starting a new medication for your diabetes and hypertension, would you like your doctor
to tell you how long you’ll be on the medication? Why would you like to know that information?^ (N = 60)
The more information the better
It would help me with my decision-making
I would know what to expect with my diabetes
I doubt a doctor would know that information
I expect to take it forever anyway
BIt would tell me basically how serious my situation is, and I would
ask questions about what do I have to do to change this and try to
get all the information that I could.^ -#897
BIf you told me one way or the other, then that would be something
that I could try to figure out…and what I need to do to help
fix the problem.^ -#418
BWell, that will put me more at ease, when I know how long I’m
going to be taking this and what benefits I’ll be expecting.^ -#331
BYour doctor is not responsible for your health, you are.^ -#728
BI don’t think it would change anything; I would still take it.^ -#478
This discrepancy may be an important reason that many
patients are resistant to the idea of treatment intensification. In
the Translating Research Into Action for Diabetes (TRIAD)
study, one-quarter of the subjects who chose not to initiate
insulin reported that they instead planned to change their health
behaviors.27 While it is important to encourage individuals to
improve their health behaviors, providers should engage
patients in a realistic conversation regarding the magnitude of
changes in diet, exercise, and weight needed to appreciably
change the need for medication. Also, improving patient
understanding of the rarity of remission may be an important strategy
for reducing delays in treatment intensification.
A patient–provider conversation about patients’
expectations for the future of their conditions may help providers
manage these expectations. This conversation would involve
eliciting patient understanding of their diabetes and/or
hypertension, the course of treatment, likely outcomes, and role of
self-management. Providers could then focus on correcting
unreasonable expectations. The use of a Bteach-back^
technique, where patients repeat key points back to the provider,
who in turn corrects the key points until consensus is reached,
can help ensure understanding and retention.
One reason to believe that this strategy may be beneficial is
that participants in our study overwhelmingly reported that they
would want to hear about treatment durations for hypertension
and diabetes from their providers. Prior research has found that
patients respond positively to seeing medication regimens
presented as a planned sequence of intensification, and they
appreciate knowing what to expect in terms of their treatment.28
Providers should consider initiating discussions regarding the
importance of initiating, continuing, and intensifying therapy for
individuals with hypertension and diabetes early in the disease
course.17,27,29,30 Providing patients with information about the
rationale for medication intensification may help them anticipate
changes in their regimen, and thus be more receptive to them.28
However, having such discussions may be time-consuming,
since we also previously showed that among these participants,
about 40 % were less likely to start a diabetes medication if they
were informed of the medication’s time requirements, and the
estimated 10-year lag before the risk of complications is
reduced.22 Thus, decision support tools may be needed to properly
inform patients about the expected treatment duration and time
requirements for diabetes and hypertension medications.
This study has several limitations. First, it was a single-site
exploratory study of patients with diabetes and hypertension
on oral medications at an urban academic center. Thus, results
may not be generalizable to patients taking insulin or who
receive care in other settings. Second, we had a small sample
size, making it difficult to look at subgroups, though our study
was very large compared to most qualitative studies. Third, the
participants tended to be healthy, with well-controlled diabetes
and hypertension, so results may not be generalizable to
individuals with poorly controlled diabetes and hypertension.
Fourth, because the interviews were conducted in person,
there is the possibility of response bias, in that participants
may have wanted to appear more masterful and optimistic
about their expectations for their diseases. Fifth, we did not
ask patients what information they had previously received
about their diabetes and hypertension. To objectively ascertain
this information would likely require corroborating data from
providers, which was beyond the scope of this study.
In summary, we found that many participants with diabetes
and hypertension were expecting to discontinue their
current medications, most anticipated no future need to
intensify medications, and many expected to be cured from
these conditions. Our results highlight the need for
healthcare providers to deliver patient education about the natural
history of diabetes and hypertension treatment. Beliefs and
expectations about illness are mutable and are constantly
reconstructed based on individual experiences and acquired
knowledge. With education, individuals with diabetes and
hypertension can learn that they may require additional
medications as their diseases progress, enabling stronger
efforts towards lifestyle change, timely treatment
intensification, and reduced risk of complications. Future research
should investigate whether educating patients on the
natural history of diabetes and hypertension treatments can
improve the adoption of and adherence to medications,
without diminishing enthusiasm for lifestyle changes.
