31 Mar 2025 Appropriate HbA1c testing
The Therapeutics Initiative produced individual prescribing Portraits on the topic of appropriate hemoglobin A1c (HbA1c) testing frequency to monitor people with type 2 diabetes (2023). The Portraits were released online to clinicians in BC who are registered for the Portrait program. Eligible clinicians (primary care physicians and nurse practitioners) were randomized to have access to the Portrait in two groups, an early group of clinicians were granted online access to this prescribing Portrait March 31, 2025 and a delayed group will be granted access approximately 1 year later (March 2026).
This Portrait was accompanied by the Therapeutics Letter: Appropriate hemoglobin A1c testing frequency to monitor patients with type 2 diabetes.1
Abbreviations used
A1c: A measure of average blood sugar (glucose) level over the past 3 months
ATC: Anatomical Therapeutic Chemical code assigned to medicine
BCN&M: British Columbia College of Nurses & Midwives
CPSBC: College of Physicians and Surgeons of British Columbia
FP: Family practitioner
GP: General practice
ICD: International Classification of Diseases
MSP: Medical Services Plan
NP: Nurse practitioner
PSP: Practice Support Program
RCT: Randomized controlled trials
T2DM: Type 2 diabetes
Data definitions
Who received this Portrait?
Clinicians who have registered online for a Portrait account and who meet all of the following criteria have access to an individual prescribing Portrait:
- General practice (GP) physicians or nurse practitioners (NP) registered to practise in British Columbia;
- Family practitioners (FP) registered by the BC Medical Services Plan and the College of Physicians and Surgeons of BC with an active practice, or physicians registered primarily as GP-emergency medicine and FP-emergency medicine physicians;
- NPs registered by the BC Medical Services Plan and the BC College of Nurses & Midwives with an active practice; and
- had ≥100 prescriptions (for any drug) filled at a community pharmacy in 2023, according to PharmaNet claims data; and
- have not opted out of the Portrait program.
How were patients assigned to this Portrait?
Patients were included in a clinician Portrait if they met all of the following criteria:
- were age 18 years or older on January 1, 2023; and
- were diagnosed with diabetes (predominantly type 2 diabetes); and
- were BC residents based on continuous BC MSP enrollment.
Data for patients who are federally insured (e.g., Veterans, RCMP, Armed Forces and beneficiaries of Non-Insured Health Benefits) were not available.
How was a diagnosis of diabetes determined?
The Portrait key messages apply to monitoring A1c for persons with type 2 diabetes (though are applicable to those with type 1 diabetes as well). The data displayed in the Portrait contain predominantly persons with type 2 diabetes though it is possible that some patients with type 1 diabetes are captured.
Diabetes diagnosis was determined if:
- patient had a hospital discharge with diabetes diagnosis (ICD-10 E10, E11, E13, E14); and
- clinician had an MSP claim for diabetes for that patient (ICD-9 250); and
- patient had at least 1 prescription for an antidiabetic/antihyperglycemic medication in 2023 according to PharmaNet claims data; and
- prescribing clinician had a diabetes management billing code from MSP for that patient.
What tests were included in this Portrait?
Hemoglobin A1c tests that were ordered by the Portrait clinician and recorded in BC Provincial Laboratory Information Solution (PLIS) database between January 1, 2023 and December 31, 2023. The Portrait presents 2 metrics:
- Chart #1 looks at all tests by a clinician in 2023, then looks back 90 days for a test by the same provider.
- Chart #2 is a distribution looking at the first test for a patient in 2023, then looks forward 12 months to count the total number of tests.
The Portrait displays HbA1c tests ordered by the Portrait clinician and does not include tests ordered by other prescribers.
Clinicians may have received a Portrait with masked or missing elements because they met the above requirements but ordered between 1 and 5 HbA1c tests for that element of the Portrait. Portrait’s data access agreement requires the suppression of data elements that contain <6 individuals. To comply with the agreement, the total number of patients may be presented as a range, and percentages were rounded to the nearest 5%.
A1c is a continuous variable, and individual test results reflect inherent biological variability, test-to-test variability, and lab error.
How was “Optimal” determined?
“Optimal” was determined to be 0 [zero] HbA1c tests in less than 90 days. This comparator was chosen based on the best available evidence: For people with type 2 diabetes whose treatment and blood glucose are stable, testing HbA1c less frequently than every 3 months (e.g., testing every 6 months) is appropriate.
We recommend developing therapeutic plans in discussion with patients. There is no evidence for one best approach. The most appropriate choice for any individual depends on patient context (e.g., baseline glycemic control, risk of harm), and patient goals and preferences.
