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The American Academy of Family Physicians (AAFP) develops and maintains continuing medical education that is relevant to modern primary care practices. One continuing medical education modality is AAFP TIPS, which are comprised of resources designed for family medicine physicians and their care teams that aid in quick and accessible practice improvement strategies, with actionable steps. Evaluating physicians’ use of and satisfaction with this modality’s content and implementation strategies has not been prioritized previously. Continuous glucose monitoring (CGM) plays an increasing role in the treatment of diabetes; uptake occurs more rapidly in endocrinology settings than in primary care settings. To help address such differences in CGM uptake and diabetes care, AAFP TIPS on Continuous Glucose Monitoring (AAFP TIPS CGM) was developed, using published evidence and input from content experts (family medicine faculty; AAFP staff; and an advisory group comprised of other primary care physicians, patients, a pharmacist, and a primary care practice facilitator). A pilot implementation project was conducted in 3 primary care practices.
To evaluate AAFP TIPS CGM in primary care practices, the research team assessed use of and satisfaction with the content and assessed barriers to and facilitators for strategy and workflow implementation.
In total, 3 primary care practices participated in a mixed methods pilot implementation of AAFP TIPS CGM between June and October 2021. Practice champions at each site completed AAFP TIPS CGM and baseline practice surveys to evaluate practice characteristics and CGM prescribing. They conducted team trainings (via webinars or in person), with the goals of implementing CGM into practice and establishing or improving CGM workflows. Practice champions and team training participants completed posttraining surveys to evaluate the training, AAFP TIPS materials, and likelihood of implementing CGM. Interviews were conducted with 6 physicians, including practice champions, 2 months after team training. Satisfaction surveys were also distributed to those who completed the AAFP TIPS CGM course via the internet during the study period.
Of the 3 practices, 2 conducted team trainings. The team training evaluation survey showed that practice staff understood their role in implementing CGM in practice (19/20, 95%), and most (11/20, 55%) did not have questions after the training. Insurance coverage for CGM was a remaining knowledge gap and potential barrier to implementing CGM in practice. Physicians and interdisciplinary care team members who took the AAFP TIPS CGM course via the internet, as well as those who attended in-person team training, expressed a high degree of satisfaction with the education, content, and applicability of the course.
This pilot implementation of AAFP TIPS CGM offers pertinent and timely information for primary care practices that desire to initiate or expand CGM use to best meet the needs of their patients with diabetes.
Continuous glucose monitoring (CGM) is recommended for many people with diabetes [
CGM is associated with improved hemoglobin A1c levels, decreased hypoglycemia, and improved quality of life, and it can reduce or replace the use of finger sticks for the self-monitoring of blood glucose [
AAFP TIPS are brief, interactive, web-based continuing medical education (CME) courses that focus on team-based tools and customizable team training slide decks, which are designed to assist physicians and care teams in making immediate practice improvements [
This mixed methods pilot implementation of the web-based AAFP TIPS CGM course assessed primary care practice adoption, experience, and feedback during the immediate 6 months following the course’s launch (April 16, 2021, through October 19, 2021). The course has a variety of education topics and resources (
A physician practice champion enrolled in and completed AAFP TIPS CGM. Team-based trainings, which roughly mirrored course lessons, were designed to be customizable by practice champions. Each slide deck took about 30 minutes to present. Practice champions were encouraged to present a team training within 30 days of completing the course, utilizing the slide decks and facilitator guide. They ultimately determined how and when to implement team trainings and which resources and slide decks to present.
AAFP TIPS CGMa lesson topics and tools.
