Personal Continuous Glucose Monitoring Use Among Adults with Type 2 Diabetes: Clinical Efficacy and Economic Impacts.

PURPOSE OF REVIEW: This article reviews recent clinical efficacy research and economic analysis of the use of personal continuous glucose monitoring (CGM) in type 2 diabetes (T2D). RECENT FINDINGS: Studies from the past 5 years include a variety of randomized controlled trials, meta-analyses, and other studies which generally favor CGM over self-monitoring of blood glucose (SMBG) in T2D, especially among people with T2D treated with insulin. Concurrently, some studies show no significant difference, but there is no evidence of worse outcomes with CGM. CGM is frequently associated with greater reduction in HbA1c than is SMBG. HbA1c reductions tend to be greater when baseline HbA1c is higher. Reductions in hypoglycemia and hyperglycemia have also been demonstrated with CGM in people with T2D, as have comfort with, preference for, and psychosocial benefits of CGM compared to SMBG. There is a small but growing evidence base on the economics and cost-effectiveness of CGM in T2D. CGM has been clearly demonstrated to have clinical benefits in people with T2D, especially among those treated with insulin. Economic and cost-effectiveness data are more scant but are generally favorable. CGM should be an important consideration in the management of T2D, and its use is likely to increase as efficacy data accumulate further and as costs associated with CGM gradually decrease.

Self-management support for chronic disease in primary care: frequency of patient self-management problems and patient reported priorities, and alignment with ultimate behavior goal selection.

BACKGROUND: To enable delivery of high quality patient-centered care, as well as to allow primary care health systems to allocate appropriate resources that align with patients' identified self-management problems (SM-Problems) and priorities (SM-Priorities), a practical, systematic method for assessing self-management needs and priorities is needed. In the current report, we present patient reported data generated from Connection to Health (CTH), to identify the frequency of patients' reported SM-Problems and SM-Priorities; and examine the degree of alignment between patient SM-Priorities and the ultimate Patient-Healthcare team member selected Behavioral Goal. METHODS: CTH, an electronic self-management support system, was embedded into the flow of existing primary care visits in 25 primary care clinics and was used to assess patient-reported SM-Problems across 12 areas, patient identified SM-Priorities, and guide the selection of a Patient-Healthcare team member selected Behavioral Goal. SM-Problems included: BMI, diet (fruits and vegetables, salt, fat, sugar sweetened beverages), physical activity, missed medications, tobacco and alcohol use, health-related distress, general life stress, and depression symptoms. Descriptive analyses documented SM-Problems and SM-Priorities, and alignment between SM-Priorities and Goal Selection, followed by mixed models adjusting for clinic. RESULTS: 446 participants with ≥ one chronic diseases (mean age 55.4 ± 12.6; 58.5% female) participated. On average, participants reported experiencing challenges in 7 out of the 12 SM-Problems areas; with the most frequent problems including: BMI, aspects of diet, and physical activity. Patient SM-Priorities were variable across the self-management areas. Patient- Healthcare team member Goal selection aligned well with patient SM-Priorities when patients prioritized weight loss or physical activity, but not in other self-management areas. CONCLUSION: Participants reported experiencing multiple SM-Problems. While patients show great variability in their SM-Priorities, the resulting action plan goals that patients create with their healthcare team member show a lack of diversity, with a disproportionate focus on weight loss and physical activity with missed opportunities for using goal setting to create targeted patient-centered plans focused in other SM-Priority areas. Aggregated results can assist with the identification of high frequency patient SM-Problems and SM-Priority areas, and in turn inform resource allocation to meet patient needs. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT01945918 .

A protocol for a cluster randomized trial comparing strategies for translating self-management support into primary care practices.

