Item #10
Rapid
A1c Availability Improves Clinical Decision-Making
Availability
of rapid A1c changes provider behavior significantly
Failure
to meet goals for glycemic control in primary care settings
may be due in part to lack of information critical to guide
intensification of therapy. Our objective is to determine
whether rapid-turnaround A1c availability would improve
intensification of diabetes therapy and reduce A1c levels in
patients with type 2 diabetes.
In
this prospective controlled trial, A1c was determined on
capillary glucose samples and made available to providers,
either during ("rapid") or after ("routine") the
patient visit. Frequency of intensification of pharmacological diabetes
therapy in inadequately controlled patients and A1c levels
were assessed at baseline and after follow-up.
We
recruited 597 subjects. Patients were 79% female and 96%
African American, with average age of 61 years, duration of
diabetes 10 years, BMI 33 kg/m2, and A1c 8.5%. The rapid
and routine groups had similar clinical demographics. Rapid
A1c availability resulted in more frequent intensification of
therapy when A1c was
 7.0%
at the baseline visit (51 vs. 32% of patients),
particularly when A1c was >8.0% and/or random glucose
was in the 8.4–14.4 mmol/l range (151–250 mg/dl). In
275 patients with two follow-up visits, A1c fell significantly
in the rapid group (from 8.4 to 8.1%) but not in the
routine group (from 8.1 to 8.0%).
There
are three major findings of our study. First, in patients with
A1c
7.0%,
glycemic control did not improve if therapy was not
intensified, whereas A1c levels improved significantly if therapy
was intensified. Second, availability of rapid A1c
determinations led to more frequent intensification of
therapy in inadequately controlled patients. Finally,
availability of rapid A1c determinations was also
associated with modest but significant decreases in A1c
levels in patients who returned for two follow-up visits.
Interestingly,
we found that availability of rapid A1c determinations enhanced
intensification of therapy if patients had modest elevation in
capillary glucose levels (random glucose 151–250 mg/dl) or
substantial elevations in A1c (>8.0%). Our findings suggest that
providers are more likely to advance pharmacological therapy in
patients exhibiting mild hyperglycemia if a rapid A1c level is
available.
Our
results also show that knowing that an A1c level is high
makes it more likely that therapy will be advanced, although
there was no difference in intensification of therapy between
the two groups for patients having a A1c in the 7.0–7.9% range.
Therefore, availability of rapid A1c is likely to change provider
behavior significantly in patients with moderate-to-severe hyperglycemia
(A1c >8.0%), but may not change their decision-making for
patients with mild-to-moderate hyperglycemia. It could be argued
that such behavior is consistent with ADA guidelines, which
suggest action only when A1c levels exceed 8.0%. However, we
believe that therapy should be intensified for A1c
7.0%
because the ADA goal is a A1c level <7.0% and because micro-
and macrovascular damage is already occurring when A1c is at
7.0%.
The
present study shows that rapid A1c availability can improve the
frequency of intensification when glucose levels are elevated. However,
the reduction in A1c may be modest unless technological innovation
is accompanied by measures to help ensure that primary care
providers will take full advantage of the added information. Thus,
attainment of better diabetes control nationwide is likely to
demand the complementation of technological and pharmacotherapeutic
advances with strategies that enhance providers’ clinical
decision-making. Diabetes
Care 26:1158-1163, 2003
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Having
the results of your patients A1c while you are with them can motivate
them to better self-control.
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