DUR: Rate of Hemoglobin A1C Testing in the Medi-Cal FFS Population
Glycemic control is paramount to the short-term and long-term management of diabetes. Monitoring of blood glucose, via the hemoglobin A1C test and self-monitoring, is the standard of care for patients with diabetes. This bulletin focuses on the A1C test and provides information about the rate of testing in the Medi-Cal Fee-For-Service (FFS) population.
Glucose Control and the Hemoglobin A1C Test
The results of the Diabetes Control and Complications Trial
and the United Kingdom Prospective Diabetes Study demonstrate
that tight control of blood glucose (with an average A1C <
7 percent) helps reduce the rate of secondary microvascular
complications such as nephropathy, neuropathy, and retinopathy.1,
2
Performing regular A1C tests allows the provider to:
- Document initial assessment of glucose control status and determine target range
- Assess average glucose levels over the past 2 to 3 months
- Detect departures from target goal and allow for timely adjustments in therapy
- Verify the patient’s self-monitored glucose meter readings
American Diabetes Association (ADA) Standards of Medical Care in Diabetes Monitoring Recommendations:3
- Perform the A1C test twice a year in patients that are at glycemic goal and stable metabolic status
- Perform the A1C test every three months in patients that are not at glycemic goal or patients that have changing therapy
- Use point-of-care testing of A1C to make therapy changes in a timely manner
- The goal A1C for most patients is 7 percent or below
Frequency of A1C testing may depend on the clinical situation, the treatment regimen used, and the judgment of the clinician. Deviations from standard A1C goals and monitoring frequency may be appropriate for the following patients: pregnant, the young and the elderly (<13 years old and >65 years old), and those experiencing hypoglycemia.
Rate of Hemoglobin A1C Testing in the Medi-Cal FFS
Beneficiary Population
A retrospective study of Medi-Cal FFS recipients with
diabetes was conducted to determine if prescribers/patients are
adhering to recommended ADA standards of care. Patients
continuously enrolled in the Medi-Cal Fee-For-Service program
between January 1, 2005 and December 21, 2005 with a diagnosis
of diabetes (ICD-9-CM code 250.xx) who had two or more paid
claims in an outpatient setting (excluding long-term and acute
care settings) AND one paid claim for a diabetic medication that
consisted of either a hypoglycemic agent, insulin or diabetic
supplies were included in the analysis. It should be noted that
this diabetic definition does not follow HEDIS measures and,
therefore, results should not be used as a direct comparison.
Recipients with a Medicare benefit were excluded. Claims for
these recipients were analyzed to determine compliance with ADA
guidelines concerning A1C testing (CPT-4 code 83036).
During the 12-month study period, 10,948 recipients with diabetes were identified:
- 76 percent had received at least one HbA1C test in 2005
- 42 percent received the ADA recommended two HbA1C tests in 2005
- 79 percent who are taking two or more drugs had an A1C test during the study period
The above results are a good start, and hopefully improvement will be made over time with an increase in A1C testing. Future studies in this area may expand diagnosis codes and place of service settings to measure the quality of care given to Medi-Cal recipients in long-term care and hospital settings.
Recommendations
Medi-Cal wants to ensure that the recipients utilizing
diabetes medications are receiving adequate monitoring. The
following steps should be followed by pharmacists and
physicians:
- Prescribers are reminded to refer to ADA guidelines for
the management of patients
with diabetes - Prescribers and pharmacists should make sure when
changing or adding medications
their patients are aware of the importance of compliance with their medication regimen - Pharmacists should consult patients taking anti-diabetic
drugs (particularly those starting
or changing therapy) to be aware of their personal A1C test values and A1C goals
- Diabetes Control and Complications
Trial/Epidemiology of Diabetes Interventions and
Complications (DCCT-EDIC) Research Group: Retinopathy and
nephropathy in patients with
type 1 diabetes four years after a trial of intensive therapy. N Engl J Med 342: 381-289, 2000. - UK Prospective Diabetes Study (UKPDS) Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 353: 837-853, 1998.
- Standards of Medical Care in Diabetes. Diabetes Care 29(1), January 2006.