Rectifying Missing A1Cs during a Pandemic

Primary care focuses on maintenance of health and management of chronic conditions. According to the Georgia Department of Public Health (GDPH), the Centers for Disease Control (CDC) and the American Diabetes Association (ADA), approximately 14.2% of the adult population have been diagnosed with diabetes mellitus (DM), and an additional 36.1% of the adult population have prediabetes. Diabetes mellitus is a leading cause of morbidity and mortality and requires consistent monitoring and treatment to minimize complications. COVID-19 has disrupted the consistent delivery of care for patients with DM and hence potentially placing them at risk for worsening disease management.

A large academic medical center in Georgia month to month monitors A1C metrics in relation to care of the person who has DM. The metrics include both an A1C greater than nine and missing A1C value. Review of data revealed an increase in both metrics beginning in March 2020 and trending upward through September 2020. An interdisciplinary group in primary care consisting of registered nurses, medical assistants, administrators, and providers reviewed the trending data in correlation with clinic closures and decreased access to primary care. The data revealed a 3% increase in the number of missing A1Cs and a 4% increase of the number of patients with an A1C greater than nine. The team wanted to understand the progressive increases. The team created a standard process to directly outreach/education to patients with diabetes, understand barriers and address the need for an A1C in accordance with the ADA standards of medical care in diabetes (2020).

The quality improvement project used A3 methodology and PDSA to create, implement, and review a standard process for direct patient outreach/education. The project included multiple components around data collection and review: access of data, identification of clinic and provider, understanding of metrics/data, review for duplication, antidotal barrier comments from patients, and a mechanism for tracking the information. Additionally, a foundational process was created which included identification of staff for outreach/education, process for outreach/education, communication scripting, scheduling patients for lab and provider visits, and follow-up. Patients who were missing an A1C received direct outreach/education from the clinical staff to include phone calls using scripted communication and education.

Over a period of two months, 1385 patients were identified as missing an A1C. Of these patients, 100% received direct outreach/education from the clinical staff, 990 provider appointments were scheduled with an A1C obtained decreasing the number of patients with a missing A1C from 1385 to 395. Anecdotal feedback from patients identified fear and lack of urgency in getting the A1C completed in the clinic. Additionally, patients expressed appreciation for the phone calls and education. As COVID-19 continues the quality improvement project will subsist to understand barriers for patients and how clinical staff can provide the support, education and access needed to care for patients with DM.