Contributors: The authors express gratitude to Demetra Gibson, MD,
MPH, Christina Leon, and Na Shin for their help in coding the
Prior Presentations: Ms. Fairchild presented this material at the 36th
Annual North American Meeting of the Society for Medical Decision
Making in Miami, Florida, in 2014.
Corresponding Author: Neda Laiteerapong, MD, MS; Department of
Medicine, Section of General Internal MedicineUniversity of Chicago,
5841 South Maryland Avenue, MC 2007, Chicago, IL 60637, USA
Compliance with Ethical Standards:
Funders: Dr. Laiteerapong is supported by a National Institute of
Diabetes and Digestive and Kidney Diseases (NIDDK) award K23
DK092783 and Dr. Huang is supported by NIDDK award K24
DK105340. Dr. Laiteerapong, Dr. Quinn, Dr. Huang, and Ms. Nathan
are members of the NIDDK Chicago Center for Diabetes Translation
Research (CCDTR) at the University of Chicago (P30 DK092949). This
research was supported by a CCDTR pilot grant and by the University
of Chicago Bucksbaum Institute for Clinical Excellence. Data were
organized using REDCap, which is supported by a National Institutes
of Health (NIH) Clinical and Translational Science Award (CTSA) UL1
TR000430. The funders had no role in the design or conduct of the
study; the collection, management, analysis, or interpretation of the
data; or the preparation, review, or approval of the manuscript.
Conflict of Interest: The authors declare that they have no conflict of
1. American Diabetes Association. Standards of Medical Care in Diabetes - 2015. Diabetes Care . 2015 ; 38 ( Suppl 1 ): 99 .
2. James PA , Oparil S , Carter BL , et al. 2014 evidence -based guideline for the management of high blood pressure in adults: report from the panel members appointed to the eighth Joint National Committee (JNC 8) . JAMA. 2014 ; 311 ( 5 ): 507 .
3. Gregg EW , Chen H , Wagenknecht LE , et al. Association of an intensive lifestyle intervention with remission of type 2 diabetes . JAMA . 2012 ; 308 ( 23 ): 2489 - 2496 .
4. Karter AJ , Nundy S , Parker MM , Moffet HH , Huang ES . Incidence of remission in adults with type 2 diabetes: the diabetes and aging study . Diabetes Care . 2014 ; 37 ( 12 ): 3188 - 3195 .
5. Dannenberg AL , Kannel WB . Remission of hypertension: the Bnatural^ history of blood pressure treatment in the Framingham Study . JAMA . 1987 ; 257 ( 11 ): 1477 - 1483 .
6. Turner RC , Cull CA , Frighi V , Holman RR , Group UPDSU. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49) . JAMA. 1999 ; 281 ( 21 ): 2005 - 2012 .
7. Stratton I , Manley S , Holman R. Hypertension in diabetes Study IV. Therapeutic requirements to maintain tight blood pressure control . Diabetologia . 1996 ; 39 ( 12 ): 1554 - 1561 .
8. Davis J , Chavez B , Juarez DT . Adjustments to diabetes medications in response to increases in hemoglobin a1c: an epidemiologic study . Ann Pharmacother . 2014 ; 48 ( 1 ): 41 - 47 .
9. Phillips LS , Branch WT , Cook CB , et al. Clinical inertia . Ann Intern Med . 2001 ; 135 ( 9 ): 825 - 834 .
10. Hicks PC , Westfall JM , Van Vorst RF , et al. Action or inaction? Decision making in patients with diabetes and elevated blood pressure in primary care . Diabetes Care . 2006 ; 29 ( 12 ): 2580 - 2585 .
11. Grant RW , Cagliero E , Dubey AK , et al. Clinical inertia in the management of Type 2 diabetes metabolic risk factors . Diabet Med . 2004 ; 21 ( 2 ): 150 - 155 .
12. Ziemer DC , Miller CD , Rhee MK , et al. Clinical inertia contributes to poor diabetes control in a primary care setting . Diabetes Educ . 2005 ; 31 ( 4 ): 564 - 571 .
