Point of Care Testing for Diabetes Management

In clinical settings, point-of-care testing (POCT) provides rapid diagnostic information to help make clinical decisions as early as possible in the care and treatment of patients.

Image Credit: EKF Diagnostics

Ensuring that such information is quickly available optimizes the entire care process. Therefore, the potential of any POCT application can be evaluated in terms of how it contributes to decision making and the care process.

However, the potential impact of POCT measurement systems versus laboratory analytical systems needs consideration because most of the evidence regarding the effectiveness of a test would have been determined using lab-based solutions.

HbA1c Testing in Diabetes Management

Over the past few decades, HbA1c testing has become an established method in the management of diabetes and, more recently, the test has also been recognized for its role in diagnosis of the disease.

The HbA1c level not only reflects the circulating glucose concentration over the lifespan of the red blood cell, but has also been shown to predict the complications of diabetes such as cardiovascular disease.

Previously, the use of HbA1c measurement was based on laboratory-based methods such as affinity chromatography and ion exchange, with other affinity and immunological techniques following later.

According to one study of biological variation, the inter- and intra-individual difference in HbA1c between non-diabetics was 4.0% and 1.7%, respectively.

Another study showed an intra-individual difference of 1.2% in non-diabetics and 1.75% in type 1 diabetics, while the respective values for fasting blood glucose were 5% and 30%. These studies demonstrate the benefits of using HbA1c measurement in the screening and management of diabetes.

In this article, the above data was used to determine the desirable analytical goals for bias, imprecision and total error as 1.9%, 1.3%, and 3.9%, respectively.

Lestra Winters et al. used similar performance criteria and found that out of eight POCT systems for HbA1c measurement, only two satisfied the required performance criteria, while Bruns and Boyd described a poor analytical performance with respect to clinical decision making.

The report prepared by Lenters and Westra, showed variation between the laboratory reference methods even though the techniques were all controlled and calibrated in their laboratory.

More about the Analysis

With regard to the viability of POCT for HbA1c in the management of diabetes, a systematic review concluded that to date, no trial data presents sufficient evidence that a POCT system is effective for HbA1c in the management of diabetes.

However, this review was based on seven studies and used two approaches to the surrogate outcome measure, thereby limiting the opportunity for meta-analysis of the entire cohort.

Furthermore, significant heterogeneity between the patient populations existed, which also limited the opportunity for pooling data and conducting a meta-analysis. Moreover, there was a significant lack of documentation regarding the treatment protocols used and therefore no evidence that patients were stratified according to the care they received.  However, there was some indication that treatment was intensified to a greater degree among those with an HbA1c level above 7.0% who were receiving POCT.

The authors highlighted key aspects in the application of POCT, which are relevant to both standard practice and research studies. These included the following:

• Patients must be stratified by their baseline HbA1c values
• A revised process of care using POCT must be defined and adhered to
• The POCT results must be discussed with patients and any treatment plans documented and implemented

Interestingly, four observational studies carried out across a total of 5700 diabetic patients where results were fed back to patients immediately, all showed considerable reductions in HbA1c levels. In fact, one of these studies showed improvement in the HbA1c level was maintained over a period of four years.

A recent systematic review of strategies to improve standards in the management of diabetes has demonstrated that quality improvement strategies regarding adherence to guidelines can contribute to improved HbA1c levels.

According to data obtained from primary care records, there is evidence to suggest that HbA1c testing has been both under-used and over-used. However, the data also suggests that patient satisfaction has improved considerably with the use of POCT and that individuals’ personal knowledge of their HbA1c levels is linked to better outcomes.

Testing HbA1c in POCT Settings

The various attributes of the HbA1c measurement are applicable not only in the management of diabetes, but also in diagnosis of the disease. Moreover, the test has been shown to perform as well as the fasting blood glucose test commonly used to screen for type 2 diabetes.

The World Health Organization has now recommended that HbA1c be used as a diagnostic measure in diabetes, with similar guidance now being followed in a number of countries.

However, a degree of caution should be employed when using the test, which should not be used in the testing of children, young people, those with suspected type 1 diabetes, pregnant women, cases of acute illness, cases of HIV infection, cases of renal failure or patients with a short duration of symptoms.

In addition, the cut-off value of 48 mmol/mol (6.5% DCCT) may not be suitable for all populations, with further research required into any populations not yet featured in the studies to date. However, patients who fall within the range of 42 – 47 mmol/mol should be considered at high risk for developing diabetes and managed with appropriate lifestyle advice and annual retesting.

