Quality Improvement in Inpatient Diabetes Care Decreases Wasteful HbA1c Testing

Presentation Number: SUN-0454
Date of Presentation: June 22nd, 2014

Lena Shalem*1, Jonah Feldman1, Gary Rothberger1, Virginia Peragallo-Dittko2 and Sarah Walmsley2
1Winthrop University Hospital, Mineola, NY, 2Winthrop-University Hospital, Mineola, NY


Excessive laboratory testing is a well-known problem in medical practice, particularly in the inpatient setting(1).  The high incidence of wasteful HbA1c testing has been attributed to the implementation of HbA1c based performance measures(2).  In 2009, our 591-bed teaching hospital began a quality improvement process that culminated in February 2013 when the hospital was awarded Joint Commission Accreditation in Advanced Inpatient Diabetes Care.  One of the requirements was that all patients with diabetes have a HbA1c test on admission unless there was another HbA1c available from the previous 90 days.  The hospital embarked on multiple electronic and educational performance improvement activities to meet this requirement.  Our goal was to study the influence of quality improvement on wasteful laboratory testing by examining the change in the rate of unnecessary repeat HbA1c tests over this four-year period. 

We performed a retrospective analysis using data from our institution’s computerized laboratory system.  We obtained all HbA1c results from tests performed on inpatients from 2009 through 2012.  Our primary outcome measure was the repeat rate, or the proportion of total HbA1c tests that were performed less than 90 days from a previous test.  Over this period, 17.7% of the total testing was unnecessary.  Notably, there was a trend toward a decrease in the monthly repeat testing rate from the baseline period to the culmination of the quality improvement process.  In the beginning of 2009, 21.44% of the HbA1c tests were performed less than 90 days from a previous test, with that number decreasing to 13.04% (p< .0001) by the end of 2012, just prior to the Joint Commission site visit.  This decrease occurred without any interventions intentionally targeting the reduction of wasteful ordering.   

Our results are compatible with previously published reports that have shown a similarly high rate of unnecessary repeat HbA1c testing. However, contrary to published speculation, we found that quality improvement did not increase the rate of wasteful HbA1c testing; in fact there was a statistically significant decrease in wastefulness.  Though quality improvement processes tend to penalize the underutilization of resources without rewarding the avoidance of overutilization, we believe that in this case the efficiency and reliability introduced by the quality improvement process led to an overall decrease in the rate of unnecessary testing.  


Nothing to Disclose: LS, JF, GR, VP, SW