Most adults with controlled diabetes get tested too often
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In a retrospective analysis of almost 32,000 patients, researchers found that HbA1c testing frequency was excessive in 5% of cases and more frequent than guidelines suggest in 55% of cases. Though all patients had good glycemic control at baseline, more insulin or glucose-lowering drugs were given to 13% of patients who were tested excessively, 9% who were tested too frequently, and 7% who were tested according to the guidelines (P<0.001).
In total, 8.4% of patients were given additional treatment, according to author Rozalina McCoy, MD, at the Mayo Clinic in Minnesota. McCoy and colleagues published their findings Tuesday in The BMJ.
"Ultimately, patients and doctors should question the value of routine tests and test bundles, increasingly built as defaults within protocols and algorithms to improve compliance with quality metrics and performance in those metrics," they wrote.
"Doing so could reduce the waste associated with marginally informative and otherwise excessive testing, and might also mitigate the practice of responding to small variations in test results with equally unwarranted and excessive treatment changes."
The American Association of Clinical Endocrinologists and the American Diabetes Association both recommend that HbA1c levels be <6.5% for most adults. But recommended levels vary: some organizations recommend 7.0% or 8.0%, depending on the goals and the individual, wrote the authors. And for patients with stable glycemic control, most guidelines assert that the group should be tested only once or twice annually.
Spencer Nadolsky, DO, a physician in Maryland, said he sees the effects of overtesting. "Excessive testing in the case of hemoglobin A1c does waste healthcare dollars when the patient is already at goal and nothing has changed clinically," he wrote in an email to MedPage Today.
He added that many patients will want their HbA1c levels checked every 3 months because that is what their last physician did. "But unless you're actively trying to get someone to goal and adjusting medicine or if new symptoms occur (e.g., glucotoxicity) then I question testing it more often," he wrote.
Data were taken from the Optum Labs Data Warehouse, which includes claims information for more than 86 million Medicare or commercially insured patients in the U.S. from 2001 to 2014. All patients in the study had controllable and stable diabetes -- only those with two consecutive HbA1c tests below 7% within a 24 month period were included. Those with type 1 diabetes and those with secondary diabetes were excluded, and all patients were at least 18 years old.
The primary outcome was HbA1c testing frequency, which was measured as excessive if there were more than five tests a year, frequent if there were three to four tests per year, and guideline recommended if there were up to two tests per year. The secondary outcome was changes to diabetes treatments as measured by comparing pharmacy claims 120 days after the index date to 120 before the date.
The mean age was 58 and the mean HbA1c was 6.2%. Sixty-two percent of patients had a low disease burden, and 84% received care from both a primary care giver and a medical subspecialist. When the HbA1c levels were measured, a third of patients did not receive any glucose-lowering drugs, 38% were being treated with one drug, 21% with two drugs, and 8.2% with three or more drugs.
The patients who received excessive or frequent tests were more likely than those who didn't to be older with more comorbid condition; they were also taking more diabetes drugs, and had a higher index HbA1c (all at P<0.001). A smaller proportion of Hispanics (5.4%) and blacks (4.9%) were excessively tested than were whites (5.7%) and Asians (5.8%), wrote McCoy and colleagues (P<0.001).
Excessive testing also varied by region, with the northeast U.S. most often excessively testing (in 8.9% of the patients), and the Midwest least often doing so (4.0%).
The number of healthcare providers seen by the patient was associated with likelihood of excessive and frequent testing. Each additional provider increased the odds for receiving excessive of frequent testing (odds ratio 1.05, 95% CI 1.04-1.07).
When the tests were part of a bundle -- done along with cholesterol and creatinine tests, for example -- the odds of excessive testing were lower than HbA1c tests alone (OR 0.82, 95% CI 0.77-0.88). Nearly 82% of the patients didn't have their treatment altered as a result of the HbA1c findings, according to the authors.
Yet about 5% of the 29% of patients not on any glucose-lowering drugs continued to be excessively tested in the 2 years after the HbA1c test, and even among the 9% of patients whose treatments were less intense, 7.2% were still tested excessively. The patient seeing an endocrinologist was a predictor of treatment intensification (OR 1.27, 95% CI 1.20-1.34).
After 2009, excessive treatment dropped dramatically, wrote McCoy and colleagues. They added that excessive testing and overtreatment could lead to harm through hypoglycemia, side effects, and increased cost of care, but the study didn't look at the those effects. Overtesting also raises the possibility of false positive findings.
"The reasons for overtreatment, particularly treatment intensification, should be further investigated through qualitative analysis of patient, provider, and system factors leading to overtesting, overtreatment, and increased healthcare use," wrote the authors.
Limitations of the study included a lack of data on undertesting. In addition, the design was based on the assumption that the stable patients did not need frequent monitoring.
Two of the authors received funding from the Agency for Research Healthcare and Quality.
The authors disclosed no relevant relationships with industry.
The authors disclosed no relevant relationships with industry.
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