Rates and Correlates of Uptake of Continuous Glucose Monitors Among Adults with Type 2 Diabetes in Primary Care and Endocrinology Settings.

BACKGROUND: Clinical trials indicate continuous glucose monitor (CGM) use may benefit adults with type 2 diabetes, but CGM rates and correlates in real-world care settings are unknown. OBJECTIVE: We sought to ascertain prevalence and correlates of CGM use and to examine rates of new CGM prescriptions across clinic types and medication regimens. DESIGN: Retrospective cohort using electronic health records in a large academic medical center in the Southeastern US. PARTICIPANTS: Adults with type 2 diabetes and a primary care or endocrinology visit during 2021. MAIN MEASURES: Age, gender, race, ethnicity, insurance, clinic type, insulin regimen, hemoglobin A1c values, CGM prescriptions, and prescribing clinic type. KEY RESULTS: Among 30,585 adults with type 2 diabetes, 13% had used a CGM. CGM users were younger and more had private health insurance (p < .05) as compared to non-users; 72% of CGM users had an intensive insulin regimen, but 12% were not taking insulin. CGM users had higher hemoglobin A1c values (both most recent and most proximal to the first CGM prescription) than non-users. CGM users were more likely to receive endocrinology care than non-users, but 23% had only primary care visits in 2021. For each month in 2021, a mean of 90.5 (SD 12.5) people started using CGM. From 2020 to 2021, monthly rates of CGM prescriptions to new users grew 36% overall, but 125% in primary care. Most starting CGM in endocrinology had an intensive insulin regimen (82% vs. 49% starting in primary care), whereas 28% starting CGM in primary care were not using insulin (vs. 5% in endocrinology). CONCLUSION: CGM uptake for type 2 diabetes is increasing rapidly, with most growth in primary care. These trends present opportunities for healthcare system adaptations to support CGM use and related workflows in primary care to support growth in uptake.

Improving annual albuminuria testing for individuals with diabetes.

BACKGROUND: Annual albuminuria screening detects the early stages of nephropathy in individuals with diabetes. Because early detection of albuminuria allows for interventions that lower the risk of developing chronic kidney disease, guidelines recommend annual testing for all individuals with type 2 diabetes mellitus and for those with type 1 diabetes for at least 5 years. However, at the Eskind Diabetes Clinic at the Vanderbilt University Medical Center, testing occurred less frequently than desired. METHODS: A quality improvement team first analysed the clinic's processes, identifying the lack of a systematic approach to testing as the likely cause for the low rate. The team then implemented two successive interventions in a pilot of patients seen by nurse practitioners in the clinic. In the first intervention, staff used a dashboard within the electronic health record while triaging each patient, pending an albuminuria order if testing had not been done within the past year. In the second intervention, clinic leadership sent daily reminders to the triage staff. A statistical process control chart tracked monthly testing rates. RESULTS: After 6 months, annual albuminuria testing increased from a baseline of 69% to 82%, with multiple special-cause signals in the control chart. CONCLUSIONS: This project demonstrates that a series of simple interventions can significantly impact annual albuminuria testing. This project's success likely hinged on using an existing workflow to systematically determine if a patient was due for testing and prompting the provider to sign a pended order for an albuminuria test. Other diabetes/endocrinology and primary care clinics can likely implement a similar process and so improve testing rates in other settings. When coupled with appropriate interventions to reduce the development of chronic kidney disease, such interventions would improve patient outcomes, in addition to better adhering to an established quality metric.

Teaching Critical Appraisal Through the Lens of Study Design in Journal Club.

Training in endocrinology presents a major challenge: How to both develop a fellow's medical knowledge and teach that fellow to independently increase that fund of knowledge as a future endocrinologist. Journal clubs hold a traditional role in teaching the most recent modern advances in medicine but frequently struggle to provide trainees with the skills needed to assess the quality of current literature. Using journal clubs to instill the skills needed for critical appraisal overcomes this difficulty and substantially enhances the value of journal clubs to trainees. Here, our journal club is reviewed, in which we teach critical appraisal by focusing on understanding study design as the key to assessing an article's strengths and weaknesses. This journal club starts the year by reviewing study designs in a structured sequence, with sessions built to foster group participation and involvement of both fellows and faculty. Later, fellows put this learning into practice as they independently assess articles alongside their faculty. Generalizing this practice allows for implementation in other programs, including even those without faculty with a background in research methodology.

