A1c TestingTeam G, Chart ReviewSAMUEL LAI
1/2015
Goals + Methods
GOALS
Promote cost-consciousness in our inpatient ward teams
Specifically, reducing unnecessary repeat lab testing
Methods
Chart review of the 15 patients admitted to Team G
Reviewing if and when A1c was ordered
Evaluating appropriate use of A1c testing given current guidelines
Guidelines
When is A1c testing warranted?
No inpatient guidelines, but the following are outpatient guidelines
Fasting glucose > 100 mg/dL, Random Glucose > 200 mg/dL with symptoms
Comorbidities of HTN, HLD
Diabetic with no A1c within 3 months (including those with no previous records)
When is it not warranted?
No history of DM II, HTN, HLD
A1c charted within the last 3 months
Initial Evaluation
Out of 15 patients
6 patients with A1c checked
5 patients during this admission
1 patient within the last 3 months
Appropriate?
Of the 6 patients, all 6 were appropriate usages of A1c
2 pts admitted for diabetes related illnesses (DKA)
All 6 had risk factors for diabetes, including HTN, HLD or BMI > 25
The Table
Patient’s History A1c History Appropriate?
33 y/o DM I, ESRD, CRPS admitted for DKA
Last A1c was 10.7 on 10/28A1c 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
Last A1c = none in chart (Transfer)A1c checked, 8.9 on 1/21
Yes, no known A1c in patient with IDDM
44 y/o DM II, HIV admitted for pneumonia
Last A1c = 5.8 on 9/2014A1c 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 chartA1c 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 12/31No A1c checked on this admission
Yes, no repeat A1c as last one was 3 months ago, normal
Discussion
Should we test more?
Other patients were:
35 y/o = DM II, 3 DM meds, no A1c in our files
55 y/o = morbidly obese, FSG in > 150s, cirrhotic patient
43 y/o = IDDM, osteomyelitis 2/2 ulcer, no A1c in our files
84 y/o = DM II, fractured hip, daily glucose in 200s, no A1c in our files
32 y/o = morbidly obese, HTN, no A1c in our files
All of these patients meet criteria for A1c testing
Previous Study
Done by Samantha Harris in 2012
Showed similar findings as above for 15 patients on Team D
Patient Pertinent History
A1c / date performed
Appropriate vs. Inappropriate
1)History of diabetes, presented with cellulitis
8.3%
1/23/12
Appropriate
Did not recheck during hospitalization
2)No history of diabetes, presented with SOB from COPD
6.0%
2/1/12
? Ordered by Gottschalk PCP
Did not recheck during hospitalization
3)Admitted for DKA, and sepsis from pyelonephritis
14.7%
2/14/12
Appropriate
No prior A1c on file, no prior admission.
4)Admitted for PNA, AMS and meningitis, with impaired fasting glucose levels 110-180
6.2%
2/12/12
Appropriate
5)History of diabetes, admitted with AMS from metastatic cancer
7.6%
2/12/12
Appropriate
No prior A1c on file, Starting steroids.
6)History of diabetes, hyperglycemia, admitted for AMS
9.4%
2/15/12
Appropriate
No prior A1c of file.
Problems/Concerns
Do we not check enough?
As noted in previous slide, multiple reasons to check
However, would it have changed management?
Did patients have transfer labs with A1c on them?
Did we forego checking as patient had out of system PCP?
Small sample size
Patients on steroids, active infection, may not need A1c