A quality improvement initiative at a large academic diabetes clinic significantly increased use of continuous glucose monitoring (CGM) among Medicare patients treated with insulin, demonstrating how targeted clinic interventions can translate policy changes into improved patient access.
In 2023, the Centers for Medicare & Medicaid Services expanded CGM coverage to include all adults with diabetes treated with any amount of insulin or those with problematic hypoglycemia.
“Insurance coverage of CGM is frequently identified in the literature as a barrier to CGM access,” explained Kristen Flint, MD, MGH, of the Diabetes Unit at Massachusetts General Hospital, Boston. “When Medicare changed its coverage rules, this major barrier to CGM access was removed, which enabled us to look at other contributors to limitations on CGM access. By focusing on the group of patients with known CGM coverage, we could trial interventions to improve processes within our clinic that streamlined CGM ordering and could be adapted to CGM ordering for other patient populations within the clinic.”
To investigate the issue, Dr. Flint and her colleagues at the specialist diabetes unit conducted an 8-month quality improvement project within the clinic. The goal was to increase CGM adoption among Medicare patients with insulin-treated diabetes while ensuring that expanded access did not create new disparities in care, they noted in Endocrine Practice.
“Our diabetes specialty clinic has a total of 34 MD and NP providers, and four to eight endocrinology fellows who provide clinical care,” said Dr. Flint. “Our clinic is situated within an academic medical center, so some of our providers are more research-focused, and others are more clinically focused; depending on a provider’s focus, that provider may have anywhere between 1 and 8 clinic sessions a week. This means that when policies change or new workflows roll out, it can take a while for their adoption by all providers in the clinic.”
The team implemented a series of interventions using Plan-Do-Study-Act cycles. These included general provider education on updated Medicare coverage and CGM ordering workflows, targeted outreach to clinicians with lists of eligible patients not currently using CGM, provider support materials and troubleshooting guides, a formulary reference outlining coverage requirements, and patient-facing educational materials explaining the new coverage rules.
“All patient-facing materials were written at a sixth grade reading level and translated into the top five languages used by patients at the clinic to minimize inequities based on language or education level,” noted Dr. Flint. “Additionally, in the lists that we sent to providers of their patients who were eligible for CGM, we included all patients so that we did not introduce bias into the intervention.”
A total of 847 Medicare patients receiving insulin therapy were eligible for CGM at baseline. Prior to the interventions, 49.6% of these patients were already using CGM; over the course of the initiative, adoption rose to 62.6%.
As part of the project, the team also examined whether the expanded access changed patterns of care across demographic groups. At baseline and after the intervention, patients using CGM tended to be younger, have higher A1c levels, and be more likely to use the electronic health record patient portal. However, there were no significant differences in CGM use based on race, ethnicity, language, income level, or education.
The Boston-based investigators suggested that lower CGM use among patients not connected to the patient portal may reflect differences in digital health literacy, highlighting an area for future intervention. They also noted that older adults may face unique barriers to adopting diabetes technologies.
Overall, the project’s findings suggest that structured quality improvement strategies – particularly those combining provider education with patient engagement – can help translate policy changes into real-world clinical practice, noted researchers.
Regarding next steps, Dr. Flint said that her team is now focusing on increasing CGM access throughout their institution’s primary care practices. “Primary care providers provide the bulk of diabetes care for patients with diabetes on one injection of insulin daily, but they do not have the same education or operational infrastructure to support CGM ordering and interpretation,” she said. “Our team is working with several different community health practices to provide that education and infrastructure so that patients can access this life-changing technology even if they do not have an endocrine provider.”
