Diabetes Case Finding using HbA1c Testing
In 2014, a pilot study was undertaken in the Emergency Departments (ED) of Blacktown and Mount Druitt Hospitals using a 2 step screening process designed to detect levels of diabetes or prediabetes.
It was noted that 38% had diabetes, 27% had pre-diabetes and 32% were unaware of their diagnosis.
Given the significant findings, testing for diabetes became routine in June 2016 for all individuals presenting to the ED’s of Blacktown and Mount Druitt Hospitals where a valid blood sample was available.
Testing undertaken for a year (approximately 30,000 tests) has revealed the presence of pre-diabetes in 29% and diabetes in 17%. It is intended that a similar process will begin in Westmead Hospital in the near future.
Previous hospital coding of Diagnosis Related Groups suggested an inpatient diabetes prevalence rate of 11% but with the advent of HbA1c testing, we have established that this is closer to 19% at Blacktown and Mt Druitt Hospitals.
In the Cardiology service, the prevalence rate has been documented to be as high as 42%.
People with diabetes have significantly increased costs compared to those with normal HbA1c. As people progress from normal to pre-diabetes to diabetes, their average cost goes from $4,541 to $5,445 to $7,358 for a single hospital admission. People with diabetes also have a 40 hour longer average length of stay than those with a normal HbA1c, reflecting the complexity of the admission and the impact to their hospital experience. This large and growing burden paints a stark picture of the difficulties facing the hospital system. With our ever-growing epidemic of diabetes, these numbers will only continue to grow.
Identification of people at risk with HbA1c testing allows the promotion of lifestyle intervention programs to work in conjunction with medications to improve diabetes control. At Blacktown Hospital, this process is reinforced by a Support Nurse who is tasked with contacting individuals (and their GPs) with abnormal HbA1c tests by telephone. The aims is to facilitate a consultation between patient and GP in the hope of progressing their management.
There is strong international evidence that enrolling patients with diabetes into comprehensive management programs decreases costs and improves patient outcomes. Moreover, evidence from the NHS indicates that HbA1c testing as a screening tool has a significant cost-benefit to patients derived from a reduction in QALYs lost to diabetes complications
There were 4580 presentations to the ED and 1267 (27%) HbA1c measurements were obtained over the 6 week period. In this cohort:
- Diabetes (HbA1c of ≥ 6.5%) was present in 38.4% (n=487)
- Diabetes was newly diagnosed in 32.2% (n=157)
Pre-diabetes (HbA1c of 5.7-6.4%) was diagnosed in 27.4% (n=347)
- Hospital coding analysis revealed 28% (n=88) of patients identified as having diabetes through ED HbA1c testing were not coded for a diagnosis of diabetes on discharge
Opportunistic testing for diabetes is effective as almost a third of individuals tested had undiagnosed diabetes. In addition, more than a quarter of individuals were at risk of developing diabetes. Early detection provides an opportunity to initiate preventative measures such as NSW Government’s ‘Get Healthy’ program.