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Many patients with type 2 diabetes undergo excessive HbA1c testing
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More than half of patients with type 2 diabetes receive more than the recommended number of HbA1c tests, according to results of a large U.S. study published in The BMJ.
Current clinical practice guidelines recommend up to two HbA1c tests per year or tests obtained 6 months apart for patients with type 2 diabetes with good blood glucose control and no history of hypoglycemia.
“Our findings are concerning, especially as we focus more on improving the value of care we deliver to our patients — not only ensuring the maximal benefit, but also being mindful of waste, patient burden and health care costs,” Rozalina G. McCoy, MD, a primary care physician and endocrinologist at the Mayo Clinic, said in a press release. “As providers, we must be ever vigilant to provide the right testing and treatment to our patients at the right times — both for their well-being and to ensure the best value in the health care we provide.”
McCoy and colleagues evaluated data from a national administrative claims database that included commercially insured individuals in the United States between 2001 and 2013 on 31,545 adults (mean age, 58 years; mean index HbA1c, 6.2%) with type 2 diabetes and stable glycemic control.
Testing frequency, measured as mean number of tests per year in the first 24 months after the index HbA1c test, was categorized as guideline recommended (up to two tests per year or tests obtained 6 or more months apart), frequent (three to four tests per year or tests obtained at least 3 months but less than 6 months apart) or excessive (at least five tests per year or tests obtained less than 3 months apart).
Frequent (54.5%) and excessive (5.8%) HbA1c testing was common. Participants who received more than the recommended number of tests were older, had more comorbidities, took more diabetes drugs and had a higher index HbA1c (P < .001 for all).
The odds for frequent or excessive testing were increased with greater patient complexity as indicated by the Charlson comorbity index ( 4), treatment ( three diabetes drugs), index HbA1c (6.5%-6.9%) and having an endocrinologist or nephrologist involved in care.
More than 80% of participants did not have their treatment altered following the index HbA1c test.
After 2009, frequent and excessive testing decreased whereas excessive testing rates were unchanged in 2003 to 2003 compared with 2001 to 2002 (P < .05 for all) and less likely in 2009 to 2010 (OR = 0.74; 95% CI, 0.67-0.83) and 2011 (OR = 0.54; 95% CI, 0.46-0.63).
“Potential reasons for more frequent testing include clinical uncertainty; misunderstanding of the nature of the test — that is, not realizing HbA1c represents a 3-month average of glycemic control; or a desire for diagnostic and management thoroughness,” McCoy said in the release. “Other times, it may be the result of fragmentation of care (more than one unconnected provider); the need to fulfill regulatory demands, such as public reporting or performance metrics; or internal tracking of performance.”
In an accompanying editorial, Rodney A. Hayward, MD, professor of medicine and public health at the University of Michigan, suggests that the results may underestimate the problem of overtreatment because current guidelines have “changed little from those opinions originally formed 25 years ago.”
“These results are yet another example of how prone our profession is to taking useful tests and treatment to excess,” he wrote. “The common belief that there is ‘no harm in looking’ continues to result in not just waste, but also palpable patient harm. The temptation to treat suboptimal numbers too often overrules more judicious judgements based on a careful assessment of risks and benefits.” – by Amber Cox
Disclosure: The researchers report no relevant financial disclosures.
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