Over 38 million Americans have type 2 diabetes (T2D), with 1.2 million Americans diagnosed every year.1 Diabetes is the eighth leading cause of death in the United States, and the total annual cost of diabetes is over $400 billion.1,2 More than 90% of people with T2D receive their care not in endocrinology but in primary care settings.3-5 This means that primary care presents a unique opportunity for accessible and equitable diabetes care, including providing access to continuous glucose monitors (CGMs). Currently, the most rapid growth of CGMs is in primary care.6 However, challenges such as lack of clinician expertise or confidence with CGM prescribing and glucose data interpretation must be addressed. Certified diabetes care and education specialists (CDCESs) have been shown to improve diabetes care, yet it has been reported that only 36% of primary care practices employ a CDCES, whether part-time or full-time.7,8
There are numerous clinical, behavioral, and psychosocial benefits associated with CGMs, including improved glycemia.9-20 The 2024 American Diabetes Association (ADA) Standards of Care in Diabetes recommends CGM use for people with type 1 diabetes (T1D) or T2D using insulin in their treatment, including basal-only insulin regimens.21 A key addition to the 2025 ADA Standards of Care includes considering CGM use in adults with T2D on glucose-lowering agents other than insulin.22 Medicare has aligned CGM coverage criteria with these recommendations and extended it for problematic hypoglycemia as well, even in the absence of insulin therapy.21 Numerous organizations, including the Association of Diabetes Care and Education Specialists, recommend CGM use to support improved glycemia and the use of CGM metrics in diabetes management.24 Despite the clinical, behavioral, and psychosocial benefits of CGM use in people with T1D and T2D, access is limited beyond endocrinology practices. A national survey of 632 primary care professionals (PCPs) demonstrated that only 38.6% of respondents had ever prescribed a CGM.7 However, the same study demonstrated that nearly three quarters of PCPs were moderately or very likely to prescribe CGMs with additional resources.7
Virtual diabetes management has been shown to be an effective alternative to in-person diabetes care delivery, benefiting diabetes outcomes such as glycemia and perceived disease burden.25 Remote monitoring is a form of telehealth that—by definition—occurs when the patient and care team are not present together for face-to-face care. Remote monitoring of CGM data, for example, can identify glucose patterns and enhance shared decision-making between the provider and patient.9,26 Recent research has shown that CGM use, when used in conjunction with telehealth visits and telemonitoring interventions, improves glycemic management and reduces diabetes distress.27-29 Virtual CGM initiation and data interpretation are also linked to increased patient confidence and engagement and can facilitate timely clinical care.10,30
To address disparities in access to CGMs and extend the reach of CDCESs to primary care practices that did not have access to these critical resources, our team designed and implemented a virtual CGM Initiation Service (virCIS) where a CDCES played a leading and critical role, among other clinical team members. This article’s objective is to describe the feasibility of implementing a virtual CGM service to help primary care practices enhance CGM usage among their patients with diabetes.
Study DesignvirCIS was designed and implemented as part of a larger trial, described in Figure 1. The coprimary objectives of virCIS were (1) to provide virtual CGM initiation and interpretation services to patients with diabetes whose primary care practices chose to participate in virCIS while (2) concurrently educating and preparing the participating practices to undertake this work themselves, without virCIS, after completing their participation. The virCIS team consisted of several part-time multidisciplinary providers, including a registered dietitian nutritionist (RDN) CDCES, two clinical pharmacists (PharmDs), two family medicine physicians, and several administrative staff who assisted with screening, scheduling, and managing patients’ progress through the service visit schedule.
ProtectionsThis project was reviewed and approved by the Colorado Multiple Institutional Review Board (Protocol 21-4269) and registered with ClinicalTrials.gov (NCT05336214).
Practice and Patient RecruitmentPractices were recruited broadly across the state of Colorado. Primarily, information about the study and recruitment were incorporated into newsletters shared with our robust, statewide network of practice transformation organizations, professional organizations, health systems, and primary care practices. Team members also provided information at events such as practice transformation organization meetings, a state health department forum for CDCESs across the state, and Colorado Medicaid regional diabetes programs. All attendees of events, members of newsletter lists, and organizations that expressed interest were sent an invitation to apply to participate.
