This study provides valuable insights into the perspectives of patients, physicians and payers regarding basal insulin therapy and the introduction of weekly basal insulins. The results underscore the distinct and overlapping priorities and concerns among key stakeholders, highlighting opportunities for advancing diabetes care. This agrees with prior experience showing that an inclusive, stakeholder-engaged approach ensures that diverse perspectives are integrated to compare strategies for diabetes management [21].

Notably, patients’ satisfaction with current basal insulin regimens was modest, with lower satisfaction observed among those with T2D compared to T1D. This difference is not backed by literature data: in a real-world study evaluating the switch to degludec, the baseline satisfaction with regards to their prior basal insulin regimen was similar between participants with T1D and T2D [22]. The discrepancy may be partially explained by differences in age, diabetes duration and treatment experience, as older individuals with longer disease duration, typical of T2D populations, may encounter more challenges in self-management. As demonstrated before in an observational Italian study [23], fear of hypoglycaemia remains as a dominant concern for both T1D and T2D, indicating the need for therapies that minimize this risk while maintaining efficacy. Interestingly, the reduction in injection frequency offered by weekly basal insulin was a highly valued benefit [24], particularly among insulin-treated patients with T2D, likely because they have experienced the burden of insulin therapy on top of a non-insulin regimen. The evolution of glucagon-like peptide 1 receptor agonist (GLP-1RA) therapy has already offered an opportunity to appreciate patients’ preferences for once-weekly oral versus once-daily injectable medications [25]. In the case of insulin, however, concerns about the single administration of a high number of units and about hypoglycaemia risk highlight the importance of comprehensive patient education and support for transitioning to such new basal insulin. There was a clear patient focus on independence and maintaining personal and professional freedom, suggesting that the adoption of weekly insulin is expected by patients to improve quality of life, particularly for insulin-experienced individuals.

From the physician standpoint, initiating basal insulin therapy in T2D was strongly driven by glycaemic control goals. Non-glycaemic benefits such as preventing microvascular complications were also valued, while improving patient quality of life ranked lower. Such a low prioritization of improving patients’ quality of life as a driver of basal insulin initiation was observed, striking when viewed in the context of the American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) consensus document, which emphasizes a patient-centred approach to holistic diabetes management [26]. The consensus advocates for treatment strategies that not only achieve glycaemic targets but also consider patient preferences, psychosocial well-being and quality of life. This divergence between guidelines and physician priorities may reflect the emphasis on metrics of treatment success relying on measurable targets for assessing glycaemic efficacy. However, this approach may inadvertently overlook the importance of factors related to quality of life, such as reduced treatment burden, flexibility in self-management and minimizing hypoglycaemia-related anxiety, which are highly valued by patients [27]. The existence of a discrepancy between patients and physicians in the evaluation of general and diabetes-related quality of life was reported before [28]. Here, we extend that concept to the priorities in evaluating new diabetes medications. These discrepancies highlight the need for increased awareness and training among healthcare providers to integrate quality of life considerations into decision-making, in line with the recommendations by scientific societies.

Challenges perceived by physicians, including concerns about weight gain, hypoglycaemia and the daily injection burden, aligned with patient-reported barriers. However, the importance placed on educational initiatives and technological tools to support patients underscores a recognition of the psychosocial and practical aspects influencing adherence. The enthusiasm for weekly basal insulin was also especially related to its potential to improve adherence and reduce injection-related issues. On the other hand, some uncertainty regarding clinical efficacy, hypoglycaemia risk and cost-effectiveness underscores the need for robust evidence in support of its implementation in clinical practice.

Payers prioritized HbA1c improvement and hypoglycaemia avoidance as major goals of basal insulin therapy, but also recognized the significance of reducing injection frequency and enhancing quality of life. This broader view, including the environmental impact of fewer injections, reflects an alignment with healthcare sustainability goals. However, concerns about cost and the need for patient education indicate that while payers acknowledge the potential benefits of weekly basal insulin, these must be balanced against economic and practical challenges. Cost-justification analysis should therefore emphasize quality of life improvements and adherence gains as central to the value proposition of weekly insulin. Simulations for cost–utility analysis have been performed for the treatment of patients with T2D in China, leading to the estimation of reasonable cost ranges for icodec, when compared to glargine or degludec [23, 29]. Furthermore, a multi-country analysis of injectable therapies for obesity and T2D has estimated the disutility associated with once-daily versus once-weekly administration [30]. It is noteworthy that a recent economic evaluation from the Italian NHS perspective revealed that once-weekly icodec, at an annual cost 25% higher than degludec, grants no incremental cost and even potential savings per patient, considering the economic benefits generated by the needle use reduction and adherence improvement [31].

