CGM Uptake Very Low for Vulnerable Diabetes Populations

Uptake of continuous glucose monitoring (CGM) was relatively low among vulnerable diabetes patients in the largest national system of safety-net primary care clinics, a retrospective cross-sectional study found.

In patients receiving primary care at federally qualified health centers (FQHCs), only 11% of those with type 1 diabetes and 1% of those with type 2 diabetes were prescribed CGM, reported researchers led by Amisha Wallia, MD, MSCI, of Northwestern University in Chicago.

This is substantially below some of the most recent estimates of CGM use in endocrinology clinics, where uptake has been the greatest, with reported rates as high as 46%, they wrote in JAMA Network Open.

The magnitude of the prescribing disparity was a surprise, Wallia told MedPage Today.

“Type 1 and type 2 diabetes differ significantly in the underlying pathophysiology of the disease, which has been reflected in decision making about policy coverage for technology such as insulin pumps and sensors such as continuous glucose monitors,” she said. “However, our results show that disparities in the prescribing of the CGM technology are markedly similar — and low — in both groups.”

Wallia and colleagues’ looked at data from January 2014 (when CGM was first prescribed) to February 2021, and included 1,168 and 35,216 type 1 and type 2 patients, respectively. From 2014 to 2020, rates of CGM prescriptions overall increased from six to 1,039. In the first 2 months of 2021, there were 214 prescriptions for CGM.

“It’s imperative that we examine how we can improve access and prescribing, especially in primary care, for our sickest patients,” said Wallia. “CGM helps improve glucose levels and assists patients with low blood sugar identification and treatment, which can be a significant quality-of-life issue for many patients with diabetes.”

Yet the question of how to achieve equitable CGM use “remains a complicated one,” wrote Rocio I. Pereira, MD, of Denver Health, in an accompanying commentary.

“Recognition that disparities exist at the prescription level is helpful, but the system-level factors serving as mediators of those disparities still need to be identified,” said Pereira. “Disparities at other steps in the process (prescription fill, initial use, and maintained use) and factors mediating those disparities will also need to be identified and addressed.”

The researchers pointed out that boosting CGM scripts in outpatient settings will have to overcome systemic barriers including a lack of time, support, and expertise among clinicians. Changes in Medicaid policy have “the greatest potential” to boost CGM use in FQHCs since it’s the primary payer in this setting, Wallia’s group said. But in the meantime, the first over-the-counter CGM approved earlier this year, is a step in the right direction toward better access.

“While there are likely systems-level factors at play, we all must think about how we can improve access to technology for our patients,” said Wallia. “CGM is now direct-to-consumer, and more patients — even those without diabetes — will be able to obtain access to the technology.”

“As physicians, we need to understand and ensure we are offering technologies that are available to our patients, especially to those who could benefit the most. Some patients prefer CGM for a multitude of reasons, and CGM has been proven to be efficacious in the care of those with diabetes,” she underscored.

The researchers used electronic health record data from 275 FQHC clinic sites nationwide to look at CGM prescribing patterns among adults with diabetes. In the type 1 diabetes group (mean 42 years, 51% male), 32% were Black and 64% were white, with 22% Hispanic. In the type 2 diabetes group (mean 58 years, 56% women), 34% were Black and 58% were white, with 37% Hispanic.

In type 1 diabetes, the researchers pinpointed a few sociodemographic and racial/ethnic factors that were predictive of lower odds of a CGM prescription:

• Hispanic ethnicity: OR 0.30 (95% CI 0.16-0.57)
• Black race: OR 0.61 (95% CI 0.38-0.99)
• Uninsured: OR 0.42 (95% CI 0.23-0.74)

The same sociodemographic predictors were also present in the type 2 diabetes population:

• Hispanic ethnicity: OR 0.43 (95% CI 0.32-0.57)
• Black race: OR 0.76 (95% CI 0.59-0.98)
• Uninsured: OR 0.42 (95% CI 0.31-0.58)

As for clinical predictors, type 2 diabetes patients with an HbA1c over 9% were significantly more likely to receive a CGM prescription (OR 3.17, 95% CI 2.37-4.21), as were those with more diabetes complications.

Among the limitations of the study was an inability to determine long-term use of CGMs, since prescriptions don’t equate to real-world usage.