Lesson | Topics | Tools (unless noted, tools are practice facing) |
Lesson 1 |
Background and overview of CGMb Types of CGM |
CGM overview handout |
Lesson 2 |
Overview of American Diabetes Association Standards of Medical Care in Diabetes Case studies Identifying patients who may benefit from CGM |
Patient CGM identification tool (handout) Perceived benefits and burdens of CGM scales (surveys) |
Lesson 3 |
Educating patients about CGM Shared decision-making Interpreting CGM data and reports Using CGM to inform treatment adjustments Case examples |
Components of a continuous glucose monitor (handout) Patient-facing DiabetesWise.org website guide (handout) Key CGM measures (handout) Patient-facing handout |
Lesson 4 |
Practice workflow and integration Ordering CGM Documentation Billing Follow-up Keeping updated Quality improvement |
Sample prescription order for CGM supplies Sample CGM practice checklist for personnel (workflow) Coding and billing for CGM (handout) CGM Staff Roles (PowerPoint team training presentation) Facilitator guide for roles, tasks, and workflow activities Quality improvement planning worksheet CGM run chart Helpful links Patient registry example |
aAAFP TIPS CGM: American Academy of Family Physicians TIPS on Continuous Glucose Monitoring.
bCGM: continuous glucose monitoring.
Screenshot of the AAFP TIPS CGM course landing page. AAFP TIPS CGM: American Academy of Family Physicians TIPS on Continuous Glucose Monitoring.
A total of 3 primary care practices from the AAFP National Research Network were selected based on their interest and their ability to implement training within the study period. Physician champions at each site were both participants of this study and part of the team executing the intervention because of their role in teaching the team training. Interviews were conducted with physician champions and additional physicians at one site.
Beyond the three participating practices, the course was available to the public from April 16, 2021, until April 15, 2023.
Practice champions completed a baseline practice survey about practice characteristics, the patient population with diabetes, and CGM use. Upon completion of a team training, practice champions and team training participants completed an anonymous, web-based evaluation that assessed satisfaction with course materials and comfort with implementing CGM workflows. Practice champions completed a CGM use postsurvey 2 months after team training. Physician training participants were invited to participate in a semistructured interview.
Course satisfaction was measured with a standard CME evaluation survey that is included in AAFP CME. Everyone who completed the final lesson of the course was presented with an optional CME evaluation. Evaluations completed between April 16, 2021, and September 30, 2021, were included in the analysis.
The data analysis included descriptive statistics for surveys and a deductive analytical approach for interview text (ie, rapid qualitative analysis) [
This study was approved by the AAFP Institutional Review Board (protocol 21-412). Physician champions were consented via electronic consent. A waiver of documentation of informed consent was granted for survey respondents and interviewees. Survey respondents received a US $25 e–gift card, and interviewees received a US $100 e–gift card. All data were deidentified and stored on a secure server.
Participating sites represented diverse practice types (a large multispecialty practice, a family medicine residency practice, and a single-physician practice).
Each site conducted customized team trainings that varied in terms of length, content, and attendees. The solo practice did not conduct formal team training, given the team’s small size. Physicians and interdisciplinary care team members who attended a team training reported a high degree of satisfaction with the training, content, and applicability of information (
Practice demographics of evaluation sites (n=3).
Site number | Practice type | Clinicians at the site, n | Patients by sex in clinics, % | Greater than 20% of practice population includes racial minority patients | Greater than 10% of patient population includes Hispanic or Latinx patients |
Payer mix |
|
|
|
|
Male | Female |
|
|
|
1 | Primary care only | 1 | 40 | 60 | Yes | Yes | Medicare: 40%; Medicaid: 15%; both Medicare and Medicaid: 0%; commercial insurance: 40%; uninsured: 5%; other: 0% |
2 | Community-based residency center | ≥21 | 51 | 49 | Yes | No | Medicare: 20%; Medicaid: 60%; both Medicare and Medicaid: 10%; commercial insurance: 7%; uninsured: 3%; other: 9% |
3 | Academic-based residency center |
≥21 | 46 | 54 | Unsure | Yes | Medicare: 19%; Medicaid: 5%; both Medicare and Medicaid: 5%; commercial insurance: 70%; uninsured: 0%; other: 1% |
Team training satisfaction results (n=20).