BACKGROUND: Advanced primary care models emphasize patient-centered care, including self-management support (SMS), but the effective use of SMS for patients with type 2 diabetes (T2DM) remains a challenge. Interactive behavior-change technology (IBCT) can facilitate the adoption of SMS interventions. To meet the need for effective SMS intervention, we have developed Connection to Health (CTH), a comprehensive, evidence-based SMS program that enhances interactions between primary care clinicians and patients to resolve self-management problems and improve outcomes. Uptake and maintenance of programs such as CTH in primary care have been limited by the inability of practices to adapt and implement program components into their culture, patient flow, and work processes. Practice facilitation has been shown to be effective in helping practices make the changes required for optimal program implementation. The proposed research is designed to promote the translation of SMS into primary care practices for patients with T2DM by combining two promising lines of research, specifically, (a) testing the effectiveness of CTH in diverse primary-care practices, and (b) evaluating the impact of practice facilitation to enhance implementation of the intervention. METHODS: A three-arm, cluster-randomized trial will evaluate three discrete strategies for implementing SMS for patients with T2DM in diverse primary care practices. Practices will be randomly assigned to receive and implement the CTH program, the CTH program plus practice facilitation, or a SMS academic detailing educational intervention. Through this design, we will compare the effectiveness, adoption and implementation of these three SMS practice implementation strategies. Primary effectiveness outcomes including lab values and evidence of SMS will be abstracted from medical records covering baseline through 18 months post-baseline. Data from CTH assessments and action plans completed by patients enrolled in CTH will be used to evaluate practice implementation of CTH and the impact of CTH participation. Qualitative data including field notes from encounters with the practices and interviews of practice personnel will be analyzed to assess practice implementation of SMS. DISCUSSION: This study will provide important information on the implementation of SMS in primary care, the effectiveness of an IBCT tool such as CTH, and the use of practice facilitation to assist implementation. TRIAL REGISTRATION: Registered with ClinicalTrials.gov - ClinicalTrials.gov ID: NCT01945918 , date 08/27/2013. Modifications have been updated.

Virtual Versus In-Person Suicide Prevention Training in the Workplace: Evaluation of the VitalCog Program.

Most suicides occur among adults of working age and workplace suicide prevention is a public health priority. Workplace suicide prevention efforts, however, remain limited. This paper describes and evaluates a workplace-based suicide prevention gatekeeper training delivered in-person and virtually. VitalCog is a 2-h suicide prevention program designed specifically for the workplace and based on best practices for gatekeeper training. It is designed to be practical and interactive, with four modules (why prevention matters, what to do if someone is suicidal, conversations about suicide, and postvention), each containing related video, group discussion, and role play exercise components. It was delivered live by experienced trainers either in-person or using synchronous technologies between 2018 and 2021. A mixed methods pre- and post-training design with no control group was used to evaluate in-person vs. virtual delivery to determine knowledge gain, confidence identifying warning signs, and comfort levels talking about suicide. One thousand two-hundred and forty-four (1244) pre- and post-training responses were analyzed, with no significant (p > .05) socio-economic differences between the pre-training and post-training respondent samples. Both in-person (n = 841) and virtual (n = 403) training groups demonstrated statistically significant increases in knowledge about suicide prevention and seeking help, confidence to identify suicide warning signs, and comfort levels talking to someone about getting help. Interestingly, the virtual group showed higher post-training outcome scores than the in-person group. While COVID-19 significantly reduced in-person training opportunities, these results suggest that offering VitalCog virtually is as effective as in-person, and potentially has advantages over in-person training.

Patient-centered medical home: how it affects psychosocial outcomes for diabetes.