Although there have been some concerns regarding the use of HbA1c in screening for diabetes in terms of cost, patient follow-up and lifestyle advice, current guidance supports the use of this test in both screening for type 2 diabetes and the management of those already diagnosed with the condition.

Conclusion

The use of POCT for HbA1c in the management of diabetes enables better access to testing and rapid clinical decision making, discussion, and implementation of optimized treatment. It also enables tests to be performed closer to the patient, making the process more convenient and therefore increasing the likelihood of treatment compliance.

Point-of-care HbA1c analyzers from EKF Diagnostics are certified to IFCC and NGSP international standards for point-of-care testing in the screening and monitoring of patients with diabetes.

Acknowledgement

Produced from articles authored by Professor Chris Price, Visiting Professor in Clinical Biochemistry, Department of Primary Care Health Sciences, University of Oxford and Dr Gary Dowthwaite, Product Manager, EKF Diagnostics.

Bibliography

1. Khaw KT, Wareham N, Bingham S, Luben R, Welch A, Day N. Association of hemoglobin A1c with cardiovascular disease and mortality in adults: the European prospective investigation into cancer in Norfolk. Ann Intern Med 2004;141:413–20.
2. Selvin E, Marinopoulos S, Meta-analysis: glycosylated hemoglobin and cardiovascular disease in diabetes mellitus. Ann of Internal Medicine 2004;141:421–31.
3. ten Brinke R, Dekker N, de Groot M, Ikkersheim D. Lowering HbA1c in type 2 diabetics results in reduced risk of coronary heart disease and all cause mortality. Prim Care Diabetes 2008;2:45–9.
4. Rohlfing C, Wiedmeyer H-M, Little R, Grotz L,Tennill A, England J, et al. Biological Variation of Glycohemoglobin. Clin Chem 2002;48:1116-8.
5. Carlsen S, Petersen PH, Skeie S, Skadberg Ø, Sandberg S. Within-subject biological variation of glucose and HbA(1c) in healthy persons and in type 1 diabetes patients. Clin Chem Lab Med. 2011;49:1501-7.
6. Braga F, Dolci A, Montagnana M, Pagani F, Paleari R, Guidi GC, et al. Revaluation of biological variation of glycated hemoglobin (HbA(1c)) using an accurately designed protocol and an assay traceable to the IFCC reference system. Clin Chim Acta 2011;412:1412-6
7. Lenters-Westra E, Slingerland RJ. Six of eight hemoglobin A1c point-of-care instruments do not meet the general accepted analytical performance criteria. Clin Chem 2010;56:44 –52.
8. Holmes EW, Ersahin C, Augustine GJ, Charnogursky GA, Gryzbac M, Murrell JV, McKenna KM, Nabhan F and Kahm SE. Analytic bias among certified methods for the measurement of haemoglobin A1c. A cause for concern? Am J Clin Pathol 2008, 129, 540-547
9. College of American Pathologists (CAP) Survey Data.
10. Bruns DE, James C. Boyd JC. Few point-of-care hemoglobin A1c assay methods meet clinical needs. Clin Chem 2010;56:4–6.
11. Al-Ansary L, Farmer A, Hirst J, Roberts N, Glasziou P, Perera R, Price CP. Point-of-Care Testing for Hb A1c in the Management of Diabetes: A Systematic Review and Metaanalysis. Clin Chem 2011;57:568-76.
12. Bubner TK, Laurence CO, Gialamas A, Yelland LN, Ryan P, Willson KJ, et al. Effectiveness of point-of-care testing for therapeutic control of chronic conditions: results from the PoCT in General Practice Trial. MJA 2009;190:624–6.
13. Cagliero E, Levina EV, Nathan DM. Immediate feedback of HbA1c levels improves glycemic control in type 1 and insulin-treated type 2 diabetic patients. Diabetes Care 1999;22:1785-9.
14. Khunti K, Stone MA, Burden AC, Turner D, Raymond NT, Burden M, et al. Randomised controlled trial of near-patient testing for glycated haemoglobin in people with type 2 diabetes mellitus. Br J Gen Prac 2006;56:511–7.
15. Kennedy L, Herman WH, Strange P, Harris A, GOAL A1C team. Impact of active versus usual algorithmic titration of basal insulin and point-of-care versus laboratory measurement of HbA1c on glycemic control in patients with type 2 diabetes: the Glycemic Optimization with Algorithms and Labs at Point of Care (GOAL A1C) trial. Diabetes Care. 2006;29:1– 8.
16. Agus MS, Alexander JL, Wolfsdorf JI. Utility of immediate hemoglobin A1c in children with type I diabetes mellitus. Pediatr Diabetes 2010;11:450–4.
17. Grieve R, Beech R, Vincent J, Mazurkiewicz J. Near patient testing in diabetes clinics: appraising the costs and outcomes. Health Technol Assess 1999;3:1–74.
18. Ferenczi A, Reddy K, Lorber DL. Effect of immediate hemoglobin A1c results on treatment decisions in office practice. Endocr Pract 2001;7:85–8.
19. Petersen JR, Finley JB, Okorodudu AO, Mohammad AA, Grady JJ, Bajaj M. Effect of point-of-care on maintenance of glycemic control as measured by A1C. Diabetes Care 2007;30:713–5.
20. Rust G, Gailor M, Daniels E, McMillan-Persaud B, Strothers H, Mayberry R. Point of care testing to improve glycemic control. Int J Health Care Qual Assur 2008;21:325–35.
21. Driskell OJ, Holland D, Hanna FW, Jones PW, Pemberton RJ, Tran M, Fryer AA. Inappropriate requesting of glycated hemoglobin (Hb A1c) is widespread: assessment of prevalence, impact of national guidance, and practice-to-practice variability. Clin Chem 2012;58:906-15.
22. Levetan CS, Dawn KR, Robbins DC, Ratner RE.Impact of computer-generated personalized goals on HbA(1c). Diabetes Care 2002;25:2– 8.
23. Peterson KA, Radosevich DM, O’Connor PJ, Nyman JA, Prineas RJ, Smith SA, et al. Improving Diabetes Care in Practice: findings from the TRANSLATE trial. Diabetes Care 2008;31:2238-43
24. Laurence CO, Gialamas A, Bubner T, Yelland L, Willson K, Ryan P, Beilby J. Point of Care Testing in General Practice Trial Management Group. Patient satisfaction with point-of-care testing in general practice. Br J Gen Pract 2010;60:e98–104.
25. Bennett CM, Guo M, Dharmage SC. HbA(1c) as a screening tool for detection of Type 2 diabetes: a systematic review. Diabet Med 2007;24:333-43.
26. World Health Organization. Use of glycated haemoglobin (HbA1c) in the diagnosis of diabetes mellitus. 2011.
27. National Institute for Health and Clinical Excellence. Preventing type 2 diabetes: risk identification and interventions for individuals at high risk. 2012.
28. ADA guidelines
29. Inzucchi SE. Clinical practice. Diagnosis of diabetes. N Engl J Med 2012;367:542-50.
30. Farmer A. Use of HbA1c in the diagnosis of diabetes. BMJ 2012;345:e7293.
31. Higgins T. HbA(1c) for screening and diagnosis of diabetes mellitus. Endocrine. 2012 Aug 21. [Epub ahead of print].
32. Ginde AA, Cagliero E, Nathan DM, Camargo CA Jr. Point-of-care glucose and hemoglobin A1c in emergency department patients without known diabetes: implications for opportunistic screening. Acad Emerg Med. 2008;15:1241-7.
33. Jelinek GA, Weiland TJ, Moore G, Tan G, Maslin M, Bowman K, et al. Screening for type 2 diabetes with random finger-prick glucose and bedside HbA1c in an Australian emergency department.

