Erum Iqbal BajwaJune 5, 2015

Chart Review of Inpatient Medicine Teams A - G

Duplicate HgA1c Testing

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Methods

• Goal: To promote high-value, cost-conscious care within our residency program by avoiding unnecessary repeat laboratory testing

• Method: Reviewed all patients currently admitted to Medicine Teams A – G in the inpatient setting at UC Irvine Medical Center• Examined hemoglobin A1c (HgA1c) values checked both during and prior to

admission in 52 patients to see if they were appropriate vs. inappropriate1

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Patient Population

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Results of Hemoglobin A1c Testing

• Of the 52 patients: 14 had HgA1c results• 11 HgA1cs were sent during the current admission • 3 HgA1cs were sent within 3 months prior to admission• 6 patients were identified that may have had usefulness of sending HgA1c

given mildly impaired fasting glucose on admission

• Appropriate vs Inappropriate HgA1c Testing• Appropriate(1-4):

• Known history of diabetes with no A1c in past 3 months• Suspected diabetes with IFG or symptoms and no A1c in past 3 months

• Inappropriate(1-4):• No history of diabetes, normal fasting glucose levels, asymptomatic• History of diabetes or IFG with A1c within past 3 months• Impaired fasting glucose on admission with possibility of diabetes based on

symptoms

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Table 1 – Analysis of patients on Team A with HbA1c checked either prior to or during hospitalization

Patient Pertinent History

A1c / date

performed

Appropriate vs. Inappropriate

1) Scalp Laceration, SeizureNone Appropriate

Glucose 96 on admission

2)Foreign Body ingestion None Appropriate

Glucose 98 on admission

3)Hepatitis C, IVDU with R Upper

Arm Abscess with Extensive Cellulitis

+ History of DMII on Metformin, Glipizide

8.7% checked prior to

admission by PCP 4/15/2015

Appropriate

Not rechecked in the hospital

4)Drug Abuse, found down with

retropharyngeal abscess+ History of DMII on Insulin

Impaired Fasting Glucose, 200s

No HgA1c result

Inappropriate if not checked

Possibly outside PCP sent records?

5)Hepatitis C, NASH Liver Cirrhosis

with Acute Kidney Injury+ History of DM II

7.0% checked prior to

admission with PCP

5/28/2015

Appropriate

Checked within 3 months and not rechecked

6)Pancreatitis at 6 weeks gestation None Appropriate

Glucose 83 on admission

7) Recent diagnosis of Liver Cancer with active Upper GI Bleed

+ History of DM II on insulin was told to stop 1 month ago

11.2%Checked on admission6/2/2015

Appropriate

History of DM II with admission glucose 234

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Team A Results

•3/7 patients had HgA1c results

•All of which were appropriate

• 1 with potential for diabetes that did not have HgA1c result noted or unclear if records obtained with HgA1c result

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Conclusions

• All of the HbA1cs checked during admission appeared to be appropriate

• In setting of infections may be useful to obtain a HgA1c as the baseline glucose increases during acute infections

• Helpful to have outpatient records from UCI PCPs now on EMR as it decreased duplicate ordering of HgA1c

• More HgA1c’s may have been helpful• Of the 6 patients who had no A1C performed:

• 1 patient had impaired fasting glucose (127 on admission) with cellulitis which may confound the fasting glucose but would not change the HgA1c

• 5 patients had impaired fasting glucose with no history of diabetes or symptoms related to DM II and no evidence of infection

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Conclusions

• Confounders: • Unsure about outside PCPs or records regarding HgA1c ordering • May be attending-dependent • Moderate size sample population• Did it really change management as an inpatient since everyone is usually

on insulin of some type?

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References:

1. American Diabetes Association Position Statement. Standards of Medical Care in Diabetes. Diabetes Care 2005; 28 (Suppl 1): S4-S36.

2. Sacks DB, Bruns DE, Goldstein DE, Maclaren NK, McDonald JM, Parrott M. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Diabetes Care 2002; 25: 750-86.

3. The Diabetes Control and Complications Trial Research Group. The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the Diabetes Control and Complications Trial. Diabetes 1995; 44: 968-83.

4. Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000; 321: 405-12.