July 15, 2013

HbA1c Not Adequate to Assess Diabetes Care

Is the measure of HbA1c really inadequate in assessing diabetes care across specialties? According to this presentation at the American Diabetes Association 2013 Scientific Sessions, HbA1c levels for patients cared for by endocrinologists are the same as or better than those for individuals seen by general internists.

Why is this a big deal? Because when patients are compared on a medication basis, the general internists generally held their own except when it came to insulin where the general internists came out ahead. The study authors concluded that this was because primary care physicians were referring these patients to endocrinologists. Then the authors state that this was the reason endocrinologists were seeing patients with higher HbA1c levels. This is the reason the study authors do not believe that HbA1c is an adequate measure and does not allow for an apples-to-apples comparison.

This may be true, but without an age comparison, can we really be confident that the study authors are not concealing something. With the pressure I am receiving to bring my A1c levels up, we know that when we are discussing insulin, that the endocrinologists are fearful of hypoglycemia and in many ways let age govern their individualization instead of individual capabilities. Even a couple of other members of our support group are feeling the pressure to allow their A1c levels to increase.

This article in Medscape states that more elderly are admitted to hospitals for hypoglycemia than hyperglycemia. Unless I missed something, in neither article do they distinguish between types 1 nor type 2 and which may be causing the problems and the conclusions they are drawing. To properly evaluate the statistics in the hypoglycemia and in the study wanting to compare apples-to-apples, without numbers of each type being reported, the results can be misleading.

The apples-to-apples study was generally about type 2 patients, except that type 1 is mentioned here, “Those also using mealtime insulin in addition to basal insulin, with or without other medications (1531). The latter group included patients with type 1 diabetes, Dr. Phillips told Medscape Medical News.” This is where the confusion comes in and we are left wondering which type they are worried about causing the HbA1c problems and preventing the apples-to-apples comparison.

This is probably the reason for this statement - “This coverage is not sanctioned by, nor a part of, the American Diabetes Association.” This I know means that the study has not been peer-reviewed and could be the reason for poor information.

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