1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. Results: Duration of DM

11. Results: Treatment Regimens

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

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

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

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

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

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

18. 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

19. HbA1C and Mortality Curve

20. 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