Is the Climb Worth the View? The Savings/Alert Ratio for Reducing Vitamin D Testing.

BACKGROUND: Despite guideline recommendations, vitamin D testing has increased substantially. Clinical decision support (CDS) presents an opportunity to reduce inappropriate laboratory testing. OBJECTIVES AND METHODS: To reduce inappropriate testing of vitamin D at the Vanderbilt University Medical Center, a CDS assigned providers to receive or not receive an electronic alert each time a 25-hydroxyvitamin D assay was ordered for an adult patient unless the order was associated with a diagnosis in the patient's chart for which vitamin D testing is recommended. The CDS ran for 80 days, collecting data on number of tests, provider information, and basic patient demographics. RESULTS: During the 80 days, providers placed 12,368 orders for 25-hydroxyvitamin D. The intervention group ordered a vitamin D assay and received the alert for potentially inappropriate testing 2,181 times and completed the 25-hydroxyvitamin D order in 89.9% of encounters, while the control group ordered a vitamin D assay (without receiving an alert) 2,032 times and completed the order in 98.1% of encounters, for an absolute reduction of testing of 8% (p < 0.001). CONCLUSION: This CDS reduced vitamin D ordering by utilizing a soft-stop approach. At a charge of $179.00 per test and a cost to the laboratory of $4.20 per test, each display of the alert led to an average reduction of $14.70 in charges and of $0.34 in spending by the laboratory (the savings/alert ratio). By describing the effectiveness of an electronic alert in terms of the savings/alert ratio, the impact of this intervention can be better appreciated and compared with other interventions.

Experience of US Patients Who Self-identify as Having an Overdiagnosed Thyroid Cancer: A Qualitative Analysis.

Importance: Overdiagnosis of cancer-the identification of cancers that are unlikely to progress-is a source of discomfort and challenge for patients, physicians, and health care systems. A major cause of this discomfort is the inability to know prospectively with certainty which cancers are overdiagnosed. In thyroid cancer, as patients have begun to understand this concept, some individuals are independently deciding not to intervene, despite this practice not yet being widely accepted. Objective: To describe the current experience of people who independently self-identify as having an overdiagnosed cancer and elect not to intervene. Design, Setting, and Participants: In this qualitative study, semistructured interviews were conducted between July 1 and December 31, 2015, with 22 community-dwelling adults aged 21 to 75 years who had an incidentally identified thyroid finding that was known or suspected to be malignant and who questioned the intervention recommended by their physicians. Verbatim transcripts were analyzed using constant comparative analysis. Main Outcomes and Measures: The experience of individuals who self-identify as having an overdiagnosed cancer and elect not to intervene. Results: Of the 22 people interviewed (16 females and 6 males; mean age, 48.5 years), 18 had elected not to intervene on their thyroid finding and had been living with the decision for a mean of 39 months (median, 40 months; range, 1-88 months). Twelve of the 18 participants reported that they experienced significant anxiety about cancer progression, but had considered reasons for choosing nonintervention: understanding issues of precision in diagnostic testing and the varied behavior of cancer, surgical risks, medication use, and low risk of death from the cancer. Twelve participants described their decisions as met with nonreassuring, unsupportive responses. Medical professionals, friends, and internet discussion groups told them they were "being stupid," "were wrong," or were "crazy" to not intervene. Although 14 individuals said they wished to connect with others about their experiences, only 3 reported success in doing so. Fifteen participants reported that they managed their overall experience through secret keeping. By the time of this study, 5 of the 18 individuals had discontinued surveillance, the recommended alternative to intervention. Despite this, only 7 participants "wished they did not know" about their thyroid finding. Conclusions and Relevance: Isolation and anxiety characterize the current experience of patients with thyroid cancer who are living with the decision to not intervene. These patients are at risk of disengaging from health care. Successful de-escalation of intervention for patients who self-identify as having overdiagnosed cancers requires explicit social and health system support and education. We hypothesize that improved support would also promote quality of care by increasing the likelihood that patients could be kept engaged for recommended surveillance.

