As a nurse, I care for many readmitted diabetic patients due to a deterioration of their condition. This has prompted me to understand strategies to address this problem. Polit and Beck (2017) and Davies (2011) considered the formulation of a PICOT question is a critical step towards evidence-based practice (EBP). According to Polit& Beck (2017), EBP is the best as it integrates clinical expertise, patient values, and preferences with research evidence to provide the most appropriate care. The PICOT model helps to come up with well-worked research questions and also provide a guide to literature search by identifying the critical concepts necessary for the specific question to be answered (Laureate Education, 2012; Polit& Beck, 2017). The model is based on the acronyms population (P), intervention (I), comparison (C), outcomes (O) and time (T).My PICOT question is: In patients with diabetes (P), does maintaining HbA1c level <7% (I) as compared to >7% (C) reduce the readmission rate (O) within 12 weeks after discharge (T).  This question is specific to my area of interest.

Literature Review

A literature search was conducted in the CINAHL, Medline, Cochrane Review and Google Scholar databases for the period between 2010 and present. Polit andBeck (2017) indicated that having the right keywords makes the literature search easier. The following keywords, as well as Boolean search phrases, were used; Hemoglobin A1c, HbA1c, glycemic control, and HbA1c AND readmission rates, HbA1c AND hospital readmission. While the literature search results had various articles, using filters such as date of publication, type of publication, type of research were used to narrow down the search to the most relevant studies just as described by Polit& Beck (2017). Evidence in the selected articles regarding the effect of maintaining HbA1c levels <7% was then reviewed. Due to the limited nature of current studies on the effect of HbA1c on readmission, an additional abstract of a recent study by Bakeri, Wakefield &Dulipsingh (2017) (which was selected based on the credibility of the authors and relevance) was included in this review. A review of these studies identified three themes related to my PICOT question. These themes include HbA1c test is infrequently ordered; high HbA1c levels correlate with disease severity and HbA1c levels <7% are related to reduced readmission rates. Appendix A provides a summary of the studies reviewed.

The test is infrequently ordered

While available evidence points to the importance of measurement of HbA1c levels in enhancing glycemic control, Strack et al. (2014) and Bakeri, Wakefield &Dulipsingh (2017) indicated that the HbA1c test is not always conducted in the inpatient setting. An analysis of the Cerner Corporation, a national data warehouse in Kansas City, showed that between 1999 and 2008, the HbA1c test was ordered only on 18.4% of patients admitted with a diabetes mellitus diagnosis (Strack et al, 2014). A similar pattern was evident in the analysis of data from Saint Francis Hospital Medical Center (SFHMC) between 1st October 2014 and 30th September 2015 which showed that 40.6% of 970 patients who had 30-day readmissions had a HbA1c test during hospitalization or inside two months prior to the initial admission (Bakeri, Wakefield &Dulipsingh, 2017). The test was conducted on only on 39% of patients without readmissions (Bakeri, Wakefield &Dulipsingh, 2017).  The presented evidence indicates that the decision to test for HbA1c can significantly alter interventions to assist the patient to manage they blood glucose levels.

HbA1c levels <7% reduce readmission rates

Available evidence indicates that the measurement of Hemoglobin A1c levels is an accurate predictor of rate of readmissions in patients admitted with a primary or secondary diagnosis of diabetes mellitus (Dungan, 2012; Torimoto et al., 2016). In the study by Strack et al. (2014), there was a considerable reduction in the readmission rates in the group in which HbA1c testing was ordered as compared to that in which the test was not ordered (9.4%  and 8.7% respectively P= 0.007). The reduction was registered regardless of the test’s outcome. According to Bakeri, Wakefield &Dulipsingh (2017), measuring Hemoglobin A1c levels in the hospital setting is helpful in that can guide coordination of care and predict the readmission rates thereby helping improve patient outcomes while avoiding potentially preventable costs. Dungan et al. (2010) indicated that an increase of HbA1c level by 1% could lead to a 2-fold increase in readmission odds. However, the HbA1c cutoff value remains controversial with the American Diabetes Association (ADA) placing it 6.5% (Sherwani et al., 2016).  Dungan (2012) considered maintaining HbA1c levels <7% as a good glycemic control.

