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

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

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 18-89 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

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

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

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

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

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?

References: 1. American Diabetes Association Position Statement. Standards of Medical Care in Diabetes. Diabetes Care 2005; 28 (Suppl 1): S4-S36. 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 2002; 25: 750-86. 3. 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: 968-83. 4. 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: 405-12.