HbA(1c) overtesting and overtreatment among US adults with controlled type 2 diabetes, 2001-13: observational population based study

Study question What is the extent and effect of excessive testing for glycated hemoglobin (HbA(1c)) among adults with controlled type 2 diabetes? Methods A retrospective analysis of data from a national administrative claims database included commercially insured individuals in the USA, 2001-13. Study patients were aged 18 years or older, had type 2 diabetes with stable glycemic control (two consecutive tests showing HbA(1c)<7.0% within 24 months), did not use insulin, had no history of severe hypoglycemia or hyperglycemia, and were not pregnant. HbA(1c) testing frequency was measured within 24 months after the second (index) HbA(1c) test, and classified as guideline recommended (≤2 times/year), frequent (3-4 times/year), and excessive (≥5 times/year). Changes in treatment regimen were ascertained within three months of the index test. Study answer and limitations Of 31 545 patients in the study cohort (mean age 58 years; mean index HbA(1c) 6.2%), HbA(1c) testing frequency was excessive in 6% and frequent in 55%. Despite good glycemic control at baseline, treatment was further intensified by addition of glucose lowering drugs or insulin in 8.4% of patients (comprising 13%, 9%, and 7% of those tested excessively, frequently, and per guidelines, respectively; P<0.001). Compared with guideline recommended testing, excessive testing was associated with treatment intensification (odds ratio 1.35 (95% confidence interval 1.22 to 1.50)). Excessive testing rates remained unchanged in 2001-08, but fell significantly after 2009. The odds of excessive testing was 46% lower in 2011 than in 2001-02. The study population is not representative of all US patients with type 2 diabetes because it was restricted to commercially insured adults with stable and controlled diabetes not receiving insulin treatment. The study design did not capture the underuse of HbA(1c) testing. What this study adds In this US cohort of adults with stable and controlled type 2 diabetes, more than 60% received too many HbA(1c) tests, a practice associated with potential overtreatment with hypoglycemic drugs. Excessive testing contributes to the growing problem of waste in healthcare and increased patient burden in diabetes management. Funding, competing interests, data sharing NDS and RGM are funded partly by the Agency for Healthcare Research and Quality (R18HS18339) and AcademyHealth Delivery System Science Fellowship (2013), respectively. No competing interests declared. Additional data are available from mccoy.rozalina@mayo.edu.