Only primary care practices in Colorado with an interest in learning to incorporate CGM use into practice workflows were included in the study. Practice access to refer to virCIS was triggered by a practice indicating their preference to be trained on CGM implementation through the virtual referral service specifically (rather than the alternative of self-guided CGM implementation using standardized education, training, and implementation materials published by the American Academy of Family Physicians, which will be reported separately). Once practices enrolled PCPs and practice staff, who were invited to attend a 1-hour webinar focused on identifying patients who might benefit from CGM use, a brief introduction to best practices for prescribing, and a brief introduction to CGM data interpretation basics. PCPs from participating practices referred patients who they felt would benefit from CGM use to virCIS. Patient-level inclusion criteria included a diagnosis of T1D or T2D and ages 18 to 89 years. The virCIS team accepted all eligible referrals and initiated contact with referred patients.
virCIS ImplementationAfter patient referral by their PCP, initial contact was attempted through an introductory email; patients were then contacted by phone, email, and/or text message to complete screening to confirm eligibility and interest in virCIS, which was required before the visit process could begin. Figure 2 illustrates the workflow for patient recruitment, enrollment, visits, and follow-up.
Table 1 details the visit schedule for patients. The virCIS visit schedule started with a warmup visit to orient the patient to the service and determine next steps regarding CGM type, ordering, and scheduling. If a patient appeared likely to qualify for insurance coverage for personal CGM based on their insurance plan’s coverage criteria, the prescription process was initiated by virCIS team pharmacists, and a professional CGM sensor was offered by the virCIS team to get the patient started while waiting on the personal CGM approval and receipt through insurance. If a patient appeared unlikely to receive insurance coverage for a CGM, the patient was offered intermittent use of professional CGM sensors from the virCIS team. In both scenarios, the professional CGM was used in an unblinded manner so that the patient was able to view their CGM data in real time. Regardless of CGM type, the visit schedule consisted of up to 3 CGM initiation visits and 3 CGM interpretation visits. In keeping with most insurance reimbursement allowances, professional CGMs could be initiated every 90 days, whereas personal CGMs could only be initiated once while a patient used that CGM system. Interpretation visits were spaced 30 to 90 days apart. The workflow was designed for each patient to have at least 1 interpretation visit with the virCIS RDN/CDCES and at least 1 interpretation visit with a virCIS clinical pharmacist to ensure emphasis on both nutrition and medication management. After each interpretation visit, patients received an after-visit summary, and a consult note was sent to their referring PCP.
The consult notes were specifically designed to provide meaningful clinical information while also sequentially introducing and advancing referring PCP knowledge and ability to undertake CGM management on their own by the time their patient(s) completed virCIS engagement. The first, second, and third interpretation visit consult notes therefore each had a unique template incorporating progressive levels of provider-directed CGM education. For example, the first consult note introduced and explained the standardized CGM metrics along with their consensus targets for most people with diabetes alongside the referred patient’s CGM metrics and an indication of which metrics were and were not meeting those targets. It also included information on which type of CGM was selected and why. The second consult note introduced the standardized 1-page Ambulatory Glucose Report (AGP), how to navigate it, and where to find each of the CGM metrics introduced in the first consult note. The referred patient’s AGP report was presented along with indications of which metrics were and were not meeting targets. The note went on to introduce practical tips for prescribing CGMs and for billing for CGM-related services. The third consult note included options for the referring PCP to schedule a warm handoff visit with the virCIS team.
The virCIS team monitored referral and participation rates regularly to identify areas for improvement or bottlenecking in the process. Team members met weekly to discuss emerging challenges and identify solutions using rapid cycle quality improvement. The agility to do this stemmed from a small, focused team and a patient-centered approach.
Data AnalysisDescriptive summary statistics were generated for practice and patient outcome measures and were produced using Microsoft Excel.
Outcome measures and sources are detailed in Table 2. Of 22 primary care practices across Colorado that actively participated in virCIS, 19 referred at least 1 patient to virCIS. As shown in Table 3, a total of 193 patients were referred to virCIS, with 137 indicating interest in participating and over half (102 of 193; 52.8%) attending at least 1 virCIS visit. Patients who initially expressed interest in participating in virCIS attended an average of 2.5 visits. Forty-two referred patients participated in all offered virCIS services, completing the 3 interpretation visits that were available to them through the service.
Patients were able to opt out of the initiation visit process if they reported feeling confident in safely and effectively inserting their CGM sensor on their own; this was often the case for patients using personal CGM devices after their first initiation visit with the virCIS team. Sixty-two patients attended a first initiation visit, and 25 and 16 attended a second and third initiation visit, respectively. Thirty-nine percent of patients (16 of 41) who were offered a third initiation visit chose to attend one.
Fifty-three patients who responded to initial outreach attempts were withdrawn without completing a warm-up visit, and 28 were withdrawn after the warm-up visit but before completing an initiation visit. The most common reason (54 of 92; 59%) for patient withdrawal was becoming lost to follow-up simply due to lack of engagement, where a patient did not respond to outreach after 4 contact attempts using a combination of all available contact methods. Other reasons included declining to participate (often due to inability or lack of desire to use the requisite technology), being ineligible to participate due to age or diagnosis, the PCP rescinding their referral, or data inaccuracies (eg, duplicate referrals or inaccurate contact information provided by the PCP). Table 4 displays the frequencies of reasons for withdrawal of referred patients.
