Implementation and Evaluation of Emergency Department Hemoglobin A1C Testing as a Population Health Initiative

Monitoring hemoglobin A1c (HbA1c) is a population health quality metric associated with improved outcomes in diabetic patients. However, the utility of emergency department (ED)-based interventions for monitoring HbA1c for institutional quality metrics is unknown.

The purpose of this study is to evaluate a program to improve measurement of HbA1c for at-risk ED patients.

This was a retrospective observational pre-/poststudy at an academic medical center. In November 2017, an alert was programmed into the ED Information System (EDIS) to identify diabetic patients within the health system who were overdue for HbA1c testing and prompt physicians to order HbA1c levels. Data were extracted from the EDIS from January 1, 2017, to September 30, 2023. The primary outcome was placement of an ED order for HbA1c testing. The secondary outcome was change in HbA1c on follow-up testing.

Of 348,490 ED patient encounters during the study period, 13,609 (3.91%) were diabetic patients within the health system who were identified as noncompliant with institutional HbA1c metrics. Following the intervention, HbA1c ordering for target patients increased from 1.5% to 12.1% (p < 0.001), but rates of testing decreased over time. Postintervention, 313 of 1416 patients (23%) who had an HbA1c ordered in the ED had follow-up HbA1c testing available, with a small average decrease in HbA1c of -0.42% (standard deviation 1.7). However, this was not statistically different compared to the preintervention group (-0.60%, p = 0.40).

A targeted ED intervention was associated with increased testing for HbA1c; however, this effect decreased over time. The program demonstrated operational feasibility, but did not appear to significantly improve HbA1c levels relative to the overall ED population. Further study is needed to assess optimal approaches to targeted population health interventions in the ED for chronic illnesses like diabetes.