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Using a Quality Initiative to Improve Population HbA1c Testing

Oct 3, 2020
Editor: Steve Freed, R.PH., CDE

Author: George McConnell, PharmD. Candidate, LECOM School of Pharmacy 

The Diabetes INSIDE program examines whether improving diabetes care can be as simple as ensuring patients receive regular testing.

Many patients do not meet guideline goals, despite new and improving therapies, more education options, and increasing disease knowledge. Some proposed solutions have included monetary incentivization, market competition, and system changes. Healthcare has seen much more support for the first two and not the third proposed solution, unlike many other sectors. To combat this, the American Diabetes Association developed the Diabetes INSIDE (Inspiring System Improvement with Data-Driven Excellence) program and has established quality improvement practices that may be implemented. The Diabetes INSIDE program is a system-wide, multiyear program aimed at population health analytics and care system redesigns.   


This study was done at Tulane Medical Group, a participant in the diabetes INSIDE program. Reduction in the number of HbA1c tests done at intervals more significant than the guidelines recommended was the primary objective. The secondary objectives were to reduce the overall population HbA1c and decrease the incidence of those with an HbA1c of over 9%. It sought to make these changes using the diabetes INSIDE program and the American Diabetes Association’s quality improvement interventions. These interventions targeted not only the health system but health care providers as well as the patients. To be considered in this study, the population had to be aged 18 or older, diagnosed with type 2 diabetes between 2010 and 2018. There were no exclusion criteria in this study. The health system interventions included a provider outreach with actionable data on HbA1c testing, patient outreach, a campaign to increase patient awareness of diabetes and the importance of HbA1c testing, provider training, and education for professionals on the latest American Diabetes Association guidelines. Monthly performance reports were provided that were color-coded with compliance and patient outcomes. The campaign to raise patient awareness summarized the patient’s history of appointments, vital signs, laboratory results, and referrals. Each patient was given comprehensive diabetes patient education materials. Provider training included one-on-one training with the electronic health record, including how to log each patient’s results appropriately.   

As this study did not have differing arms or exclusion criteria, the results were compared to the same data from prior years. Mean values before and after the interventions were compared using t-tests to evaluate the effects on HbA1c and testing frequency. While the American Diabetes Association guidelines recommend testing HbA1c every three months while glucose is uncontrolled, 47% of the patients in this study were initially tested at intervals greater than six months, with 13% being tested less frequently than once every two years! While the proportion of those receiving an HbA1c test more often than once every six months did not change, the frequency of those that had a test greater than every six months decreased significantly (P < 0.0001 with a 20% reduction in the number of patients who received a test at intervals greater than six months). There was a decreased frequency of testing in those with an increased HbA1c. The quality improvements significantly reduced the number of people with poor HbA1c control from 13% to 11% (P < 0.001) as well as the overall HbA1c from 7.4% to 7.2% (P < 0.001). Of the different departments, family medicine and internal medicine saw statistically significant improvements (19% to 15% and 10% to 8%, respectively) of the HbA1c (both P < 0.001). In comparison, the endocrinology department saw improvements (17% to 15%) that were not statistically significant (P < 0.07).  

Quality improvements resulted in an improved care process and statistically significant improvements in HbA1c under testing and the number of patients with an HbA1c of over 9%. Unsurprisingly, quality control rollouts were slower than expected. The initial timeline predicted it would take three months for the rollout, but two clinics did not complete their rollout by six months into the study. As expected, improving the design of the healthcare provided resulted in improved outcomes for patients. Despite all these improvements, the sustainability of quality improvement initiatives has come into question. Previous attempts at quality improvement interventions have resulted in short-term successes that have faded over the decades. Quality improvements are a long-term solution for encouraging proper patient care, but they must be continuously acted upon, lest their benefits be lost.   

Practice Pearls: 

  • There was a statistically significant decrease in HbA1c under-testing and HbA1c levels following the QI initiatives.  
  • Those with higher HbA1c were more likely to have an increased delay in HbA1c testing, highlighting the importance of reaching out to them.   
  • Quality improvement initiatives must be adhered to for them to provide the most benefit.   


Furman, Roy E., et al. Diabetes INSIDE: Improving Population HbA1c Testing and Targets in Primary Care With a Quality Initiative. Diabetes Care, American Diabetes Association, 1 Feb. 2020, care.diabetesjournals.org/content/43/2/329.  


George McConnell, PharmD. Candidate, LECOM School of Pharmacy