ASSESSING REFERRALS AND IMPROVING INFORMATION AVAILABILITY FOR CONSULTATIONS IN AN ACADEMIC ENDOCRINOLOGY CLINIC.

OBJECTIVE: Outpatient specialty consultations rely on the timeliness and completeness of referral information to facilitate a valuable patient-specialist interaction. This project aimed to increase essential diagnostic information availability at the initial consultation for patients referred for common endocrine conditions frequently lacking such data-diabetes mellitus, thyroid nodule, thyrotoxicosis, and hypercalcemia. METHODS: At an endocrinology clinic at an academic medical center in rural New England, providers see several thousand new patients annually, the majority of whom are referred by providers external to the clinic's healthcare system. Through consensus, endocrinology clinic providers agreed on the two or three data elements essential for a meaningful initial consultation for each. A quality improvement team employed a planned series of interventions based on previously published methods and an innovative approach: dissemination of a referral guideline, an assessment of referral adequacy in the endocrinology clinic workflow, coupled with focused requests for missing items, and a pre-visit lab appointment. RESULTS: Between April 2015 and March 2016, 762 referrals were reviewed. At baseline for the four conditions, referrals contained all essential elements only 27.5% (22 of 80) of the time. Over a 7-month period, the team implemented the interventions, with subsequent referrals containing all essential elements increasing to 75.5% (P<.0001), largely attributable to the pre-visit lab appointment. CONCLUSION: Incoming referrals that lack essential information are a significant problem in specialty care and may adversely affect patient experience, provider satisfaction, and clinic efficiency. Improvement may require innovative approaches, such as the potentially transferable and generalizable ones employed here. ABBREVIATIONS: DHMC = Dartmouth-Hitchcock Medical Center EHR = electronic health record PDSA = Plan-Do-Study-Act.

Interventions to Improve the Quality of Outpatient Specialty Referral Requests: A Systematic Review.

Requests for outpatient specialty consultations occur frequently but often are of poor quality because of incompleteness. The authors searched bibliographic databases, trial registries, and references during October 2014 for studies evaluating interventions to improve the quality of outpatient specialty referral requests compared to usual practice. Two reviewers independently extracted data and assessed quality. Findings were qualitatively summarized for completeness of information relayed in a referral request within naturally emerging intervention categories. Of 3495 articles screened, 11 were eligible. All 3 studies evaluating software-based interventions found statistically significant improvements. Among 4 studies evaluating template/pro forma interventions, completeness was uniformly improved but with variable or unreported statistical significance. Of 4 studies evaluating educational interventions, 2 favored the intervention and 2 found no difference. One study evaluating referral management was negative. Current evidence for improving referral request quality is strongest for software-based interventions and templates, although methodological quality varied and findings may be setting specific.

Renal impairment as a surgical indication in primary hyperparathyroidism: do the data support this recommendation?

CONTENT: Management of primary hyperparathyroidism has evolved over the past two decades, yet impaired renal function has consistently been a surgical indication. This recommendation has been based upon the historical association between primary hyperparathyroidism and renal impairment, and a review of the literature is needed to determine whether such a recommendation is warranted. EVIDENCE ACQUISITION AND SYNTHESIS: PubMed was utilized to identify English-language articles published between January 1990 and February 2014 using keywords related to hyperparathyroidism and renal function. The keywords were "primary hyperparathyroidism," "surgery," "parathyroidectomy," "kidney," "renal," "glomerular filtration rate," and "creatinine." Of the 1926 articles obtained with this search, all articles germane to the topic that quantified the relationship between primary hyperparathyroidism and renal function were included. All references within these articles were investigated for inclusion. When helpful, data tables were constructed to summarize the results succinctly. CONCLUSIONS: A secondary elevation of PTH levels has not been consistently shown to occur at the threshold currently indicated for surgical intervention. While renal impairment is seen with more significant disease, mild asymptomatic primary hyperparathyroidism has not been conclusively associated with renal impairment. Furthermore, there is no evidence to suggest that surgically curing primary hyperparathyroidism via a parathyroidectomy has any impact upon renal function.