Speaker 1:

Welcome to AACE Podcasts. Thanks for tuning in as we elevate clinical endocrinology by taking deep dives into trends and topics that can help us improve our patient care and global health. Find the latest episodes on aace.com/podcasts. And now let's meet the endocrine experts who will be talking with us today.

Dr. Cecilia Lansang:

Well, to everyone, welcome to another episode of the AACE Podcast. I'm Dr. Cecilia Lansang. I have the pleasure of being an associate editor of Endocrine Practice. I'm also professor of medicine and director of endocrinology at main campus at the Cleveland Clinic. Joining me is Dr. Kristen Flint to discuss her and her team's endocrine practice article, Expanding Access to Continuous Glucose Monitoring in Medicare Patients Receiving Specialty Diabetes Care: A Quality Improvement Project.

Dr. Flint is the interim director of quality and safety for endocrinology at the Mass Gen Hospital. She is currently an attending endocrinologist at Mass Gen and is an instructor at Harvard Medical School. Dr. Flint, welcome to our podcast.

Dr. Kristen Flint:

Thank you for having me. I'm so excited to be here.

Dr. Cecilia Lansang:

That's great. I read your quality improvement project with great interest because, as I mentioned a while ago to you in our informal chat, we are also in the midst of implementing a QI project around diabetes technology. Can you please share with us how your diabetes specialty clinic is structured and how that helped you as the framework for your plan do study act or what people know as the PDS cycle?

Dr. Kristen Flint:

Sure. Our Diabetes Specialty clinic has a total of about 34 MD and NP providers. I think the breakdown for this project was 27 MDs and seven NPs. We also have three nurses, two medical assistants, a dietitian, and several patient services coordinators all working with us. And then, each year, about four to eight endocrinology fellows also see patients in the clinic.

Our clinic is situated in 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 one and eight clinic sessions each week. So, it's a pretty big clinic with providers spending very different levels of time in the clinic. 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.

Our project was focused on improving access to CGM for patients using Medicare, because of that 2023 change in coverage requirements, expanding coverage to all patients with diabetes on insulin. For Medicare patients, CGM is covered as durable medical equipment, and in our clinic, our medical assistants are primarily the ones handling durable medical equipment orders.

Orders flow directly from the prescribing provider to that MA team, but not everyone is aware of this. Because multiple role groups are involved in the process, when we started planning our PDSA cycles, it was critical to involve people from all the different role groups so that we could really understand our baseline state and create reasonable interventions. So, our project team ultimately included four MDs, one NP, and both of our medical assistants who help with the durable medical equipment at our clinic.

As we brainstormed interventions for the PDSA cycles, we tried to develop interventions that targeted all the stakeholders in the process, all those different role groups, so that we could have the greatest impact. We had two interventions aimed at providers, one aimed at patients, and then two that were more designed to help our nursing and administrative staff so that we could support everyone who's engaged in the CGM ordering process.

Dr. Cecilia Lansang:

Now, Dr. Flint, this is very useful information, especially also for people who would want to replicate something that you've done. Can you share how many sites you have and how was the integration amongst sites?

Dr. Kristen Flint:

So, this particular quality improvement project was conducted at just the MGH diabetes clinic, so it was only one site.

Dr. Cecilia Lansang:

Thank you. Now, please remind us, how did you choose the patients for this project? So, what were the criteria for selection, if there was any, and was this type one diabetes, type two diabetes, or all-inclusive in that manner?

Dr. Kristen Flint:

So, I think, to understand how we chose the patients involved in the project, it's helpful to know how the project came about in the first place. I was seeing patients actually as an endocrine fellow and my preceptor reminded me that the Medicare coverage had changed. I was unaware of this because I had only been practicing for a couple of years, but I did more research into this and I learned that, since 2017, Medicare had covered CGM for patients who checked their blood sugars a number of times each day and who took multiple daily injections of insulin.

Then, in April of 2023, Medicare changed the requirements for CGM coverage so that it included all patients with any type of diabetes, treated with at least one injection of insulin daily. And so, in our clinic, that meant that there was a large cohort of patients with type two diabetes on insulin who were newly eligible for CGM.

So, for our project, the inclusion criteria was people who had type two diabetes, who used any amount of insulin, and who had Medicare as a primary or a secondary insurance. We excluded patients who had type one diabetes because their coverage hadn't really changed. They already took multiple daily injections or they were on insulin pumps. So, we didn't think that the interventions would really benefit them in the same way.

At baseline, we identified the patients who are eligible by using an electronic medical record-based diabetes registry that we keep that includes demographic information, insulin use, et cetera. And then, we actually conducted chart reviews to look at utilization of CGM prior to any interventions.

We ultimately had an open cohort because, as the project went on, more of these patients established within our clinic. So, the denominator of eligible patients continued to shift. At the end of the intervention period, we did re-identify all of the patients in our clinic who met the inclusion criteria, and we reevaluated the CGM utilization for the full cohort.