Fragmentation of the current U.S. health care system and the increased prevalence of chronic diseases in the U.S. have led to the recognition that new models of care are needed. Chronic disease management, including diabetes, is often accompanied by a myriad of associated psychosocial issues that need to be addressed as part of a comprehensive treatment plan. Diabetes care should be aligned with comprehensive whole-person health care. The patient-centered medical home (PCMH) has emerged as a model for enhanced primary care that focuses on comprehensive integrated care. PCMH demonstration projects have shown improvements in quality of care, patient experience, care coordination, access to care, and quality measures for diabetes. Key PCMH transformative features associated with psychosocial issues related to diabetes reviewed in this article include integration of mental and behavioral health, care management/coordination, payment reform, advanced access, and putting the patient at the center of health care. This article also reviews the evidence supporting comprehensive and integrated care for addressing psychosocial issues associated with diabetes in the medical home.

Expansion of telehealth curriculum: National survey of clinical education leaders.

INTRODUCTION: In response to the COVID pandemic and the rapid changes in delivery of and education on telehealth services, the Research Committee of the Alliance of Clinical Education (ACE) surveyed its multidisciplinary group of medical educators to determine how telehealth was being taught pre-COVID versus during-COVID. METHODS: An online survey was developed by the ACE Research Committee and sent via email to the ACE delegation. The objective of the survey was to determine changes in telehealth curriculum for medical students due to the rapid transition to telehealth, and the barriers for developing and delivering a telehealth curriculum. RESULTS: Forty-nine percent of recipients (31/63) responded representing eight different disciplines in addition to institutional curriculum developers. Most programs had no formal didactics and no clinical experiences in telehealth prior to the pandemic. Most respondents added didactics and clinical telehealth encounters during COVID, although few schools required this of all students. DISCUSSION: Given the barriers of faculty training to pivot to telehealth, and the potential benefits to healthcare cost and patient satisfaction, there is a need for more formal study on best practices for teaching telehealth to prepare our future physicians.

Trends in Registered Dietitian Nutritionists' Knowledge and Patterns of Coding, Billing, and Payment.

The US health care system has been undergoing substantial changes in reimbursement for medical and nutrition services. These changes have offered opportunities and challenges for registered dietitian nutritionists (RDNs) to bill for medical nutrition therapy and other nutrition-related services. During the past 10 years, the Academy of Nutrition and Dietetics has periodically surveyed RDNs providing medical nutrition therapy in ambulatory care settings to learn about their knowledge and patterns of coding, billing, and payment for their services. In 2018, the Academy of Nutrition and Dietetics conducted the latest iteration of this survey. This article compares the results of the 2008, 2013, and 2018 surveys to examine changes in RDNs' knowledge of billing code use and reimbursement patterns over time; understand the potential influences on coding and billing practices in a changing health care environment; and understand the effects of newer practice settings and care delivery models on billing and reimbursement for medical nutrition therapy services. Results from these surveys demonstrate that during the past 10 years RDNs' knowledge of billing and coding has been stable and very low for RDNs not in supervisory roles or private practice. RDNs reported an increase in providing medical nutrition therapy services to patients with multiple conditions. Since 2013, a dramatic increase was noted in the reported proportion of reimbursement from private/commercial health insurance plans. Results also indicate that most RDNs are not aware of changes in health care payment. Individual RDNs need to understand and be held accountable for the business side of practice and their value proposition in today's health care environment.

A Cluster Randomized Trial Comparing Strategies for Translating Self-Management Support into Primary Care Practices.

