Improving Annual Hemoglobin A1c Testing Among Patients with a Resident Primary Care Provider

From the 2023 HVPA National Conference

Aretina Leung MD (Thomas Jefferson University Hospital), Suzanna Talento MD, Jonathan Gross MD, JD, Ashley Traczuk MD, Jason Ojeda MD

Background:
Appropriate frequency of diabetes testing by hemoglobin A1c (“A1c”) level is well established and has been shown to improve patient outcomes, specifically glycemic control. [1-2] At Jefferson Internal Medicine Associates (“JIMA”), quality metrics derived from the electronic medical record have shown that among patients aged 18 to 75 with the diagnosis of diabetes, those with a resident primary care provider (“PCP”) fell behind in all measures of diabetes health when compared to patients who have an attending PCP (Figure 1). Our focus is to improve the percentage of patients who have obtained A1c testing in the past 12 months (“annual A1c testing”).

Objective:
To increase the percentage of annual A1c testing among patients aged 18 to 75 who are diagnosed with diabetes and have a resident PCP to meet the department’s internal annual goal of 83%.

Methods:
We created a root cause analysis to uncover the many factors contributing to the lack of annual A1c testing among patients with a resident PCP (Figure 2). We then contacted a convenience sample of 40 patients to elicit barriers to A1c testing. JIMA does not perform phlebotomy in the clinic, so many patients who had to go to external laboratories such as Quest Diagnostics or LabCorp were unaware that labs were ordered or had forgotten. The majority of these patients had the electronic patient portal MyChart activated. Our intervention consisted of sending a MyChart reminder message to patients who had yet to obtain annual A1c testing.

Results:  
Our pilot intervention was performed from March 20, 2023 to April 23, 2023 (1 month). Of 262 patients with the diagnosis of diabetes and resident PCPs, 60 patients who did not have annual A1c testing were identified. The mean age was 51.95 and the mean A1c was 8.07%. 45 patients had MyChart activated (75%), and of these 45 patients contacted, 4 patients (9%) obtained A1c testing. The percentage of patients who had annual A1c testing improved 2% (79% from 77%).

Conclusion:
In this pilot intervention, reminders to obtain A1c testing via MyChart were shown to be effective in improving the annual A1c testing metric among patients with resident PCPs. We hope to eventually automate these MyChart messages to send a reminder 1 week after in-office visits, and monthly thereafter. Of the patients who do not have MyChart activated or who have not read the MyChart messages, phone calls would be another intervention to be further studied.

Clinical Implications:
With more frequent A1c testing, physicians will have more data to improve the care of patients with diabetes, including changing medication regimens to improve glycemic control. Furthermore, establishing that patients with diabetes need to have their A1c tested at least annually may serve as a gateway to improve rates of other recommended screening tests, such as annual eye exams.

[1] American Diabetes Association; 6. Glycemic Targets: Standards of Medical Care in Diabetes—2021. Diabetes Care 1 January 2021; 44 (Supplement_1): S73–S84. https://doi.org/10.2337/dc21-S006.
[2] Roy E. Furman, Timothy S. Harlan, Lesley LeBlanc, Elise C. Furman, Greg Liptak, Vivian A. Fonseca; Diabetes INSIDE: Improving Population HbA1c Testing and Targets in Primary Care With a Quality Initiative. Diabetes Care 1 February 2020; 43 (2): 329–336. https://doi.org/10.2337/dc19-0454.

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