Items | Ratings | |||||
|
Rating, mean (SD) | 5, n (%) | 4, n (%) | 3, n (%) | 2, n (%) | 1, n (%) |
How do you rate the training materials (PowerPoints, handouts, and interactive activities) overall?a | 1.45 (0.6) | 0 (0) | 0 (0) | 1 (5) | 7 (35) | 12 (60) |
The training met my expectationsb | 1.2 (0.41) |
0 (0) | 0 (0) | 0 (0) | 4 (20) | 16 (80) |
I will be able to apply the knowledge I learnedb | 1.2 (0.41) | 0 (0) | 0 (0) | 0 (0) | 4 (20) | 16 (80) |
The content was organized and easy to followb | 1.35 (0.67) | 0 (0) | 0 (0) | 2 (10) | 3 (15) | 15 (75) |
The materials distributed were pertinent and usefulb | 1.2 (0.41) | 0 (0) | 0 (0) | 0 (0) | 4 (20) | 16 (80) |
Class participation and interaction were encouragedb | 1.15 (0.37) | 0 (0) | 0 (0) | 0 (0) | 3 (15) | 17 (85) |
Adequate time was provided for questions and discussionb | 1.35 (0.67) | 0 (0) | 0 (0) | 2 (10) | 3 (15) | 15 (75) |
I understand what role I will play in CGMc workflowsb | 1.4 (0.6) | 0 (0) | 0 (0) | 1 (5) | 6 (30) | 13 (65) |
aRatings: 5=very poor; 4=poor; 3=average; 2=good; 1=excellent.
bRatings: 5=strongly disagree; 4=disagree; 3=neutral; 2=agree; 1=strongly agree.
cCGM: continuous glucose monitoring.
Team training results (n=20).
Question and responses | Respondents, n (%) | |
|
||
|
I have no questions or concerns | 11 (55) |
|
I have questions or concerns about how CGM works | 3 (15) |
|
I have questions or concerns about how to introduce CGM to patients | 2 (10) |
|
I have questions or concerns about how to interpret CGM data | 2 (10) |
|
I have questions or concerns about my role/responsibilities in the CGM workflow | 2 (10) |
|
I have questions or concerns about insurance coverage for CGM for our practice's patients | 5 (25) |
|
I have questions or concerns about billing or coding for CGM | 2 (10) |
|
I have other questions or concerns (please specify) | 0 (0) |
aCGM: continuous glucose monitoring.
During the study period, 376 individuals completed AAFP TIPS CGM. Respondents who completed the CME evaluation (n=117) expressed high levels of satisfaction with the education, tools, and resources. An overwhelming majority (112/116, 96.6%) agreed or strongly agreed that they would recommend the activity to colleagues (
AAFP TIPS CGMa CMEb evaluation survey results (n=117).
Items | Poor or strongly disagree, n (%) | Fair or disagree, n (%) | Good or neutral, n (%) | Very good or agree, n (%) | Excellent or strongly agree, n (%) |
How well did this activity provide you with practical knowledge or strategies you can immediately apply to your practice?c | 0 (0) | 2 (1.7) | 10 (8.5) | 45 (38.5) | 60 (51.3) |
How would you rate the effectiveness of the tools?c | 0 (0) | 1 (0.9) | 12 (10.4) | 37 (32.2) | 65 (56.5) |
How well did this activity address barriers to your optimal patient management?c | 0 (0) |
3 (2.6) | 19 (16.5) | 42 (36.5) | 51 (44.3) |
I would recommend this activity to my colleaguesd | 0 (0) | 1 (0.9) | 3 (2.6) | 45 (38.8) | 67 (57.8) |
aAAFP TIPS CGM: American Academy of Family Physicians TIPS on Continuous Glucose Monitoring.
bCME: continuing medical education.
cThe responses for this item were “poor,” “fair,” “good,” “very good,” and “excellent.”
dThe responses for this item were “strongly disagree,” “disagree,” “neutral,” “agree,” and “strongly agree.”