INTRODUCTION: Self-management support (SMS) is a key factor in diabetes care, but true SMS has not been widely adopted by primary care practices. Interactive behavior-change technology (IBCT) can provide efficient methods for adoption of SMS in primary care. Practice facilitation has been effective in assisting practices in implementing complex evidence-based interventions, such as SMS. This study was designed to study the incremental impact of practice education, the Connection to Health (CTH) IBCT tool, and practice facilitation as approaches to enhance the translation of SMS for patients with diabetes in primary care practices. METHODS: A cluster-randomized trial compared the effectiveness of 3 implementation strategies for enhancing SMS for patients with diabetes in 36 primary care practices: 1) SMS education (SMS-ED); 2) SMS-ED plus CTH availability (CTH); and 3) SMS-ED, CTH availability, plus brief practice facilitation (CTH + PF). Outcomes including hemoglobin A1c (HbA1c) levels and SMS activities were assessed at 18 months post study initiation in a random sample of patients through medical record reviews. RESULTS: A total of 488 patients enrolled in the CTH system (141 CTH, 347 CTH + PF). In the intent-to-treat analysis of patients with medical record reviews, HbA1c slopes did not differ between study arms (CTH vs SMS-ED: P = .2243, CTH + PF vs SMS-ED: P = .8601). However, patients from practices in the CTH + PF arm who used CTH showed significantly improved HbA1c trajectories over time compared with patients from SMS-ED practices (P = .0422). SMS activities were significantly increased in CTH and CTH + PF study arms compared with SMS-ED (CTH vs SMS-ED: P = .0223, CTH + PF vs SMS-ED: P = .0013). The impact of CTH on SMS activities was a significant mediator of the impact of the CTH and CTH + PF interventions on HbA1c. CONCLUSION: An interactive behavior change technology tool such as CTH can increase primary care practice SMS activities and improve patient HbA1c levels. Even brief practice facilitation assists practices in implementing SMS.

Practice Characteristics Associated with Better Implementation of Patient Self-Management Support.

BACKGROUND: Advanced primary care models emphasize patient-centered care, including self-management support (SMS). This study aimed to promote the translation of SMS into primary care practices and reported on key baseline practice characteristics that may impact SMS implementation. METHODS: Thirty-six practices in Colorado and California participated in the study from December 2013 to March 2017. Practice administrators completed a Practice Information Form describing practice characteristics. Clinicians and staff (n = 716) completed the Practice Culture Assessment and the Patient-Centered Medical Home (PCMH) Monitor. Descriptive statistics were computed to determine practice characteristics related to culture, quality improvement, level of PCMH, and SMS implementation. Field notes and key informant interviews provided contextual details about practices. Iterative qualitative analyses identified important facilitators and barriers and change capabilities around SMS implementation. RESULTS: In bivariate analyses, rural locations, fewer uncontrolled patients with diabetes, higher Medicaid or uninsured populations, underserved designation, and higher level of "PCMHness" were associated with greater reported implementation of patient SMS (all P < .05) at baseline. In the final multilevel model, specialty (FM vs mixed, P = .0081), rural location (P = .0109), and higher percent Medicaid (P < .0001) were associated with greater SMS. Practices described key facilitators (alignment, motivation, a visible champion, supporting infrastructure, and functional quality improvement and care teams) and barriers (no shared vision, no visible champion, siloed infrastructure, competing programs, turnover, and time constraints) to improving SMS delivery. CONCLUSIONS: Careful attention-and action-on key practice characteristics and context may create more favorable initial conditions for practice change efforts to improve SMS in primary care practices.

Recruiting Primary Care Practices for Research: Reflections and Reminders.

BACKGROUND: Recruiting primary care practices for research projects has always required carefully tended relationships, a compelling message, and good timing. Recruiting practices to participate in practice transformation research trials may take more and different efforts. We reflect on practice recruitment for a recently-concluded trial of a diabetes self-management support system in 2 states and 36 practices. METHODS: Iterative qualitative analysis of field notes, semistructured clinician and staff interviews, and meeting notes from a 2-state, cluster-randomized trial that aimed to improve self-management support for patients with type 2 diabetes mellitus. RESULTS: Although all 36 enrolled practices finished the study, fully recruiting practices early on took considerable effort, yielding 2 primary lessons: 1) practice-based research networks (PBRNs) must recruit more stakeholders at more levels, at the clinic, in the system, and across roles; and 2) practice recruitment is a process and may take longer than expected with unplanned turnover of key contacts. Adjusting our recruitment strategies required: helping with communication efforts in practices; aligning our study message according to stakeholders' interests; allowing for minor adaptations at the practice-level to align with critical practice workflows, staffing, and resources; re-engaging with clinical leadership over time; and identifying a "backup" champion due to turnover. CONCLUSIONS: When undertaking a pragmatic clinical trial requiring substantial practice change in a PBRN setting across a large number of practices, it is important that PBRN leaders develop a comprehensive strategy to identify and engage a broad group of stakeholders within each practice, understand their needs and priorities around research, and design and implement a structured communications strategy to maintain engagement throughout every phase of the project.

