Primary care practices' choice of implementation strategy for continuous glucose monitoring for patients with diabetes: a multiple methods study within a larger hybrid type-3 effectiveness-implementation study

Abstract

Background: Most diabetes care occurs in primary care. Continuous glucose monitoring (CGM) is associated with clinical, behavioral, and psychosocial benefits. While CGM uptake in primary care is increasing, understanding models to support CGM use in diverse primary care practices is needed. The PREPARE 4 CGM study evaluated strategies to implement CGM in primary care. We compared characteristics among practices choosing a practice-led, self-paced CGM implementation strategy or referral to a virtual CGM implementation service that provided patients and their referring primary care practices CGM initiation and data interpretation support for at least six months.

Methods: Colorado PC practices interested in implementing CGM enrolled and chose to use the American Academy of Family Physicians Transformation in Practice Series (TIPS): CGM implementation modules or refer patients to a virtual CGM initiation and education service designed and staffed by a primary care multi-disciplinary team. In this multiple methods study, baseline practice characteristics were compared across study arms using chi-square and t-tests. Semi-structured interviews with practice members provided additional context to explain study arm selection.

Results: Of 76 practices enrolled, 46 chose self-paced implementation using TIPS modules, 16 of which (35%) had a diabetes care and education specialist (DCES) in the practice; of the 30 that chose the virtual CGM initiation service, none (0%) had a DCES, X²(1, N = 62) = 11.046, p <.001. Aside from having a DCES, no differences in 37 other practice characteristics were seen between groups.

Conclusions: Primary care practices were eager to implement CGM. All practices with a DCES chose to implement CGM on their own; of the practices without a DCES, implementation method selection was evenly split (half chose to implement on their own, half chose virCIS). DCESs may have potential as diabetes technology champions in primary care practices. Referral to the virtual CGM implementation service allowed access to a certified DCES and multidisciplinary team for practices without them. As many practices without a DCES also chose to implement CGM on their own, multiple models may be necessary to foster CGM implementation in primary care.

Trial registration: This project was reviewed and approved by the Colorado Multiple Institutional Review Board (COMIRB; Protocol 21-4269) and registered with ClinicalTrials.gov on March 23, 2022 (NCT05336214).

Keywords: Continuous glucose monitoring; Diabetes education and care specialist; Diabetes mellitus, type 1; Diabetes mellitus, type 2; Diabetes technology; Primary health care; Wearable electronic devices.