Dr. Cecilia Lansang:

That's great. I think a lot of thought was put into it for those people who would be benefiting from it. So, can you tell us who were the providers you reached out to? Did this include endocrinologists that were not very aware of your project, and how about the primary care providers who are taking care of these patients outside of your endocrinology clinic? And, I guess, a second question to that is, what was their reaction when they received a list of their patients who might be eligible for such but they were not yet on a CGM?

Dr. Kristen Flint:

So, I'll take that question in three parts. First of all, although this particular project was really focused within the MGH Diabetes Center and the interventions targeted providers, were primarily targeted at diabetes providers, we did develop a second project aimed at improving access to CGM in the primary care setting.

Primary care at our institution needed more infrastructure and education before we could really start other interventions. And so, we've actually published on that research in the Journal of General Internal Medicine with our efforts within primary care.

For this project, we really had the two interventions that were aimed at providers, and it's important that there were two because the first intervention was general provider education at our monthly clinic practice meeting. So, all of the providers get together once a month and we talk about changes to workflows or new quality improvement initiatives going on in the clinic.

At that meeting, I presented the project. I walked everybody through a process map describing how CGM is ordered in our clinic for patients who use Medicare or who need CGM ordered as durable medical equipment, and then I told everybody that I would be sending them targeted emails including a list of their patients who were eligible for CGM based on the chart review, but who were not currently prescribed or using CGM.

At the clinic meeting, we let everybody know that there were no expectations around this email. Providers were not expected to respond, they were not expected to chart review. Providers could really engage with the lists as they chose. We are really curious to see if just sending the targeted lists would help raise awareness and also reinforce what we had reviewed at the meeting.

So, I sent messages to all of the MD providers after the meeting. The NP providers co-manage patients with MDs, so I left them off so that there wasn't duplicated work, and the reactions were mixed, as you might expect. So, of the 27 or so MD providers who we messaged, 12 of them replied to the email. Five of the providers were grateful to receive a short actionable list, and they expressed great appreciation for the project. Two of our providers immediately recognized some of the patients as good candidates for CGM, and they actually reached out to those patients to schedule follow-up appointments to have more discussion. The other five providers reviewed their lists and determined that the patients were either not good candidates for CGM or that they had previously been offered CGM and declined for reasons unrelated to insurance coverage.

I was really excited to see that we had almost half of our providers engaged with the patient lists to the point where they were sending me replies, even though that was not the expectation. But that kind of active engagement with the targeted intervention helped us see that it was probably going to be more effective than the general provider education, which was also what I had suspected, and it's what you usually see in quality improvement projects. There's a lot of education, but it tends to be more passive.

Dr. Cecilia Lansang:

It looks like there was active engagement from the number of people that you thought you were going to hear from. At the same time, the baseline CGM use was 49.6%, so about 50%. Were you surprised with this number, knowing that it's from a diabetes center, versus just pleasantly surprised again that at least 50% were already on CGM?

Dr. Kristen Flint:

Definitely both. I was surprised. When I originally tried to evaluate baseline utilization within the clinic, I pulled prescription records from Epic, which is the electronic medical record that we use, and I got a much lower percentage of people, because those records don't actually capture our durable medical equipment orders. So, when I went back and did the chart review, it was orders of magnitude greater.

The difference in data, that was kind of eye-opening, but I was pleasantly surprised that our clinic population was already using so much technology. I think, like you point out, on the one hand, because our patients are coming to a diabetes specialty clinic, they have greater medical complexity, so they might be more likely to use multiple daily injections of insulin and already be eligible for CGM. They also just have greater access to care in general. They were able to get into the specialty clinic, so they're more likely than some other patients to be able to access different types of treatment.

Based on research, other research, evaluating barriers to CGM utilization, I did think that there would be a little bit more resistance to CGM based on patient factors, clinician factors, and some of the logistics around navigating insurance coverage. So, I was pleasantly surprised to see that we were almost at 50% utilization at baseline in this cohort.

Dr. Cecilia Lansang:

That's great. So, let us remind the audience that, after the intervention, the percentage was 62.6% from a baseline of 49.6%, and you indicated five interventions, some of which you'd already spoken about: general provider education, targeted provider education, provider support, revision to the formulary guide, and patient education. There were the three things that you had not had the chance to speak about yet, provider support revision to the formulary guide and patient education. Would you care to briefly describe those three?

Dr. Kristen Flint:

Yes, I can do that. The provider support documents that we describe in the paper, what we did is we created a one-page document that had answers to frequently asked questions about CGM. Originally, the idea was that nurses would be able to use this document to quickly answer patient questions, but it actually... Providers ended up printing the document and handing it to patients. They would send it over our patient gateway, which is the communication through the electronic medical record. It's just been used in many different ways. We also created a couple of provider support documents outlining how patients could download the applications for each CGM to their phone, and then, how they could connect their application to our clinic CGM portals and share their CGM data in real time.