A total of 158 professional CGM sensors were mailed to 75 unique virCIS patients throughout the course of the study, equating to an average of 2.1 sensors per patient who required them at any point during the study. Additionally, 15 patients were loaned handheld readers by the study team as an alternative to the associated smartphone apps. The majority of those (52 of 75; 69%) who received professional CGM sensors from virCIS relied on these for CGM interpretation. In other words, these 52 patients were unable to obtain personal CGMs due to being unable to receive insurance coverage and/or reporting inability to afford the cost. Less frequently, patients reported that they received professional CGM sensors from their doctor’s office, although this was not explicitly tracked for our purposes; thus, the number of patients for whom this was the case is unknown.
Many primary care patients with diabetes stand to benefit from use of CGMs in keeping with recommended standards of care, but many practices lack the resources, staff, or training to provide CGM initiation and interpretation on their own.7,31 A separately reported assessment of 51 characteristics of practices participating in this study showed that the only characteristic associated with selecting participating in virCIS was having a CDCES on staff; among practices without a CDCES, exactly half elected to participate in virCIS.32
The results from this study demonstrate that implementation of a virtual CGM initiation service is feasible and can benefit patients whose diabetes is managed in primary care settings by increasing their use of CGMs. Engagement in the program was high, with 86% of practices participating in virCIS referring at least 1 patient and 53% of referred patients completing at least 1 visit. Most patients who enrolled in virCIS received at least 1 visit with the CDCES, increasing the reach of CGM use and diabetes education. At a minimum, the use of professional CGMs enabled virCIS to provide intermittent CGM use to patients who would have otherwise had to pay out-of-pocket for the technology.33,34 This may be a particularly practical strategy for primary care practices to offer CGMs to their patients because the small cash investment needed can be recaptured and surpassed by billing for the provided CGM services. Although 42 of 75 patients received all available virCIS offerings, more were introduced to CGMs through use of professional CGMs (n = 75) and/or completion of at least 1 interpretation visit (n = 55).
Limitations of this study include that it only enrolled primary care practices in Colorado, which may not be representative of the broader US primary care population. Additionally, practices that participated in virCIS did so by selfselection, not by randomization, which should be considered when interpreting the results reported here.
An overarching lesson learned through this project was to individualize the approach to meet each patient’s needs. The requisite technology (HIPAA compliant, 2-way video capability, and CGM smartphone apps) proved challenging for some patients, but the virCIS team was able to identify patients who struggled with technology during the warm-up visit and recommend that those patients enlist a support person for their subsequent visits. Between the virCIS team and the patient’s support person, patients were able to successfully activate their CGM sensor, and many felt confident enough after that point to not need their support person for future visits. Likewise, just 16 of 41 patients (39%) who were offered a third initiation visit chose to attend one, suggesting that most patients’ confidence in using CGMs improved over time through their participation in virCIS. However, there were also patients who did not feel confident enough using their CGM’s smartphone app or who did not have a compatible smartphone; for such instances, the virCIS team maintained a supply of CGM reader/receivers that could be loaned to patients instead, which we would recommend to anyone considering offering such a service. Communicating back to the patient’s PCP was also often a challenge; despite confirming contact information at the beginning of the project, several providers stated they had not seen the consult notes the virCIS team had sent to them in the manner requested. The team implemented several strategies to rectify this: Contact information was rechecked and updated, the option for secure emails was added in addition to secure faxing, and the native electronic health record (EHR) platform was used when possible, a;though this was only rarely the case due to the disparate nature of practices spanning multiple health systems across the state and therefore multiple EHR platforms.
Another lesson learned was that authorization for personal CGMs is challenging and timeconsuming and can impact patient engagement. The loss of engagement from patients while waiting for their insurance to process and authorize their personal CGM was noted early during the regular team review of patient data and prompted the team to identify a solution: Patients were provided with a professional CGM sensor in order to complete their first initiation and interpretation visit while waiting on their personal CGM, before their enthusiasm could wane.
The results of this study provide initial evidence that a CDCES-led, multidisciplinary, virtual CGM service can be successful in helping primary care practices increase CGM use among their patients with diabetes. Further research is needed to see if this model can be replicated in other settings and to assess its effectiveness to improve patients’ clinical outcomes.
This study was supported by a research grant from The Leona M. and Harry B. Helmsley Charitable Trust.
Study data were collected and managed using REDCap electronic data capture tools hosted at the University of Colorado. REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for importing data from external sources.
See Harris et al. Research electronic data capture (REDCap) - a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381.
This publication was supported by NIH/NCATS Colorado CTSA Grant Number UL1 TR002535. Its contents are the authors’ sole responsibility and do not necessarily represent official NIH views.
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