A total of 3 practice champions and 3 other physicians at the community residency site were interviewed. Due to scheduling challenges, we were not able to interview physicians or clinicians at the academic residency. Physician interviewees (n=6) had little to no previous experience with prescribing CGM, but some had seen patients using a continuous glucose monitor prescribed by a specialist. Overall, they expressed the desire to be better informed about how to successfully prescribe CGM, answer patients’ questions, and interpret CGM data to potentially improve patient outcomes.
Interviewees reported perceived benefits of CGM prescribing and CGM data interpretation, including alleviating reliance on specialists, bolstering decision-making with patients, influencing patient outcomes and behavior change, aiding adherence, and preventing discomfort issues with traditional blood glucose monitoring finger sticks.
With regard to course utility, participants thought that the course provided foundational knowledge for clinical care and data interpretation. Interviewees cited the
CGM prescribing workflows varied across sites because of differences in practice models, staffing, patient needs, and impacts of the COVID-19 pandemic. Interviewees cited barriers (eg, prior authorizations and insurance coverage, issues with workflow refinement and follow-up, and patient hesitancy) for incomplete CGM implementation at the time of interviews.
Interviewees provided suggestions for course improvement, including expanding case studies (eg, electronic health record prescription navigation, patients with cognitive limitations or cognitive decline, and patients with financial concerns), adding more brand-specific information, including more professional CGM information, and refining some tools to specify physician tasks and staff tasks. Interviewees also suggested more information on insurance authorization processes and local and regional particularities that impact obtaining continuous glucose monitors. Lastly, they wanted manufacturer resources (eg, samples and videos).
This study describes a pilot implementation of AAFP TIPS CGM—a course designed for physicians and care teams to initiate or expand CGM use in primary care practices. Respondents reported being highly satisfied with and informed by the course materials. Sites were able to modify or create new CGM prescribing workflows. Interviewees also had suggestions for additional content (eg, information on successful prescription and insurance authorization [
This study has limitations. This study’s short duration, which was compounded with the implementation of new workflows during the COVID-19 pandemic, contributed to difficulties in implementing new steps. Further, navigating insurance authorizations presented challenges, and no one utilized billing and coding tools or practice checklist tools. Additionally, team trainings were inconsistent across sites. Practice champions developed in-person trainings, and sites did not include all training sections. We also did not measure pre- and post-CGM knowledge. Lastly, our sample of practices leaned heavily on residency programs.
This pilot implementation offers pertinent and timely information for primary care practices seeking to initiate or expand CGM use to best meet the needs of their patients with diabetes. Although course information was relevant and useful, additional resources and strategies, especially those for insurance coverage and authorizations, would be helpful for successful CGM workflow implementation.
American Academy of Family Physicians
American Academy of Family Physicians TIPS on Continuous Glucose Monitoring
continuous glucose monitoring
continuing medical education
The authors would like to note that AAFP TIPS is trademarked by the American Academy of Family Physicians (AAFP). This study was done in partnership with the AAFP through the AAFP National Research Network. The AAFP has not contributed to this publication, and the information, content, and conclusions are those of the authors. This study would not have been possible without the participation of the AAFP National Research Network practices, individual physicians, and care team members. We thank them for their essential contributions to this work. The authors would also like to thank Elizabeth Staton, MSTC, for her thorough review of the manuscript.
The authors disclose the receipt of the following financial support for the research, authorship, and publication of this article: this work was supported by a grant from Abbott Diabetes Care (no grant number).
The data are hosted on the research team’s internal servers and can be provided under reasonable request.
TKO and SMO have served as consultants for DiabetesWise.org, Dexcom, and Medscape and have received grant funding for an investigator-initiated research study from Abbott Diabetes. The other authors report no disclosures.