Those processes are not always intuitive and providers can have a very time-intensive session with a patient working through those. So, we had screenshots of how to do all of these steps on the phone.

So, that was provider support. The formulary guide in our clinic, we have a packet which reviews how all of the different diabetes medications are covered by various insurances. We also had a page about how regular glucometers are covered, but we didn't have a page about how CGM gets covered. So, we added a couple of pages that review how CGM is covered by Medicare, by MassHealth because we're in Massachusetts, and then by the different commercial insurances.

So, that was the formulary guide.that gets updated annually by our diabetes nurses. They are true assets to our clinic. And then, the fifth thing was patient education. So, we really wanted a belt and suspenders approach. Hopefully, the provider is talking about CGM with the patient, but we wanted to empower the patient to bring it up with the provider, as well. So, we created flyers, which we posted around the clinic, just advertising this change in Medicare coverage and announcing that patients who are using insulin and who are covered with Medicare might now be eligible for CGM, and just reminding them to ask their doctor.

Dr. Cecilia Lansang:

That's a great delineation Of those steps. Amongst those five, do you think that one may have contributed most to your success, and maybe what do you think was the least effective of those five interventions?

Dr. Kristen Flint:

That is a great question. I think one of the challenges with quality improvement projects is, a lot of the interventions occur in somewhat rapid succession. And so, our interventions were designed to build upon each other and avoid losing momentum with this cultural change within the clinic. But we collected data on CGM orders monthly, so, I don't think we can truly say from the data if one intervention was specifically better or more effective than another.

However, now that it's been a year since we did the project, I can highlight the interventions that have really been sustained. The provider support documents that I mentioned have had excellent uptake. Our front desk is sending a lot of the documents about how to connect the phone app and how to connect to our portal. The front desk sends those to patients before their virtual appointments, which is really useful in ensuring that the clinician has the data before they join that virtual appointment.

Even for in-person appointments, having that document available can speed up data download and sharing. Additionally, because we have these support documents, we've been able to share them with other divisions at our institution like primary care, and that has been a huge resource to help build their infrastructure and get CGM orders off the ground in other divisions.

The CGM formulary guide has also been really helpful, and that has been another resource that is now extended outside of the MGH Diabetes Center, and is being used by other divisions within the institution. So, I like to think that both of those interventions, given their persistence, have been pretty effective.

Dr. Cecilia Lansang:

Yeah, that's good to know that durable education materials are actually sustaining at least part of this successful program. And then, do you want to touch on some social demographic findings of your population, so that people can again see how they can translate this into their own locales?

Dr. Kristen Flint:

Yes. So, differences in CGM prescribing and utilization related to sociodemographic factors have been well documented in the literature. I was very surprised that, when we looked at the baseline state for our clinical cohort, we didn't see significant differences based on sociodemographic factors between patients who were using CGM or not using CGM.

I think that might be related to differences in access to healthcare upstream of the actual specialty diabetes clinic appointment, and a potential interesting future direction of the project could be to examine overall access to specialty care at our institution and look at how some of the sociodemographic factors affect patients getting in the door in the first place.

We did reevaluate at the end of the project to ensure that we didn't create new differences in care, and it was very reassuring to see that, again, there were no significant sociodemographic differences between patients using or not using CGM. As we developed our interventions, we did specifically consider how we could target our interventions to benefit everybody coming into the clinic. So, all of our documents were written at a sixth grade reading level, and we translated all of the patient-facing documents into the top five languages used within our clinic.

Dr. Cecilia Lansang:

There's actually very good insight about not creating new sociodemographic changes amongst the population, so thank you for that. So, what is your take home message to our listeners, especially those who do want to promote the care of their patients in this Medicare population?

Dr. Kristen Flint:

I think quality improvement projects can really bridge the translational gap between clinical research and healthcare delivery. This kind of work can help implement policy changes rapidly and they can really be targeted towards whatever clinical environment you're in. I do think that when trialing interventions, it's important to include all stakeholders in their development, and it can be most impactful when you target interventions towards multiple role groups. And then, finally, like we were saying, it's really important to create interventions, keeping in mind that you want to avoid worsening any disparities or differences in care as innovations are adopted.

Dr. Cecilia Lansang:

That's great. This was a very informative session. Dr. Flint. Thank you for gracing our podcast, and for our audience, you can read the full article in the August 2025 issue of Endocrine Practice. Thank you to everyone.

Dr. Kristen Flint:

Thank you.

Speaker 1:

Thanks for listening to another great AACE podcast. Join us for another episode at aace.com/podcasts and help us in our mission to elevate clinical endocrinology. Together we are AACE.