The Guidelines Moved Faster Than Prescribing Did

Clinical guidelines can change quickly, but prescribing habits often take longer to follow. A new Medicare study highlights the gap between diabetes treatment guidelines and real-world prescribing, particularly for medications that protect the heart and kidneys. Researchers found that SGLT2 inhibitor prescribing improved after updated recommendations, while gains for GLP-1 receptor agonists were smaller. The findings raise an important question: If the evidence is strong, why does treatment adoption remain uneven? The answer involves more than physician knowledge. Medication costs, insurance coverage, clinical workflows, and patient preferences all influence whether recommended treatments reach patients.

Table of Contents

1. What the Medicare Study Revealed About Diabetes Prescribing
2. Why Diabetes Prescribing Still Lags Behind Guidelines
3. Closing the Gap Between Evidence and Clinical Practice
4. What the Findings Mean for Diabetes Care
5. Conclusion
6. Frequently Asked Questions

What the Medicare Study Revealed About Diabetes Prescribing

A study published October 27, 2026, in JAMA Network Open examined prescribing patterns among 177,284 Medicare beneficiaries with type 2 diabetes. The patients received care from 1,061 endocrinologists who later participated in the American Board of Internal Medicine's Longitudinal Knowledge Assessment program.

Researchers analyzed Medicare claims from 2017 through 2022, focusing on changes following the American Diabetes Association's 2019 guideline update. These recommendations emphasized SGLT2 inhibitors and GLP-1 receptor agonists for appropriate patients with cardiovascular disease, heart failure, or chronic kidney disease.

The results showed meaningful but unequal progress. Between 2018 and 2022, adjusted SGLT2 inhibitor fill rates increased by 11.4 percentage points more among guideline-targeted patients than among patients outside those target groups. In contrast, the corresponding difference for GLP-1 receptor agonists was only 2.4 percentage points.

Importantly, these figures represent differences in changes between patient groups, not overall prescribing rates.

The study also examined physician knowledge scores. Patients treated by endocrinologists in the highest knowledge-score quartile experienced an additional 3.9-percentage-point increase in the relative SGLT2 inhibitor fill rate compared with those treated by physicians in the lowest quartile.

However, the association between physician knowledge and GLP-1 prescribing changes was not statistically significant.

These findings suggest that clinicians who stay current with diabetes treatment recommendations may be more likely to prescribe certain evidence-based therapies. Nevertheless, the observational study cannot establish that physician knowledge scores or guideline changes directly caused the prescribing improvements.

Why Diabetes Prescribing Still Lags Behind Guidelines

Clinical recommendations increasingly emphasize preventing complications rather than focusing only on blood glucose levels. However, translating that shift into everyday practice requires overcoming several barriers.

Medication Costs and Insurance Restrictions

SGLT2 inhibitors such as Jardiance (empagliflozin) and Farxiga (dapagliflozin) offer demonstrated benefits for selected patients with type 2 diabetes and cardiovascular or kidney disease.

Similarly, GLP-1 receptor agonists such as Ozempic (semaglutide) and Trulicity (dulaglutide) can improve glycemic control and provide additional benefits in appropriate populations.

Yet affordability can determine whether patients start or continue treatment. Insurance formularies, prior authorization requirements, copayments, and coverage limitations may complicate access.

For Medicare beneficiaries managing several chronic illnesses, even modest out-of-pocket costs can create difficult choices. In addition, patients may abandon prescriptions when pharmacy costs exceed their expectations.

Therefore, an appropriate clinical recommendation does not always translate into a filled prescription.

Clinical Workflow and Patient Preferences

Busy clinical practices also face challenges identifying patients who qualify for newer therapies. Electronic health records may not clearly highlight cardiovascular risk, kidney function, or treatment eligibility during routine appointments.

Moreover, clinicians must consider potential adverse effects, existing medications, frailty, and individual treatment goals.

Some patients prefer oral medication over injections. Others worry about gastrointestinal symptoms, genital infections, dehydration, or changes to established routines.

These concerns deserve careful discussion rather than automatic dismissal.

For example, Diabetes in Control's coverage of early SGLT2 inhibitor and GLP-1 receptor agonist treatment explores the importance of balancing cardiovascular benefits against individual treatment considerations.

As a result, prescribing decisions reflect a combination of medical evidence, practical barriers, and shared decision-making.

Closing the Gap Between Evidence and Clinical Practice

Improving guideline-concordant diabetes prescribing requires healthcare systems to address barriers that go beyond simply knowing the latest recommendations.

The ADA Standards of Care in Diabetes 2026 recommend SGLT2 inhibitors and/or GLP-1 receptor agonists with proven benefits for appropriate high-risk patients, regardless of whether additional glucose lowering is needed.

Consequently, treatment reviews should consider cardiovascular and kidney risks alongside A1C results.

Electronic health record alerts could help clinicians identify eligible patients with heart failure, chronic kidney disease, or established cardiovascular disease. Additionally, pharmacists and diabetes educators can help address medication access, safety concerns, and adherence challenges.

Healthcare teams can also review prescribing patterns to identify missed opportunities.

However, performance measures should distinguish avoidable treatment gaps from appropriate decisions based on contraindications, adverse effects, or informed patient preferences.

The study's findings suggest that continuing medical education remains valuable. Still, education works best when paired with practical systems that make evidence-based treatment easier to deliver.

What the Findings Mean for Diabetes Care

The Medicare study reinforces an important distinction between publishing recommendations and implementing them successfully.

Although SGLT2 inhibitor adoption improved, GLP-1 prescribing showed a smaller relative response to updated guidelines.

Furthermore, the study measured prescription fills rather than confirmed medication use or improved patient outcomes. Its findings also reflect traditional Medicare beneficiaries treated by participating endocrinologists, limiting how broadly they can be applied.

For clinicians, the practical message is clear. Following current diabetes treatment guidelines means reviewing medications regularly, considering cardiovascular and kidney protection, and discussing potential barriers with patients.

Ultimately, better implementation depends on aligning clinical evidence with what patients can safely obtain, afford, and sustain.

Conclusion

The latest Medicare evidence shows that diabetes prescribing patterns can respond to updated clinical guidelines, but progress remains uneven.

While stronger physician knowledge was associated with greater SGLT2 inhibitor uptake, knowledge alone cannot explain every prescribing decision.

Addressing cost, access, workflow limitations, and patient preferences may help healthcare teams close the gap between recommended treatment and real-world care.

Frequently Asked Questions

What Does Guideline-Concordant Prescribing Mean in Diabetes Care?

It means selecting diabetes treatments that align with current evidence-based clinical guidelines while considering each patient's medical history, risks, and preferences.

Why Did SGLT2 Inhibitor Prescribing Increase After Guideline Updates?

The study found greater uptake among patients targeted by updated recommendations. However, its observational design cannot prove that the guidelines alone caused the increase.

Why Was GLP-1 Receptor Agonist Prescribing Growth Smaller?

The study did not establish a single cause. Potential influences include medication costs, insurance restrictions, tolerability, injection preferences, and clinical decision-making.

Does Physician Knowledge Influence Diabetes Prescribing?

Higher knowledge assessment scores were associated with larger relative increases in SGLT2 inhibitor fills. However, the corresponding GLP-1 association was not statistically significant.

How Can Healthcare Practices Improve Guideline Adherence?

Clinicians can review cardiovascular and kidney risks, strengthen medication reconciliation, improve patient education, and address insurance barriers. Shared decision-making remains essential.

This content is not medical advice. For any health issues, always consult a healthcare professional. In an emergency, call 911 or your local emergency services.