1. Duplicate HgA1c Testing
Chart Review of Inpatient Medicine Teams A - G
Erum Iqbal Bajwa
June 5, 2015

2. 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

3. Patient Population
Reviewed patients admitted to inpatient teams at UC Irvine Medical Center on June 5, 2015 at 1:30 PM
Pneumonia
Altered Mental Status
Cholangitis
AIDS
24 men and 28 women, aged
Pyelonephritis
Vision Loss/Headache
Osteomyelitis
Of the 52 patients chart evaluated, reasons for admission:
Diabetes
Intraabdominal abscess
Gangrene
Syncope
CHF
Bilateral Orbital Fracture
Ingestion of foreign bodies
Delirium
Cellulitis
Respiratory Failure
Pancreatitis
GI Bleed

4. 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

5. 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, Seizure
None
Appropriate
Glucose 96 on admission 2)
Foreign Body ingestion
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
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
Checked within 3 months and not rechecked 6)
Pancreatitis at 6 weeks gestation
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 admission
6/2/2015
History of DM II with admission glucose 234

6. 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

7. 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

8. 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?

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