Multiple implementation methods can assist primary care practices in using CGM

• Virtual CGM initiation services are appropriate for primary care practices.
• Virtual CGM implementation was chosen by clinics that did not have diabetes care and education specialists.

According to the two speakers, primary care practices can effectively implement continuous glucose monitoring for their diabetic patients by using the American Academy of Family Medicine’s resources or virtual CGM initiation services.

PCPs are less likely to be trained in the use of CGM than endocrinologists. Bonnie T. Hjortberg, Ph.D., RDN, CDCES; Lack of training could mean that CGMs aren't being used by diabetes patients who are being treated by their primary care physician, said Jortberg, an associate professor in the department of family medicine, associate director of clinical innovation programs and director of e-learning at the University of Colorado Anschutz Medical Campus. Because CGMs play a larger role in diabetes care today, it's crucial that primary care physicians find ways to introduce the devices, Jortberg said in a presentation at the annual meeting of the Association of Diabetes Care Education Professionals.

“Primary care has an opportunity to reach more diabetes patients, especially in rural areas of the United States where endocrinologists are scarce,” Jordberg told Healio. “There's a trusting relationship between patients and primary care clinics, and I think that's an ideal environment to promote 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 to initiate CGM therapy for referred patients, train them on its use, optimize device settings, and inform treatment recommendations. The other 46 practices used the American Academy of Family Physicians' Treatment Transformation Series (TIPS) resources to implement CGM. The 46 practices using TIPS were randomly assigned 1:1 to use TIPS recommendations along with specialized practice facilitation services to help implement the guidance or to use TIPS alone without any additional services.

“We chose three different strategies for CGM implementation for several reasons.” Sean M. Osar, MD, MPH, CDCES; Jonathan Myers, associate professor in the Department of Family Medicine, director of the Practice Innovation Program, and associate director of the Primary Care Diabetes Institute at the University of Colorado Anschutz Medical Campus, told Healio, “First, we know that PCPs can be very different, and choice is always helpful. In particular, differences in practice factors may make one approach seem more feasible than another. We also wanted to ensure that all practices could experience the CGM implementation effort, so even the most low-effort strategy is possible for CGM implementation in this study. We also wanted to incorporate an element of randomization to achieve a particularly high level of rigor in this study, so we needed to offer three strategies when allowing both choice and randomization.”

The researchers assessed practice management and demographic factors across clinics to examine their association with the choice to implement CGM. Clinics with diabetes care and education specialists on staff were more likely to choose the TIPS intervention than virtual CGM clinics (X² = 11.05; P < .001). Of the clinics that chose to use TIPS, 35% had diabetes care and education specialists on staff compared to 0% of clinics that chose to implement virtual CGM. Of the 60 clinics that did not have diabetes care and education specialists on staff, half chose to use a TIPS implementation program and the other half chose a virtual implementation.

No other factors were associated with clinics' choice to implement CGM.

“We found that diabetes care and education specialists play a vital role in primary care,” Ozer said during the presentation, “and that was the only predictor of which implementation pathway would be chosen. [of primary care practices] “There is an exciting opportunity here to demonstrate the value that diabetes care and education experts can bring to primary care clinical practice.”

Ozer said virtual CGM services may be ideal for clinics that don't have diabetes care and education specialists on-site. Clinics in the virtual arm referred 193 patients to the virtual clinic. Of those patients, 99 enrolled and 94 completed the clinic. Ozer said preliminary results showed improvements in all CGM metrics for people referred to the virtual CGM clinic.

“In retrospect, I'm glad we were able to provide multiple ways to do this, because there's no one size fits all,” Ozer said.

Educating PCPs about CGM was key to the success of the virtual arm, according to Ozer: For the intervention to work, virtual staff must teach clinics the indications for CGM use, how to interpret CGM data, and how to enter the data into electronic health records, Ozer said.

“Implementing the virtual service arm of this study was an opportunity to test a new way to help primary care providers start CGM on their patients, while also receiving information about how they can start CGM in their own practices,” Jortberg told Healio.

One of the biggest challenges the researchers faced was getting approval to prescribe a personal CGM, according to Hjortberg. He said healthcare organizations that use the TIPS recommendations have struggled with the approval process and reforms are needed to make the process easier.

Rather than jumping right into using personal CGMs, Hjortberg suggested having patients start by using a professional CGM owned by the practice, which he said rarely requires insurance approval and can be purchased at a low cost.

“This has really turned out to be a win-win situation for both the healthcare organization and the patient,” Jordberg said.

The data presented by Hjortberg and Osel is preliminary, with a final analysis expected in early 2025. But both presenters said they were encouraged by the study's early results.

“Our early experience is that all three implementation strategies work to advance CGM adoption in primary care,” Osel told Healio. “In the coming months, we plan to analyze which strategy is more effective, how effective they are, and the relative economics of each strategy.”