October 19, 2013

Diabetes Tests, What Is Wrong?

The American Society for Clinical Pathology (ASCP) is going after doctors and endocrinologists while not pointing the fingers totally at themselves. Labs are not always giving the proper ranges of what the test results mean, especially in the area of HbA1c. There is plenty of room for criticism on both sides, but for one profession to point the finger at another profession seems like the wrong way to get cooperation.

Although I don't think that the HbA1c test should be a monthly test, if the Society of General Internal Medicine (SGIM) holds to their “Choosing Wisely” tactics, then I think that the HbA1c tests should become mandatory on a monthly basis. Some people with extremely well-managed type 2 diabetes are currently using the home HbA1c tests on a monthly basis and very seldom see a doctor. Read this blog on Health Central by David Mendosa about the fate of our home HbA1c test. And, to see why I would recommend monthly HbA1c tests if the SGIM continues on their ill-advised campaign.

In the study findings presented at the ASCP 2013 Annual Meeting lead investigator Ross Molinaro, PhD, from the Emory University School of Medicine in Atlanta stated, "We're hearing about overuse of this test, but even when it is used appropriately, the result may not be. Of the less than 20% of patients with diabetes who meet the nationally recommended frequency for glycated hemoglobin (HbA1c) testing, more than a third are not prescribed treatment changes when their levels increase significantly.”

They then use the American Diabetes Association (ADA) and I am guessing the American Association of Clinical Endocrinologists (AACE), even though the author of the article uses the term “other organizations,” recommend that the HbA1c test be performed every six months for people in the target range. Then the article continues that if the person with diabetes is not in the target range or if their therapy had changed, that the HbA1c test be done every three months.

Even if Dr. Molinaro says, “The survey results show that endocrinologists are unclear about what constitutes a statistically significant reference change value and would find that information useful; I might believe that the questions may have been twisted to elicit this response. My conversations with endocrinologists lead me to believe that they do understand what a statistically significant reference change value means but maybe those surveyed do not keep records to compare current results to past results.

At least Dr. Molinaro puts his organization on notice that they need to do more when he states, "Our study suggests that better communication between the lab and the clinician is needed on when to follow up with a patient who has a significant change in HbA1c. I think the onus is on the lab to find a better way to communicate test results."

ASCP president-elect William Finn, MD (not involved in the study) said that it is possible the study data does not give a complete picture. Still, the study highlights a well-known issue; however, the information given to the clinicians needs to close the process to be sure the physician is counseled on what the test means. At least the ASCP incoming president understands that the significant change in HbA1c results should apply to other laboratory test.

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