The Fit Family Challenge: A Primary Care Childhood Obesity Pilot Intervention.

BACKGROUND: Childhood obesity has increased dramatically over several decades, and the American Academy of Pediatrics has recommended primary care practices as ideal sites for the identification, education, and implementation of therapeutic interventions. The objective of this study was to describe the implementation and results for the Fit Family Challenge (FFC), a primary care-based childhood obesity intervention. METHODS: A single-intervention pilot project that trains primary care practices on childhood obesity guidelines and implementation of a family-focused behavior modification curriculum. A total of 29 family medicine and pediatric community practices in Colorado participated. Participants included 290 patients, aged 6 to 12 years, with a body mass index (BMI) above the 85th percentile. The main outcome measure included the feasibility of implementation of a childhood obesity program in primary care; secondary outcomes were changes in BMI percentile, BMI z-scores, blood pressure, and changes in lifestyle factors related to childhood obesity. RESULTS: Implementation of FFC is feasible, statically significant changes were seen for decreases in BMI percentile and BMI z-scores for participants who completed 9 to 15 months of follow-up; lifestyle factors related to childhood obesity in proved Spanish-speaking families and food insecurity were associated with less follow-up time (P < .01). CONCLUSIONS: A primary care-based childhood obesity intervention may result in significant clinical and lifestyle changes.

Registered dietitian nutritionists bring value to emerging health care delivery models.

Health care in the United States is the most expensive in the world; however, most citizens do not receive quality care that is comprehensive and coordinated. To address this gap, the Institute for Healthcare Improvement developed the Triple Aim (ie, improving population health, improving the patient experience, and reducing costs), which has been adopted by patient-centered medical homes and accountable care organizations. The patient-centered medical home and other population health models focus on improving the care for all people, particularly those with multiple morbidities. The Joint Principles of the Patient-Centered Medical Home, developed by the major primary care physician organizations in 2007, recognizes the key role of the multidisciplinary team in meeting the challenge of caring for these individuals. Registered dietitian nutritionists (RDNs) bring value to this multidisciplinary team by providing care coordination, evidence-based care, and quality-improvement leadership. RDNs have demonstrated efficacy for improvements in outcomes for patients with a wide variety of medical conditions. Primary care physicians, as well as several patient-centered medical home and population health demonstration projects, have reported the benefits of RDNs as part of the integrated primary care team. One of the most significant barriers to integrating RDNs into primary care has been an insufficient reimbursement model. Newer innovative payment models provide the opportunity to overcome this barrier. In order to achieve this integration, the Academy of Nutrition and Dietetics and RDNs must fully understand and embrace the opportunities and challenges that the new health care delivery and payment models present, and be prepared and empowered to lead the necessary changes. All stakeholders within the health care system need to more fully recognize and embrace the value and multidimensional role of the RDN on the multidisciplinary team. The Academy's Patient-Centered Medical Home/Accountable Care Organizations Workgroup Report provides a framework for the Academy, its members, and key partners to use to achieve this goal.

Curriculum redesign for teaching the PCMH in Colorado Family Medicine Residency programs.

