Multiple implementation methods can assist primary care practices with CGM use
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Key takeaways:
- A virtual CGM initiation service is feasible for primary care practices.
- Virtual CGM implementation was chosen by practices that did not have a diabetes care and education specialist.
Primary care practices can successfully implement continuous glucose monitoring for patients with diabetes by using American Academy of Family Physicians resources or a virtual CGM initiation service, according to two speakers.
PCPs tend to have less training on CGM use than endocrinologists, according to Bonnie T. Jortberg, PhD, RDN, CDCES, associate professor in the department of family medicine, associate director of practice innovation program and director of eLearning at the University of Colorado Anschutz Medical Campus. She said the lack of training could lead to CGM not being used for people with diabetes who receive care from a PCP. With CGM playing a greater role in diabetes care today, it is crucial for PCPs to discover ways to implement the devices, Jortberg said during a presentation at the Association of Diabetes Care and Education Specialists annual meeting.
“Primary care has an opportunity to reach many more patients with diabetes, particularly in rural areas of the U.S. where endocrinologists are rare,” Jortberg told Healio. “I also think there’s trust between patients and their primary care practices, which is an ideal environment for encouraging CGM use.”
In the PREPARE 4 CGM study, 76 PCPs in Colorado participated in one of three interventions. Thirty practices chose to implement CGM using a virtual program that included a one-time CGM webinar and a virtual clinic that would start CGM therapy for the referred patients, train them on how to use it, optimize the device settings and inform treatment recommendations. The other 46 practices used the American Academy of Family Physicians’ Transformation in Practice Series (TIPS) resources for implementing CGM. The 46 practices using TIPS were randomly assigned, 1:1, to use TIPS recommendations plus receive professional practice facilitation services to help implement the guidance, or use TIPS alone without additional services.
“We chose three different strategies for CGM implementation for several reasons,” Sean M. Oser, MD, MPH, CDCES, associate professor in the department of family medicine, director of practice innovation program, and associate director of the primary care diabetes lab at the University of Colorado Anschutz Medical Campus, told Healio. “First, we know that PCPs can be very different from one another and that choice is always helpful, especially since different practice factors might make one approach seem more feasible than another. We also wanted to make sure that all practices were able to experience a CGM implementation effort, so even the lowest-touch strategy in the study still offers CGM implementation. We also wanted there to be a randomized element to allow especially high rigor in the study, so if allowing both choice and randomization, we needed three strategies to offer.”
Diabetes educators crucial in CGM initiation
Researchers assessed practice management and demographic factors among practices to examine associations with choice of CGM implementation. Practices who had a diabetes care and education specialist on staff were more likely to choose the TIPS intervention over the virtual CGM clinic (X2 = 11.05; P < .001). Of the practices that chose to use TIPS, 35% had a diabetes care and education specialist on staff compared with 0% of those choosing the virtual CGM implementation. Among 60 practices without a diabetes care and education specialist on staff, half chose to use the TIPS implementation program and half opted for virtual implementation.
No other factors were associated with a practice’s choice of CGM implementation.
“We learned that the diabetes care and education specialist plays a pivotal role in primary care,” Oser said during the presentation. “It was the only predictor of which implementation path would be chosen. We know that only 36% [of primary care practices] have one and there’s this great opportunity to demonstrate the value of the diabetes care and education specialist to clinical practice in primary care.”
Virtual CGM implementation feasible
Oser said virtual CGM services may be best for practices who do not have a diabetes care and education specialist available. The practices in the virtual arm referred 193 patients to the virtual clinic. Of those patients, 99 were enrolled and 94 completed the clinic. Oser said preliminary results revealed improvements in all CGM metrics among people referred to the virtual CGM clinic.
“We are glad, in hindsight, that we offered multiple methods to do this, because one size does not fit all,” Oser said.
Educating PCPs about CGM was key to the success of the virtual arm, according to Oser. For the intervention to work, Oser said, the virtual staff needs to teach practices about indications for CGM use, how to interpret CGM data and how to put data into the electronic health record.
“Implementing the virtual service arm of the study was also an opportunity to test a novel method for helping primary care initiate CGM with their patients while still receiving information about how they could initiate CGM in their own practices,” Jortberg told Healio.
Consider using professional CGM
One of the biggest challenges researchers faced was getting prescription authorization for personal CGM, according to Jortberg. She said practices using TIPS recommendations struggled with the authorization process, and reforms are needed to make the process easier.
Instead of starting immediately with personal CGM, Jortberg suggested practices start patients with a professional CGM that is owned by the practice. She said professional CGMs require little or no insurance authorization and can be purchased for a low cost.
“This turned out to be a real win-win situation for both the practices and the patients,” Jortberg said.
The data Jortberg and Oser presented was preliminary, and a final analysis is expected in early 2025. However, both presenters said they were encouraged with the early findings of the study.
“Our early experience is that all three implementation strategies work and increase CGM implementation in primary care,” Oser told Healio. “What remains to be seen is if one strategy is more effective, and how much so, as well as the relative economics of the strategies, all of which we have planned in our analysis in the coming months.”
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Jortberg B, et al. Abstract D08C. Presented at: ADCES24; Aug, 9-12, 2024; New Orleans.
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