Table 2 Selected excerpts from qualitative data by theme

Patient gender

“And the statins, I was never really comfortable with the under forties. We have a lot of thirty-four year old women that you guys want me to put on an ACE or a statin. And I’m just not going to do it, because they're going to end up pregnant on two class X medications.” (MD)

“Well, I talk to them about birth control, and if they’re on. A lot of them have had their tubes tied, so then I, you know, go ahead and prescribe it if they’re willing to take it. And then some of them are pretty unreliable with their methods, or questionable. So then I, you know, talk to them, try to get them on more reliable birth control. And then … if they’re willing to do that, then, you know, I’m willing to do it.” (MD)

Prior prescriptions

“I find that a fair number of my patients do have side effects to Statins and we just can’t find one that doesn’t cause them myalgias.” (NP)

“I mean, it varies. But yeah, usually they [patient] don’t want to try another one [if have side effects].” (NP)

Provider type

“… I think historically NPs are really good at following guidelines. … Ultimately it’s going to be like, okay, well, if the … Board of Physicians has decided that this is what should be done, I’m probably going to follow it. I think there’s something about the hierarchy of education level and training.” (NP)

“… I’ve practiced long enough to have known lots of MDs who are guideline resistant. You know, in terms of telling me how I have to practice kind of thing.” (MD)

Primary care provider

"I’m not going to manage somebody’s diabetic. If you’re a diabetic you need a home.” (MD)

Competing needs

“… these are fifteen minute appointments. When someone has a migraine you’re not going to be like, so enough about the migraine. Like what’s up with your insulin, you know? So I think that so many of our patients come here for acute pain needs, that this stuff is all overlooked.” (RN)

“If I have a new diabetic I talk to them … [about] the fact that there are all sorts of recommendations about medications that we use to treat not only the blood sugar, but also to help prevent complications of it. And if we put you on every medicine that’s recommended you’d walk out of here and you’d have a … shopping bag full. And I say, but that’s not where we’re going to start. … I do it piecemeal. It’s so overwhelming otherwise, I think.” (MD)

Concurrent medications

… shared that her Russian patients do not like pills as a general rule and are highly resistant to multiple meds. In their culture, they have an old saying: "You treat one and kill the other one…. [RN] told me that this thinking is pervasive in their culture, so many patients refuse preventive meds completely … this is a real problem for her patients who … are already taking an anti-glycemic agent … will refuse any other meds because one should be enough. (observation field note)

Wonders if there are any meds we can suspend or discontinue, she is feeling burdened with the amount of pill she takes … PLAN: continue ACEi … suspend statin today to reduce pill burden. (PA encounter notes from patient chart)

Changing guidelines

“Which is was a little unclear to me around, like if I have like a nineteen year old, you know, should I put them on a statin? And then that changed even more recently with the AHA Guidelines. And so to me it felt like a moving target.” (Resident)

“[W]hat was the age cut off again? You know, it's like those things change over time. Was it forty, was it fifty? … how many other risks do they have to have before I put them on this medicine, you know?” (RN)

Patient age

"And you're twenty-seven years old, and I'm going to make you take a bunch of pills for the rest of your life. It's hard … I feel much better about doing it for middle-aged people with bad diabetes." (NP)

“I’m not convinced that by putting someone on a tiny dose of an ACE it’s going to really reduce their cardiovascular risk if they’ve only had diabetes for two years and they’re less than fifty.” (MD)