About EKF Diagnostics

EKF Diagnostics is a global medical diagnostics business with a long history in point-of-care testing and central laboratory manufacturing.  Our products have a hard earned reputation for ease of use, reliability and accuracy.

Our core focus is the Point of Care market with over 80,000 haemoglobin, A1c, glucose and lactate analyzers in regular use in more than 100 countries running more than 50m tests every year.

Our range of HbA1c analyzers and glucose analyzers are used in GP surgeries, sports clinics, and diabetes clinics. They deliver fast and reliable results that provide both practitioner and patient with the information they need to make clinical or lifestyle decisions in minutes.

EKF Diagnostics offer the largest range of hemoglobin and hematocrit analyzers on the market, giving physicians and specialists a choice of product with different methodology, measurement speed, connectivity and price options.  Our aim is to make blood donation and anaemia screening easier, more affordable and more accessible than ever before.

The EKF Maternal & Women’s Health Point of Care range aims to improve healthcare outcomes for women and children by providing physicians with a suite of products covering pregnancy testing, anaemia screening, fetal scalp lactate testing and post birth creamatocrit measurement.

EKF Diagnostics is also a global manufacturer of central laboratory products including Stanbio Chemistry reagents, benchtop laboratory analyzers, rapid tests and centrifuges.  Our chemistry reagents can be used on the majority of analyzers found in hospital laboratories around the world.

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