W.S.T. Swarnasri1, Noel P. Somasundaram2 The impact of point of care HbA1C on clinical decision making of medical professionals W.S.T. Swarnasri1, Noel P. Somasundaram2 1Senior Registrar in Endocrinology, 2Consultant Endocrinologist, Diabetes & Endocrinology Unit, National Hospital Sri Lanka, Colombo

Introduction International & Local Guidelines recommend HbA1C for diagnosis & follow up HbA1C has a strong predictive value for complications of diabetes HbA1C is not available in most govt. hospitals Clinics use FPG/PPG SMBG is underutilized

HbA1C: How it should be used? Perform HbA1C at least 2 times a year in stable patient Perform HbA1C quarterly in unstable patients or when therapy has changed Use of POC testing provides opportunity of more timely treatment changes Ref: ADA, Standards of Diabetes Care 2014

HbA1C VS FPG/PPG HbA1C FPG/PPG Indicates long term control Depend on few factors RBC turnover, Hb variants Reliable Not freely available Expensive Can miss out glycemic variability Indicates short term control Depend on many factors Relationship to meals, drugs etc, etc Less reliable Freely available Cheap

Objective The impact of point of care (POC) HbA1C on clinical decision making of medical professionals catering to diabetes patients attending the diabetes clinic of a tertiary care hospital

Methods Study Setting: Diabetes Clinic, NHSL Inclusion criteria: Routine clinic patients, either T1DM or T2DM Followed up for at least 1 year Exclusion criteria: HbA1C done within last 6 months Any condition that can affect HbA1C results

Methods: Steps Randomly selected patients were explained the procedure, consent obtained Patients’ finger prick capillary blood taken for POC-HbA1C assessment by using Bio-Rad A1C in-office analyzer

Methods: Steps cont. The patient was sent to the clinic doctor as a routine patient At the end of the consultation HbA1C result was shown to the doctor Any changes made to the original management plan were recorded

Results Total: 100 patients Females: 65 Males: 35 T1DM: 3 T2DM: 97

Results: Duration of DM

Results: Treatment Regimens

Results: HbA1C Group average HbA1C: 9.25% (SD 1.88%) HbA1C

Results: HbA1C Males: 8.19% Females: 9.53% HbA1C Number of patients

Results: FPG/PPG Average FPG: 143.60 mg/dL (n=84) Average PPG: 182.3 mg/dL (n=61) mg/dL Number of patients

Results: Change of plans after HbA1C 31/100 Consultations 69/100 Consultations p <0.05 (t-test of proportions)

Results: The Change in 69/100 The change was increased drug,

Reasons for no change in 31/100 Patient has poor compliance with diet and drugs Changes were already done after seeing high FPG/PPG

Conclusions Without HbA1C glycemic control tends to be underestimated POC HbA1C leads to positive changes in management Availability of HbA1C avoids treatment errors “Satisfactory control” with FPG/PPG may be misleading Cost effectiveness of HbA1C needs to be worked out

HbA1C and Mortality Curve

References Standards of Medical Care in Diabetes: Position Statement: Diabetes care, volume 35, supplement 1, January 2012; S11-S65 Clinical guidelines-The Endocrine Society of Sri Lanka; Diabetes Mellitus: Glucose Control, Sri Lanka Journal of Diabetes, Endocrinology and Metabolism 2013; 3: 45-57 Miller CD, Barnes CS, Phillips LS, et al. Rapid A1c availability improves clinical decision-making in an urban primary care clinic. Diabetes Care 2003;26:1158–1163 Al-Ansary L, Farmer A, Hirst J, et al. Point-of-care testing for HbA1C in the management of diabetes: a systematic review and meta analysis. Clin Chem 2011; 57:568–576