Continuous glucose monitoring (CGM) is a technology that helps individuals with diabetes track their sugar levels in real-time, leading to more in-range blood sugars, fewer episodes of dangerously low blood sugar, and improved quality of life. Despite these benefits, CGM is not widely used in primary care settings, where most people receive their diabetes care. The investigators aim to make CGM more accessible and equitably prescribed in primary care practices. The study team will support primary care to increase CGM use with a program called SPARK-CGM (Supporting Primary Care Adoption, Resources, and Knowledge for CGM) across a large network of primary care clinics at Montefiore Medical Center. This program will provide primary care providers (PCPs) with education, tools, and support to incorporate CGM into their routine care for people with diabetes. Investigators plan to test SPARK-CGM to evaluate whether it increases CGM prescriptions who are eligible to receive this technology.

Continuous glucose monitoring (CGM) has been shown to reduce HbA1c levels, hypoglycemia, and improve quality of life, representing a powerful tool to improve population-level outcomes in diabetes. The American Diabetes Association (ADA) recommends CGM for all individuals with any type of diabetes on insulin, but its widespread adoption into primary care remains low.

SPARK-CGM (Supporting Primary care Adoption, Resources, and Knowledge for CGM) is a hybrid effectiveness-implementation trial evaluating a multifaceted practice transformation package designed to increase new continuous glucose monitoring (CGM) prescriptions among adult patients with diabetes treated wtih insulin. This includes: (1) strengthening clinic capacity by streamlining CGM prescribing pathways; (2) optimizing pharmacy and insurance authorization workflows to reduce administrative burden; (3) providing prescriber-focused training on CGM workflows, data access, and interpretation to support effective clinical use; (4) training nursing and support staff to facilitate device initiation, patient education, and data management; and (5) delivering regular performance feedback on prescribing rates across clinics and providers.

The effectiveness component will be evaluated using a stepped-wedge cluster randomized trial in which primary care clinic clusters sequentially transition from usual care to the SPARK-CGM implementation intervention over the study period until all clinics receive the intervention. The implementation component will include mixed-methods evaluation using surveys and semi-structured interviews with patients, providers and clinic staff to assess implementation outcomes.

Based on pre-implementation clinic counts, the stepped-wedge trial will include 14 non-pilot primary care clinics. The investigators expect to include up to approximately 20,000 adult patients with insulin-treated diabetes who may contribute data to the effectiveness analysis (Aim 1) during the study period . For implementation evaluation and semi-structured interviews (Aim 2), investigators plan to recruit up to 40 adults with insulin-treated diabetes (10 per cluster) and 15-20 clinicians or clinic staff participants (4-5 per cluster) in order to reach thematic saturation.

Inclusion Criteria:

Clinic level:

• All adult Montefiore primary care sites
• Clinician and clinic staff will be eligible if they provide direct patient care or are involved in CGM prescribing, authorization, onboarding, or education at participating primary care clinics. Eligible clinicians include physicians, nurse practitioners, physician assistants, and clinicians in training. Eligible clinic staff may include nurses, medical assistants, and other relevant administrative staff

Patient level:

• Age 18 years or older
• Receive primary care at participating sites
• Diagnosis of any diabetes mellitus
• Treated with insulin therapy

Exclusion Criteria:

Clinic level:

- Sites participating in pilot phase of CGM initiative

Patient level:

- Existing CGM prescription within 24 months before the study start

The data sharing plan includes the following:

In Specific Aim 1, valuable SPARK-CGM efficacy data may be of interest to other diabetes, health equity and primary care researchers.

In Specific Aim 2, in-depth qualitative data of PCP and patients with diabetes may be of interest to investigators who want to apply similar interventions to new populations. Information on analytic methods will be shared with other collaborators, including providing statistical code and process logs that could be used to either confirm our results or apply similar statistical methods to related projects. Additional resources developed during this project, such as study protocols, educational materials for primary care providers, will be shared upon request or made available through appropriate channels

De-identified individual participant data will be deposited in an approved open data repository within six months of publication or within eighteen months of the conclusion of the funding period if the study remains unpublished.

Data sharing will require:

1. Institutional Review Board approval,
2. Appropriate measures to ensure security of the data,
3. Commitment to destroying or returning the data after the analyses are completed.