13. Lafata J , Dobie E , Divine G , Ulcickas Yood M , McCarthy B . Sustained hyperglycemia among patients with diabetes: what matters when action is needed? Diabetes Care . 2009 ; 32 ( 8 ): 1447 - 1452 .
14. Marshall IJ , Wolfe CDA , McKevitt C . Lay perspectives on hypertension and drug adherence: systematic review of qualitative research . BMJ . 2012 ; 345 : e3953 - e3953 .
15. Kronish IM , Leventhal H , Horowitz CR . Understanding minority patients' beliefs about hypertension to reduce gaps in communication between patients and clinicians . J Clin Hypertens (Greenwich) . 2012 ; 14 ( 1 ): 38 - 44 .
16. Saver BG , Mazor KM , Hargraves JL , Hayes M. Inaccurate risk perceptions and individualized risk estimates by patients with type 2 diabetes . J Am Board Fam Med . 2014 ; 27 ( 4 ): 510 - 519 .
17. Strain WD , Cos X , Hirst M , et al. Time to do more: addressing clinical inertia in the management of type 2 diabetes mellitus . Diabetes Res Clin Pract . 2014 ; 105 ( 3 ): 302 - 312 .
18. Ratanawongsa N , Crosson JC , Schillinger D , Karter AJ , Saha CK , Marrero DG . Getting under the skin of clinical inertia in insulin initiation: the Translating Research Into Action for Diabetes (TRIAD) Insulin Starts Project . Diabetes Educ . 2012 ; 38 ( 1 ): 94 - 100 .
19. Ogedegbe G , Mancuso CA , Allegrante JP . Expectations of blood pressure management in hypertensive African-American patients: a qualitative study . J Natl Med Assoc . 2004 ; 96 ( 4 ): 442 - 449 .
20. Mann DM , Ponieman D , Leventhal H , Halm EA . Misconceptions about diabetes and its management among low-income minorities with diabetes . Diabetes Care . 2009 ; 32 ( 4 ): 591 - 593 .
21. Kravitz RL . Measuring patients' expectations and requests . Ann Intern Med . 2001 ; 134 ( 9 Pt 2 ): 881 - 888 .
22. Laiteerapong N , Fairchild PC , Nathan AG , Quinn MT , Huang ES . How information about the time requirements and legacy effects of treatments influence decision making in patients with diabetes and hypertension . BMJ Open Diabetes Res Care. Accepted 2016 .
23. Roccaforte WH , Burke WJ , Bayer BL , Wengel SP . Validation of a telephone version of the mini-mental state examination . J Am Geriatr Soc . 1992 ; 40 ( 7 ): 697 - 702 .
24. Patton M. Designing Qualitative Studies: Purposeful Sampling. Qualitative evaluation and research methods . Beverly Hills, CA: Sage; 1990 : 169 - 186 .
25. Harris PA , Taylor R , Thielke R , Payne J , Gonzalez N , Conde JG . Research electronic data capture (REDCap) - A metadata-drive methodology and workflow process for providing translational research informatics support . J Biomed Inform . 2009 ; 42 ( 2 ): 377 - 381 .
26. Silverman , D. Doing Qualitative Research: A Practical Handbook , 2nd ed. London, UK: Sage Publications, LTD; 1999 : 456 .
27. Karter AJ , Subramanian U , Saha C , et al. Barriers to insulin initiation: the translating research into action for diabetes insulin starts project . Diabetes Care . 2010 ; 33 ( 4 ): 733 - 735 .
28. Grant RW , Pabon-Nau L , Ross KM , Youatt EJ , Pandiscio JC , Park ER . Diabetes oral medication initiation and intensification: patient views compared with current treatment guidelines . Diabetes Educ . 2011 ; 37 ( 1 ): 78 - 84 .
29. Ross SA . Breaking down patient and physician barriers to optimize glycemic control in type 2 diabetes . Am J Med . 2013 ; 126 ( 9 Suppl 1 ): S38 - 48 .
30. Moser M. Physician or clinical inertia: what is it? Is it really a problem? And what can be done about it ? J Clin Hypertens (Greenwich) . 2009 ; 11 ( 1 ): 1 - 4 .