Upon a qualitative comparison of the reports from the different survey respondents, we note a considerable convergence in the recognition of hypoglycaemia avoidance, adherence improvement and quality of life as critical factors across stakeholders. However, divergence exists in the prioritization of such objectives, with physicians and payers focusing on clinical and economic outcomes, while patients emphasize independence and convenience. This divergence emphasizes the need for a multidimensional approach to introducing weekly basal insulin, addressing not only clinical and cost concerns but also patient-centred outcomes.

These considerations have implications for the adoption of weekly basal insulin in clinical practice. Indeed, the willingness of patients and physicians to consider weekly basal insulin is encouraging, but its success will depend on addressing some outstanding concerns that have emerged in the literature [32] and in our survey. First, education and support programs will need to address patient and physician concerns about single high-dose administration and hypoglycaemia risk in various situations. Second, the generation of robust real-world evidence would complement data from trials in the efficacy, safety and cost-effectiveness relative of weekly basal insulin compared to daily insulin in the free-living conditions of routine care. Finally, it will be important to collaborate with payers to develop pricing strategies that reflect the broader benefits of weekly basal insulin, incorporating patient-centred aspects such as reduced injection burden and improved adherence.

In view of these differences in stakeholder perspectives, it should be noted that the slower implementation of new treatment options often stems from the need to gather sufficient real-world evidence addressing these multifaceted considerations. For instance, even if a new treatment offers a clear advantage in one domain (such as convenience), concerns about potential risks, long-term outcomes, or cost-effectiveness may slow its adoption. This multidimensional decision-making process has an inherent trade-off that stakeholders must consider before integrating weekly basal insulin into routine practice. Additionally, we wish to emphasize the need for further evidence and education to ensure that the benefits of reduced injection burden do not come at the expense of other critical treatment goals.

We wish to acknowledge limitations of this study. This report relied on self-reported data, which may introduce biases, particularly regarding demographic and clinical characteristics. The lack of NHS data integration and reliance on an online survey format may limit generalizability. A similar concern may arise from the fact that most physicians were recruited in the hospital setting or a diabetes clinic, rather than in a primary care context. Regarding the interpretation of payers’ responses, it should be underlined that we do not have evidence that all respondents had a direct or indirect decision-making role in financing or reimbursing medicines, but some of them could only be involved in the supply of drugs and/or in monitoring costs. Furthermore, the questionnaire was not validated with a standard methodology, implying that its internal and external validity have to be considered critically. The use of a limited set of survey questions, somewhat arbitrarily selected by the board, represents an inherent limitation of the methodology. While the focused approach allowed for concise and efficient data collection across multiple stakeholders, it may have constrained the depth and breadth of insights obtained. Specifically, the choice of questions may reflect the perspectives and priorities of the board rather than being informed by a broader consensus or validated frameworks. This limitation raises the possibility of omitted areas that could have provided valuable context or alternative viewpoints, such as psychosocial dimensions, cultural considerations, or barriers unique to underrepresented groups. The lack of open-ended questions restricted participants’ ability to freely elaborate on their experiences, potentially limiting the richness of the data. Future endeavours should focus on physicians from other specialities as well as on general practitioners, to provide a more comprehensive view of physicians’ perspectives on weekly insulin treatment.

The major strength of the study is its multi-stakeholder perspective, providing a comprehensive view of basal insulin therapy and the potential impact of weekly basal insulin from diverse but interconnected perspectives. Sample size was large, allowing one to address different populations of patients, physicians with different specialties and payers with different backgrounds. The use of structured questionnaires with quantitative scales ensures consistency and facilitates the aggregation of data across stakeholder groups.