A Quality Improvement Project to Increase Continuous Glucose Monitor Utilization In Primary Care Practices

Diabetes is a disease that affects millions internationally. Incidence of the disease is growing at a staggering rate. Complications include nephropathy, neuropathy, retinopathy, and macrovascular complications such as myocardial infarction and stroke. Complications will decrease in frequency with improved glycemic control. ADA has recommended an A1c of < 7% for all non-pregnant adults. However, decreasing A1c by even 1% is difficult for most patients with diabetes.
Continuous glucose monitoring (CGM) is an efficacious technology to significantly reduce A1C levels. CGM technologies have shown to significantly reduce A1C levels by 0.5 to 1.3% points. There is a reduction of time outside target glucose, suggesting an improvement of glucose variability. Currently CGM initiation is done mainly in endocrine practices. Unfortunately, there is a shortage of endocrine providers, and the average wait time to see a provider to start therapy is> 30 days.
The purpose of this study is to increase the utilization of CGM technology in primary care practices. Albert Bandura social cognitive theory provides the theoretical framework for this project. The model for improvement framework from the IHI was the model for this QI project. We established interventions to provide support and training to our primary care providers and staff.
The first PDSA cycle included the creation of a patient education process. There was a patient information sheet developed. We created an ordering flowchart to assist the providers with how to order the CGM products if they should proceed with starting therapy. Training included two information sessions, first with the providers and nurses to review the details of CGM therapy. The education session was 1-hour long and included a review of the new patient education sheet and the ordering flowchart. We educated the providers on which patients would benefit, how the CGM works, how to initiate therapy, and how to interpret the results. The second information session was with the nurses and medical assistants reviewing the new workflow.
The new workflow included the MA reviewing the chart before clinic and identifying patients who have a scheduled diabetes visit. The MAs placed the ordering flowsheet and patient education sheet attached to the patient intake card. Patients were provided with the education sheet on CGM therapy after the intake process was done. Patients were provided time to review this sheet while they were waiting for the provider. When the provider entered the room, they saw the ordering flowsheet attached to the patient vitals card. This was a reminder that this patient may be considered. Then together with patient, they decided if they were to proceed with treatment. If so, provider utilized the ordering flowsheet. The primary aim was to increase CGM utilization use in patients of the internal medicine practice by 20% over baseline with a 3-month intervention period. The secondary aim was for providers to report confidence in initiating CGM therapy in patients with diabetes. Data collection has concluded, and data analysis is underway with a completion date of October 30th.