BACKGROUND AND OBJECTIVES: The patient-centered medical home (PCMH) is a practice model that is intended to improve the quality of care by making it safer, more comprehensive, integrated, and personal. However, most family medicine residency programs are not fully prepared to train residents on this idealized model. The Colorado Family Medicine Residency PCMH Project's overall objective is to transform 10 residency practices into PCMHs through practice improvement and curriculum redesign. This paper focuses on the programs' implementation of key PCMH components into the residency curricula and the impact on resident self-perceived competence in and use of PCMH components. METHODS: Mixed-method evaluation assessed PCMH curricular characteristics, routine use of PCMH components in patient care, and perceived resident competence after implementation of quality improvement coaching and PCMH curriculum tools. Baseline and follow-up PCMH semi-structured curriculum interviews assessed elements included in the residency programs' curricula. The PCMH Clinician Assessment (PCMH-CA) Survey assessed routine use of PCMH components in patient care. The PCMH Competency Self-Assessment Survey assessed residents' perceived competency in applying PCMH elements in patient care. RESULTS: Qualitative data results demonstrated active efforts by the residency programs to implement key PCMH components. Survey results showed significant improvement from baseline to follow-up (12--36 months). CONCLUSIONS: Implementation of the key components of PCMH into practice improvement efforts and residency curricula improved residents' routine use of PCMH in patient care and their perceived PCMH competence.

Overcoming early barriers to PCMH practice improvement in family medicine residencies.

BACKGROUND AND OBJECTIVES: Residency programs face inevitable challenges as they redesign their practices for higher quality care and resident training. Identifying and addressing early barriers can help align priorities and thereby augment the capacity to change. METHODS: Evaluation of the Colorado Family Medicine Residency PCMH Project included iterative qualitative analysis of field notes, interviews, and documents to identify early barriers to change and strategies to overcome them. RESULTS: Nine common but not universal barriers were identified: (1) a practice's history reflected some negative past experiences with quality improvement or routines incompatible with transformative change, (2) leadership gaps were evident in unprepared practice leaders or hierarchical leadership, (3) resistance and skepticism about change were expressed through cynicism aimed at change or ability to change, (4) unproductive team processes were reflected in patterns of canceled meetings, absentee leaders, or lack of accountability, (5) knowledge gaps about the Patient-centered Medical Home (PCMH) were apparent from incomplete dissemination about the project or planned changes, (6) EHR implementation distracted focus or stalled improvement activity, (7) sponsoring organizations' constraints emerged from staffing rules and differing priorities, (8) insufficient staff participation resulted from traditional role expectations and structures, and (9) communication was hampered by ineffective methods and part-time faculty and residents. Early barriers responded to varying degrees to specific interventions by practice coaches. CONCLUSIONS: Some barriers that interfere with practices getting started with cultural and structural transformation can be addressed with persistent attention and reflection from on-site coaches and by realigning the talents, leaders, and priorities already in these residency programs.

Weight loss in a community initiative that promotes decreased energy intake and increased physical activity and dairy consumption: Calcium Weighs-In.

BACKGROUND: This project addresses the need to identify feasible, effective weight-management programs that can be implemented within communities. The controversial role of dairy products in weight-management programs is also explored. METHODS: The "Calcium Weighs-In" weight-loss program placed equal emphasis on diet and physical activity and was delivered within a community intervention to promote dairy consumption in Calcium, New York. One hundred ninety-nine adults in Calcium, NY, participated in the weight-loss program. Weight loss, increase in dairy intake, increase in steps, decrease in blood pressure, decrease in waist circumference, and decrease in body mass index (BMI) were examined. RESULTS: The mean weight loss for 116 subjects who completed the program was 6.0 +/- 4.2 kg (mean +/- SD, P < .0001) with a percent weight change of 6.4% +/- 4.2% (P < .0001). An increase of 3582 +/- 4070 steps (P < .0001), as well as an increase of 0.8 +/- 1.2 dairy servings (P < .0001) was seen. Higher average dairy consumption was associated with greater weight loss and a greater decrease in waist circumference. CONCLUSION: The results show that effective weight-management programs can be implemented within communities. The results are also consistent with recommendations to include low-fat dairy products and a physical activity component in weight-management programs.