Inpatient Laboratory Testing: To A1c or Not to A1c Cost Conscious Analysis: DSR2 Jodi Nagelberg 5/2017

Goals + Methods Goals: To promote high-value, evidence-based and cost-conscious care in the inpatient setting by reducing duplicate or unnecessary laboratory testing Methods: Reviewed all inpatient charts on Medicine Teams A+B from 3/1/17 - 3/14/17 Evaluated appropriateness of HbA1c test ordered relative to current standards of care

Criteria for Testing for Diabetes Patients >45 years old + Risk Factor Risk factors: Overweight or obese Physical inactivity A1c >5.7% High risk race/ ethnicity Women with h/o gestational DM H/o CVD, HLD or HTN If normal result, test every 3 years If pre-diabetic, test annually Can test via: fasting plasma glucose, OGTT or a1c High risk race- e.g., African American, Latino, Native American, Asian American, Asian Pacific Islander American Diabetes Association Position Statement. Standards of Medical Care in Diabetes. Diabetes Care 2017; 40 (Suppl 1) S10-14.

When to Check an A1c? Indications to test: (There is no formalinpatient consensus) In known diabetics: Every 6 months with stable a1c at goal Every 3 months if prior a1c above goal, has not been re- checked in last 3 months Fasting glucose >126 mg/dL or random >200 mg/dL with symptoms >45 y/o + comorbidities: HTN, HLD, CAD, etc. Lack of indication to test: Hba1c documented within prior 3 months No history of DM2, HTN, HLD Under 45 years old without symptoms or risk factors https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3114322/

Criteria for Diagnosis of Diabetes 1) Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L) 2) 2-hr plasma glucose ≥200 mg/dL (11.1 mmol/L) during OGTT (75-g) 3) Random plasma glucose ≥200 mg/dL (11.1 mmol/L 4) A1C ≥6.5% (48 mmol/mol)

Patient Data Reasons for admission included: Evaluated all patients on Medicine Team A + B from 3/1/17 to 3/14/17 Of the 102 patients evaluated (Team A- 45 visits, Team B 57 visits) 18 Hba1c lab tests ordered during hospitalization 3 ordered prior to hospitalization Reasons for admission included: Etoh withdrawal, CHF, osteomyelitis, DKA, SOB, syncope, GIB, hyponatremia, generalized weakness, malignancy

Sample Table Patient’s History A1c History Appropriate 44 y/o DM1, pancreatic/ ESRD s/p renal transplant, CAD admitted for L toe osteomyelitis Latest: 5.3 on 3/15/17 Prior: 4.9 on 7/11/16 Yes, DM1 w/ last a1c>3 mo ago 75 y/o DM2, cirrhosis, HTN, hypotyhroid admitted for GIB Latest: 5.6 on 3/13/17 Prior: None Yes, DM2 w/o known a1c 60 y/o DM2, HFrEF, HTN, HLD, AAA, lung ca, COPD, DVT/PE admitted for SOB Latest: 6.5 on 3/8/17 Prior: 6.6 on 2/9/16 Yes, DM2 w/ last a1c>3 mo ago 62 y/o IDDM, HTN, CAD admitted for dizziness and CP Latest: 6.7 on 3/14/17 Prior: None Yes, IDDM w/o known a1c 41 y/o IDDM, nephrotic syn, HTN, osteomylitis admitted for SOB and AKI Latest: >15.6 on 3/2/17 Prior: 15.5 on 11/20/17 Yes, IDDM w/ last a1c>3 mo ago 45 y/o pre-DM, HTN admitted for angioedema and DKA Latest: 14.4 on 3/6/17 Prior: None Yes, admitted w/ DKA w/o prior a1c 85 y/o DM2, ocular myasthenia, sarcoma admitted for generalized weakness Latest: 10.6 on 3/3/17 Prior: 10.6 on 3/2/17; and 3rd documented at 10.5 from transferring OSH No, DM2, although 2 tests performed during same hospital stay (and 3rd from OSH records) 46 y/o DM, HLD, HTN, admitted for new onset HF Latest: 7.6 on 3/8/17 Prior: 9.7 on 1/19/17 No, DM2 w/ last a1c<3 mo ago

Appropriate ordering? Of the 18 Hba1c tests ordered during hospitalization: 16 tests for people were appropriate: With DM without a1c in last 3 months Without DM, although >45 y/o + risk factors 1 visit with 2 tests completed 1 visit with a1c repeated within 3 months

Previous Study Done by Sam Lai in 2015, showed similar results for Team G patients, although without redundant orders found Patient’s History A1c History Appropriate? 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 A1c checked, 8.9 on 1/21 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 DKA Last 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

Additional Considerations Cost of A1c testing: $30-100+ Ordering practices influenced by level of training, attending and patient’s reason for admission Small sample size OSH transfer records or PCP charts would likely reduce duplicate testing Utility of inpatient a1c value on acute care plan or outpatient discharge DM medication regimen? Do we change a patient’s home regimen based on a1c value? Otherwise, why order inpatient?

References 1) American Diabetes Association Position Statement. Standards of Medical Care in Diabetes. Diabetes Care 2017; 40 (Suppl 1) S10-14. 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 2011; 34(6): 61-99.