Public health

Admission HbA1c screening doesn’t lead to better inpatient diabetes care

Routine blood glucose assessment of patients admitted to hospital does not by itself lead to improved management of diabetes by the hospital, a NSW trial has found.

Hospitals need to have additional staff and resources to act on the results from routine HbA1 screening of patients admitted from emergency departments, according to diabetes specialists writing in the MJA.

In a commentary article, Dr Matthew Hare and Professor Jonathan Shaw noted the results from a randomised controlled trial in in 18 NSW hospitals showed that automatic admission screening did not result in higher detection rates of previously undiagnosed diabetes or increases in follow‐up plans for patients with admission blood glucose levels of 14 mmol/L or more.

The study involved 133 837 patients who had blood glucose assessed when admitted to hospital from an ED, and for whom the diabetes team were notified if there was a positive result.

Surprisingly, it found higher rates for the primary outcome of numbers of new diabetes diagnoses with documented follow‐up intervention (73/278 [26%] vs 83/506 [16%]) in control hospitals compared to those that had admission screening.

The number of new diabetes diagnoses with or without plans was similar in both control and screening hospitals (31%). There were also no differences in secondary outcomes of  30‐day re‐admission rates  (22% vs 31%) and post‐hospital mortality rates (22% vs 24%) for patients in control and intervention hospitals.

The slightly higher rate of follow up plans for the control group may have been because it included the only hospital with a dedicated inpatient diabetes team, the commentary authors suggested.

“Another possibility is that an automatic notification system without adequate financial and personnel support is potentially harmful; admitting teams are perhaps less likely to pay attention to hyperglycaemia if they perceive diabetes management to be the responsibility of another unit,” they wrote.

They said the negative findings should not be misinterpreted as arguing against routine glucose screening for admitted patients, but as an argument for comprehensive systems-based solutions to improve diabetes management within hospitals.

Without resources for a dedicated specialist inpatient diabetes team to follow up the HbA1c screening results, they may “fall between the cracks” due to  fragmented care, poor interdepartmental communication and suboptimal clinical handover, they argued.

“Poor documentation of follow-up plans in the discharge summary may reflect recognised problems with the clinical handover process. Clinical notes are typically written by overburdened junior clinicians who sometimes have only been peripherally involved in the care of the patient.

So while the aim of identifying undiagnosed diabetes through admission screening is a good one, “in isolation, automatic HbA1c assessment and notification are unlikely to have a positive impact,” they concluded.

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