Please refer to Therapeutics Letter: Appropriate hemoglobin A1c testing frequency to monitor patients with type 2 diabetes.1 for a more detailed assessment of the evidence.
Reference
- Therapeutics Initiative. Appropriate hemoglobin A1c testing frequency to monitor patients with type 2 diabetes. Therapeutics Letter. 2025 (March); Limited early release:1-2.
Research component
The research objective is to determine the impact of the Portrait on clinician prescribing and ordering of tests. This impact will be evaluated at an aggregated level over the coming year by comparing pooled data from clinicians in the early group to pooled data from clinicians in the delayed group. All prescribing data analyzed for this evaluation will not contain names, only encrypted patient and clinician numbers. No clinician or patient will be identified in any reports or publications. Portrait’s data access agreement requires the masking of data elements when <6 individuals (patients or clinicians) are included. Ethics approval for this evaluation will be obtained from the University of British Columbia Clinical Ethics Review Board. This evaluation is being led by Drs. Wade Thompson, Anshula Ambasta, Greg Carney, and Colin Dormuth, University of British Columbia, Faculty of Medicine, Department of Anesthesiology, Pharmacology, & Therapeutics.
If you have any questions or would like further information with respect to this evaluation, you may contact the Portrait team at (604) 822-4887 or email Portrait@ti.ubc.ca
FAQs
Can I request the names of my patients included in this Portrait?
No. Portrait’s data access agreement only permits access to encrypted patient identifiers. There is no way for us to identify individual patients in the data or to provide you with a list. However, other resources may be available for you. Physicians can contact the Practice Support Program (PSP) regional team to discuss how they might help you use your EMR to identify these patients.
I have a unique/specialized practice and do not believe that my data should be compared to GPs. Shouldn’t my comparison cohort be other clinicians with practices similar to mine?
Our ability to accurately include clinicians depends on how each clinician is listed in the BC MSP data. For example, to be included in the program, a clinician must be defined as a Nurse Practitioner or a General Practitioner with a licence status of Private Practice in the MSP data; beyond that, it is difficult to accurately identify any individual’s specific work environment, as many clinicians work in multiple locations. We try to keep Portraits relevant to recipients by having a minimum prescribing (or ordering of tests) criterion for each Portrait topic. Clinicians who order no or very few tests may not receive a Portrait.
Creating accurate comparison cohorts is difficult for the same reasons. We often include the BC median as a points of interest when it is feasible, but we know that many clinicians have unique or specialized practices and this comparator is not ideal. Hopefully, as we continue to build and refine the Portrait program, we will be able to provide comparisons that are more relevant to a variety of practices.
Portraits are really intended to be a tool for you to reflect upon and consider your own prescribing. Rest assured that we are not directly comparing your prescribing or ordering of tests to any particular cohort. You are the only one who ever sees your own Portrait data, and you can decide for yourself whether you think your prescribing and ordering of tests is in line with the evidence given your unique clinical setting. You will only receive future Portraits for which you have prescribed or ordered tests more than the minimum inclusion criteria, so you shouldn’t receive anything that is irrelevant to your practice.
Why does my Portrait show ranges of patients that I treated (1-20, 20-30, etc.), and not exact numbers?
Clinicians may have received a Portrait with masked or missing elements (i.e., no blue red bars shown) because they met the above requirements but prescribed between 1 and 5 tests for that section element of the Portrait. Portrait’s data access agreement requires the suppression of data elements that contain <6 individuals. To comply with the agreement, the total number of patients may be presented as a range (e.g., 1-5 patients), and percentages were rounded to the nearest 5%. Clinicians with no tests (“0 tests”) will have this element displayed.
Are my data confidential and secure?
Yes. We follow the Ministry of Health’s strict privacy protocols to ensure the privacy and confidentiality of your Portraits. Administrative health data used to create Portraits use encrypted patient identifiers, so there is no way to identify individual patients in the data. Graphs containing fewer than 6 patients are masked to prevent possible identification due to small numbers.
During every aspect of production and delivery, your prescribing data are completely confidential and protected. Portraits are assigned a random number throughout production, and printed Portraits are sealed within a Privacy Envelope before matching to the appropriate name and address. No one except you sees your prescribing data alongside your name.
I don’t see my question here. Where can I find more information?
Please check out our program FAQ section. We also welcome your feedback. Questions can be directed to our Portrait team by phone (604) 822-4887 or email Portrait@ti.ubc.ca.
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