title: HbA1c overtesting and overtreatment among US adults with controlled type 2 diabetes, 2001-13: observational population based study.
abstract: OBJECTIVE
  What is the extent and effect of excessive testing for glycated hemoglobin (HbA1c) 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 HbA1c<7.0% within 24 months), did not use insulin, had no history of severe hypoglycemia or hyperglycemia, and were not pregnant. HbA1c testing frequency was measured within 24 months after the second (index) HbA1c 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.
  
  
  CONCLUSIONS
  Of 31,545 patients in the study cohort (mean age 58 years; mean index HbA1c 6.2%), HbA1c 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 HbA1c testing.
  
  
  CONCLUSIONS
  In this US cohort of adults with stable and controlled type 2 diabetes, more than 60% received too many HbA1c 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.
  
  
  BACKGROUND
  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.
authors.affiliation: Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic mccoy.rozalina@mayo.edu.
authors.forename: Rozalina G
authors.initials: RG
authors.lastname: McCoy
authors.affiliation: Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic Robert D and Patricia E Kern Center for Science of Health Care Delivery, Mayo Clinic.
authors.forename: Holly K
authors.initials: HK
authors.lastname: Van Houten
authors.affiliation: Section of General Internal Medicine and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven.
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Ross
authors.affiliation: Division of Endocrinology Metabolism and Nutrition, Department of Medicine, Mayo Clinic Knowledge and Evaluation Research Unit, Mayo Clinic.
authors.forename: Victor M
authors.initials: VM
authors.lastname: Montori
authors.affiliation: Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic Optum Labs, Cambridge, MA, USA.
authors.forename: Nilay D
authors.initials: ND
authors.lastname: Shah
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000378:metabolism*; D003924:Diabetes Mellitus, Type 2 / Q000097:blood* / Q000188:drug therapy / Q000453:epidemiology; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism*; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D008297:Male; D000069342:Medical Overuse / Q000706:statistics & numerical data*; D008875:Middle Aged; D015995:Prevalence; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology; D055815:Young Adult
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents