1. A1c Testing Team G, Chart Review SAMUEL LAI 1/2015

2. Goals + Methods  GOALS  Promote cost-consciousness in our inpatient ward teams  Specifically, reducing unnecessary repeat lab testing  Methods  Chart review of the 15 patients admitted to Team G  Reviewing if and when A1c was ordered  Evaluating appropriate use of A1c testing given current guidelines

3. Guidelines  When is A1c testing warranted?  No inpatient guidelines, but the following are outpatient guidelines  Fasting glucose > 100 mg/dL, Random Glucose > 200 mg/dL with symptoms  Comorbidities of HTN, HLD  Diabetic with no A1c within 3 months (including those with no previous records)  When is it not warranted?  No history of DM II, HTN, HLD  A1c charted within the last 3 months

4. Initial Evaluation  Out of 15 patients  6 patients with A1c checked  5 patients during this admission  1 patient within the last 3 months  Appropriate?  Of the 6 patients, all 6 were appropriate usages of A1c  2 pts admitted for diabetes related illnesses (DKA)  All 6 had risk factors for diabetes, including HTN, HLD or BMI > 25

5. The Table Patient’s HistoryA1c HistoryAppropriate? 33 y/o DM I, ESRD, CRPS admitted for DKA Last A1c was 10.7 on 10/28 A1c checked, 12.1 on 1/22 Yes, last A1c was > 3 months ago in a diabetic patient 54 y/o IDDM, HFrEF, Obesity, HLD admitted for R ankle fracture Last A1c = none in chart (Transfer) A1c checked, 9.6 on 1/1 Yes, no known A1c in patient with IDDM 58 y/o schizophrenia, IDDM, admitted for auditory hallucinations Last A1c = none in chart (Transfer) A1c checked, 8.9 on 1/21 Yes, no known A1c in patient with IDDM 44 y/o DM II, HIV admitted for pneumonia Last A1c = 5.8 on 9/2014 A1c checked, 6.6 on 1/22 Yes, DM II patient with last A1c > 3 months ago 32 y/o DM II admitted for DKALast A1c = none in chart A1c checked, 6.8 on 1/16 Yes, DKA patient with no A1c listed in our charts 69 y/o HTN, Afib, Hx of ICH, admitted for sepsis from UTI Last A1c = 4.9 on 12/31 No A1c checked on this admission Yes, no repeat A1c as last one was 3 months ago, normal

6. Discussion  Should we test more?  Other patients were:  35 y/o = DM II, 3 DM meds, no A1c in our files  55 y/o = morbidly obese, FSG in > 150s, cirrhotic patient  43 y/o = IDDM, osteomyelitis 2/2 ulcer, no A1c in our files  84 y/o = DM II, fractured hip, daily glucose in 200s, no A1c in our files  32 y/o = morbidly obese, HTN, no A1c in our files  All of these patients meet criteria for A1c testing

7. Previous Study  Done by Samantha Harris in 2012  Showed similar findings as above for 15 patients on Team D

8. PatientPertinent History A1c / date performed Appropriate vs. Inappropriate 1) History of diabetes, presented with cellulitis 8.3% 1/23/12 Appropriate Did not recheck during hospitalization 2) No history of diabetes, presented with SOB from COPD 6.0% 2/1/12 ? Ordered by Gottschalk PCP Did not recheck during hospitalization 3) Admitted for DKA, and sepsis from pyelonephritis 14.7% 2/14/12 Appropriate No prior A1c on file, no prior admission. 4) Admitted for PNA, AMS and meningitis, with impaired fasting glucose levels 110-180 6.2% 2/12/12 Appropriate 5) History of diabetes, admitted with AMS from metastatic cancer 7.6% 2/12/12 Appropriate No prior A1c on file, Starting steroids. 6) History of diabetes, hyperglycemia, admitted for AMS 9.4% 2/15/12 Appropriate No prior A1c of file.

9. Problems/Concerns  Do we not check enough?  As noted in previous slide, multiple reasons to check  However, would it have changed management?  Did patients have transfer labs with A1c on them?  Did we forego checking as patient had out of system PCP?  Small sample size  Patients on steroids, active infection, may not need A1c