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

2. 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

3. 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.

4. 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

5. 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)

6. 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

7. 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

8. 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

9. 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

10. Additional Considerations
Cost of A1c testing: $
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?

11. 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):