Providing diabetes prevention services and navigating care transitions: perspectives from primary care providers

BMC Primary Care Smart et al. BMC Primary Care (2025) 26:362 https://doi.org/10.1186/s12875-025-03040-4 Open Access RESEARCH Providing diabetes prevention services and navigating care transitions: perspectives from primary care providers Mary H. Smart1*, Yuka Asada2, Deci Limpoco2, Janet Y. Lin3, Brian T. Layden4,5, Yuval Eisenberg4, A. Simon Pickard1, Lisa K. Sharp6, Alana Biggers7 and Angela Kong1 Abstract Background This qualitative study examined how primary care providers (PCPs) prioritize addressing diabetes prevention with patients newly diagnosed with prediabetes and identified barriers and facilitators to providing diabetes prevention services (DPS). To examine transitions of care, we also evaluated how PCPs received and acted on screening information obtained outside of a primary care visit among their patients with prediabetes. Methods We interviewed PCPs practicing in Chicago using semi-structured interviews guided by the updated Consolidated Framework for Implementation Research (CFIR 2.0) from March to May 2023. Framework analysis in combination with hybrid coding was used to analyze transcripts. Results Nineteen PCPs were interviewed, and most (58%) prioritized talking to patients with prediabetes about diabetes prevention. Major themes identified included: (1) social determinants of health (SDOH) undermining diabetes prevention care, (2) perceptions of barriers and facilitators differing by provider background, and (3) delay of DPS due to prioritizing the patient’s other needs. Providers noted challenges in sharing information across health systems despite existing interoperability platforms. Conclusions Our study observed challenges in providing DPS, particularly among PCPs serving patients impacted by SDOH. We also identified opportunities for improving transitions of care and engagement between patients with prediabetes and PCPs. Keywords Primary care, Prediabetes, Diabetes screening, Transitions of care *Correspondence: Mary H. Smart 1 Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, IL 60612, USA 2 School of Public Health, University of Illinois Chicago, Chicago, IL, USA 3 Department of Emergency Medicine, College of Medicine, University of Illinois Chicago, Chicago, IL, USA 4 Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Illinois Chicago, Chicago, IL, USA 5 Jesse Brown Veterans Affairs Medical Center, Chicago, IL, USA 6 Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois Chicago, Chicago, IL, USA 7 Division of Academic Internal Medicine, Department of Medicine, University of Illinois Chicago, Chicago, IL, USA © The Author(s) 2025. 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To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Smart et al. BMC Primary Care (2025) 26:362 Background There are over 130 million United States (U.S.) adults with type 2 diabetes and prediabetes[1]. Prediabetes, an intermediate high-risk condition of type 2 diabetes, is often asymptomatic and associated with poor health outcomes, impaired quality of life, and high economic burden[2, 3]. Early detection of prediabetes, followed by intense lifestyle changes and/or pharmacologic treatment, can delay or prevent type 2 diabetes and its associated complications[4]. The United States Preventive Service Task Force recognizes the importance of primary care providers (PCPs) in addressing diabetes prevention[5]. PCPs can facilitate early detection of prediabetes, provide lifestyle counseling, and refer patients to evidence-based diabetes prevention interventions[6]. However, gaps exist between guideline recommendations in providing these diabetes prevention services (DPS) and actual practice in primary care[7]. Challenges exist in providing and referring patients to DPS, which include PCPs’ lack of awareness, inadequate time, and perceived patient-related barriers such as economic constraints and other social determinants of health (SDOH)[8–11]. Provider-reported barriers that impact their patients’ participation in DPS include patients’ limited access to fresh or healthy foods, transportation issues, and lack of time[11, 12]. These challenges impede diabetes prevention efforts, particularly among patient populations disproportionately affected by diabetes[1, 13, 14] who may also be less likely to engage in preventive care that could delay diabetes[15–17]. These disparities in the continuum of prediabetes care contribute to diabetes-related health inequalities in the U.S[18, 19]. A novel emergency department(ED)-based diabetes screening program was implemented to expand diabetes screening opportunities to populations less likely to engage with primary care, which has been described elsewhere[20]. A goal of this ED-based screening program is to connect newly diagnosed patients with prediabetes during their ED visit to a PCP in routine care. Identifying patients with screen-detected prediabetes is only the first step in diabetes prevention, and effectively moving these patients from acute to primary care for diagnosis confirmation and disease management is needed[21, 22]. PCPs in the routine care setting are central to managing chronic health conditions, such as prediabetes[23]. The role of PCPs includes but is not limited to, receiving and acting on pertinent patient information and having an awareness of available evidence-based recommendations to offer[24]. However, currently how PCPs perceive these transitions of care (i.e., screening for prediabetes in ED to following up with primary care for diabetes prevention services) is unknown. Failure to understand PCPs’ perspectives, who are an important stakeholder in this Page 2 of 9 care continuum, may result in poor follow-up of newly diagnosed patients with prediabetes, resulting in delays in care and worsening outcomes[25, 26]. Therefore, we conducted a multi-method study with PCPs to examine (a) current DPS provided by PCPs, (b) implementation barriers and facilita (...truncated)