Diabetes technology has ushered in a new era that allows patients to make necessary changes to achieve blood sugar control while simultaneously providing real-time data to clinicians. Yet, clinical practice has continued to lag behind; primary care uptake has been inconsistent, and only 50% of patients with diabetes reportedly achieve glucose control.

The American Diabetes Association currently recommends that doctors offer continuous glucose monitors (CGMs) to patients with type 1 or type 2 diabetes who are using insulin. CGMs provide real-time blood sugar measurements every 5 minutes, alert users to peaks and lows, and facilitate the ability to learn factors that influence glucose, not to mention track trends over time. Use of CGMs have been shown to provide significantly better glucose control than blood glucose monitors in patients with type 2 diabetes treated with basal insulin without prandial insulin. They’ve also been associated with important behavioral changes (eg, avoiding certain foods that spike blood sugar), ultimately improving outcomes and quality of life. 

Why then, are CGMs underutilized in primary care settings?

“We know from data that primary care, which sees over 90% of patients with type 2 diabetes, that there’s not much uptake or usage of CGMs despite really becoming standard of care,” said Bonnie Jortberg, PhD, RD, CDE, RDN, associate professor in the Department of Family Medicine at the University of Colorado School of Medicine in Aurora.

Jortberg is co-author of a recent study, the findings of which underscored the benefit of several strategies to address practice constraints regardless of practice size or geographical location.

Virtual Care and Data Collection

Jortberg and her colleagues conducted an 18-month study that examined the primary care practice characteristics that drive selection of one of three CGM uptake strategies. 

Participating practices were randomized to self-study of the American Academy of Family Physicians’ Transformation in Practice (TIPS) self-paced online educational module with the support of a practice facilitator. Or they were able to select a virtual CGM initiation service led by a diabetes care and education specialist and two family physicians.

The purpose of the virtual care arm was to instruct patients on CGM initiation and use and provide data interpretation to practices, while at the same time, preparing practices to undertake the work themselves. 

Overall, 76 Colorado-based practices enrolled, over half of which specialize in family medicine only; 28 clinicians and staff from 21 practices were interviewed. 

The majority (46 of 76) chose self-paced TIPS implementation. Of these, 35% of which (n = 16) had a diabetes care specialist on staff while 30 chose the virtual CGM initiation service; none had a care specialist in their practice.

“There were no significant differences between any of the arms; they performed equally well and the patients all did equally well,” said Jortberg. But she also pointed out that the determining factor was the presence or absence of a diabetes care and education specialist (DCES).

“It really gets to the point that a DCES, or somebody who’s certified as a diabetes educator or specialist in practices is a great resource. But many practices don’t have them,” said Michele Talley, PhD, CRNP, ACNP‐BC, professor, associate dean of Clinical & Global Partnerships, and director of the PATH Clinic at the University of Alabama at Birmingham. 

“A CGM champion in the office who knows how to navigate things like insurance pre-authorization, and teach patients how to apply their sensors, connect, and share data with the office would be a bonus,” said Tanya Munger, DNP, FNP-BC, nurse practitioner at Duke Health in Durham, North Carolina.

Munger also said that virtual visits were beneficial for her own patients. 

“Our certified diabetes educators offer telehealth,” said Munger. “It’s helpful for folks that live far away and for whom travel and its cost (eg, gas, lack of a car) is a big burden. It really helps increase access for a lot of folks,” she said. 

Can Interprofessional Teams Close the Gap?

Talley’s research interests extend to the role of interprofessional models of care for serving under-resourced patients with chronic diseases such as diabetes. She said that nurse practitioners and physician assistants can help bridge the gap, especially in areas with a shortage of healthcare providers. 

“This is certainly an area where an NP or PA can become part of an interprofessional team, where everyone is able to practice at the top of their license,” she said, adding that many graduates at the UAB School of Nursing also have extensive training in quality improvement projects, “translating evidence into practice.”

“If you have a DNP-prepared NP working in a rural setting, you have two in one, right? You have the practice facilitator and diabetes expert that can be leveraged in that population to help the practice move forward, improve patient outcomes, and then, reduce the costs associated with diabetes,” said Talley.

Additional Considerations

One strategy for becoming familiar with CGM initiation and technology is to wear the devices, something that, Jortberg recently explored during a workshop held at this past June’s annual conference of the American Association of Nurse Practitioners. 

Munger said that she knew colleagues who attended the workshop.

“When providers are given the opportunity to learn how to apply these sensors, set them up using their phone or receiver, and look at the data, they can see how easy it is to prescribe them and for the majority of patients, to handle using the technology,” she said. 

But Munger also cautioned that providers need to remain open to patients’ abilities to adopt CGMs.

“We shouldn’t be making assumptions about patients’ capabilities, or make assumptions about who is going to be successful using the technology,” said Munger. “Affordability and cost can be a barrier. But CGMs should be offered to and discussed with patients.”

Additional barriers include concerns over device pre-authorization, and reimbursement.

“It’s important that providers know that if they do take this challenge on, have a champion in the clinic who can start the patients on CGMs, or choose to do it virtually, that it’s reimbursable,” said KC Arnold, ANP, BC-ADM, nurse practitioner and owner of The Diabetes Center in Ocean Springs, Mississippi.

“For CGMs, there’s a reimbursement code. They can bill for the services of interpreting the data, and analysis, interpretation, and reporting of the CGM sensors,” she said. 

Incorporating GGMs into primary care practice takes time and effort. But “I think that we’ve shown with our findings that it can be done,” said Jortberg. “CGM devices are absolute game changers for patients. And it’s well worth the time for primary care physicians and practices to invest in learning how to use them,” Jortberg said. 

Jortberg, Munger, and Talley reported no relevant financial relationships. Arnold is owner of The Diabetes Center. 

Liz Scherer is an independent health and medical journalist.