HbA1c levels can be used to predict disease severity

HbA1c is considered an important glycemic control indicator with decreasing values indicating improved glycemic control (Dungan, 2012; Torimoto et al., 2016).  Elevated HbA1c levels indicate increased the risk of developing diabetes-associated complications such as cardiovascular disease and stroke (Dungan, 2012; Sherwani et al., 2016).  This is because hyperglycemia is known to have a role in diabetic cardiomyopathy (Dungan et al., 2010; Sherwani et al., 2016; Torimoto et al., 2016). However, diabetes may be a primary or secondary diagnosis, and this has an effect on the link between HbA1c measurement and readmission rates Strack et al. (2014). In fact, Bakeri, Wakefield &Dulipsingh (2017) found that 5.8% of readmitted patients whose HbA1c had been measured had a primary diagnosis of diabetes mellitus and that those readmitted had higher HbA1c levels as compared to those in which diabetes was a secondary diagnosis. This suggests that high levels of HbA1c indicate increasing diabetes severity and therefore increased the risk of readmission. Strack et al. (2014) suggested that higher readmission rates in those with diabetes as the secondary diagnosis but had HbA1c measured may be because attention to diabetes care may have been less.

Preliminary Conclusions

The current recommendations provided by ADA for the measurement of HbA1c and its effect on readmission rates is supported by research evidence as determined in this literature review. The evidence indicates that maintaining the HbA1c levels <7% near the normal value is a strong indicator of good glycemic control and a predictor of reduced readmission rates. By the physicians adopting this evidence-based practice, it will be possible to improve patient outcomes given that a mere measurement of HbA1c has been shown to correlate with lowered readmission rates meaning that the patients register a better glycemic control when their HbA1c levels are measured. However, there is a need to conduct randomized controlled trials, which Polit andBeck (2017) indicated are of high quality, and their evidence can be used to inform clinical decisions.

Summary

There is no doubt that promoting EBP through research can help address a given clinical problem (Polit&Beck, 2017). With poor glycemic control leading to increased severity of diabetes and increased readmission rates, the HbA1c test has been shown to a strong predictor of risk of readmission. A literature search provided evidence which indicates that this test is infrequently ordered despite its benefits in determining disease severity and risk of admission. It is becoming increasingly important for healthcare providers to adopt evidence-based strategies to help patients in glycemic control and the HbA1c test is promising to be valuable in this regard. Ordering this test will help reduce readmission rates of patients with diabetes.

References

Bakeri, H., Wakefield, D., &Dulipsingh, L. (2017). The Role of Hemoglobin A1c on Readmission Rates for Patients with Diabetes. Endochrine Society. Retrieved 28 June 2017, from http://www.endocrine.org/meetings/endo-annual-meetings/abstract-details?ID=31015

Davies, K. S. (2011). Formulating the evidence based practice question: a review of the frameworks. Evidence Based Library and Information Practice, 6(2), 75-80.

Dungan, K., Osei, K., Nagaraja, H., Schuster, D., & Binkley, P. (2010). Relationship between glycemic control and readmission rates in patients hospitalized with congestive heart failure during implementation of hospital-wide initiatives. Endocrine Practice, 16(6), 945-951.

Dungan, K. M. (2012). The effect of diabetes on hospital readmissions. J Diabetes SciTechnol, 6(5), 1045–1052.

Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Wolters Kluwer.

Sherwani, S. I., Khan, H. A., Ekhzaimy, A., Masood, A., &Sakharkar, M. K. (2016). Significance of hba1c test in diagnosis and prognosis of diabetic patients. Biomarker insights, 11, 95.

Strack, B., DeShazo, J. P., Gennings, C., Olmo, J. L., Ventura, S., Cios, K. J., &Clore, J. N. (2014). Impact of HbA1c measurement on hospital readmission rates: analysis of 70,000 clinical database patient records. BioMed Research International, 2014, 781670.

Torimoto, K., Okada, Y., Sugino, S., & Tanaka, Y. (2016). Determinants of hemoglobin A1c level in patients with type 2 diabetes after in‐hospital diabetes education: A study based on continuous glucose monitoring. Journal of Diabetes Investigation, 8(3), 314–320.

Appendix A