Definition

Percentage of adults aged 18 or older with diagnosed diabetes who self-report they had at least two A1C tests during the prior 12 months.

Numerator

Number of adults 18 or older with diagnosed diabetes who had at least two A1C tests in the past 12 months.

Denominator

Total number of surveyed adults 18 or older who were ever told by a health care professional that they had diabetes (excludes women with a history of gestational diabetes). Responses of "Don't know" and "Refused" were excluded from the analysis.

Data Interpretation Issues

Beginning in 2011, BRFSS data include both landline and cell phone respondent data along with a new weighting methodology called iterative proportional fitting, or raking. This methodology utilizes additional demographic information (such as education, race, and marital status) in the weighting procedure. Both of these methodology changes were implemented to account for an increased number of U.S. households without landline phones and an under-representation of certain demographic groups that were not well-represented in the sample. More details about these changes can be found at the following [https://ibis.health.utah.gov/pdf/opha/resource/brfss/RakingImpact2011.pdf link].

Why Is This Important?

Proper diabetes management requires regular monitoring of blood sugar levels. Glucometers provide immediate feedback on blood sugar levels. An A1C test, however, tells a person what his or her average blood sugar level has been over the past two or three months and is a more reliable indicator of blood sugar control. An A1C level indicates the amount of sugar that is attached to red blood cells (hemoglobin cells). Red blood cells are replaced every two or three months and sugar stays attached to the cells until they die. When levels of blood sugar are high, more sugar is available to attach to red blood cells. For most people with diabetes, the target A1C level is less than 7 percent. Higher levels suggest that a change in therapy may be needed. Therefore, obtaining regular A1C tests plays an important role in diabetes management. The American Diabetes Association [http://care.diabetesjournals.org/cgi/content/full/27/suppl_1/s15#T7 recommends] that people with diabetes have an A1C test at least two times a year. However, the test should be conducted more often for individuals who are not meeting target blood sugar goals, or who have had a recent change in therapy.

Healthy People Objective D-11:

Increase the proportion of adults with diabetes who have a glycosylated hemoglobin measurement at least twice a year
U.S. Target: 71.1 percent

Other Objectives

The American Diabetes Association recommends a target A1C level of less than 7%. This level corresponds to an average plasma blood glucose level of 170 mg/dL over the past 60-90 days. The Healthcare Effectiveness Data and Information Set (HEDIS) uses indicators to measure performance by health plans in the U.S. The HEDIS A1C indicator measures the number of insured adults who have at least one A1C test a year. Please [https://ibis.health.utah.gov/ibisph-view/indicator/view/HEDISHbA1c.html see] the HEDIS A1C indicator that is included in the IBIS-PH list.

How Are We Doing?

The percentage of people with diabetes who had at least two A1C tests a year is approximately 70% in Utah and in the U.S.

How Do We Compare With the U.S.?

The 2019 age-adjusted rate for Utah is higher than that for the U.S., 70.2% vs. 69.2%, respectively. However, the U.S. data only includes 24 states.

What Is Being Done?

A public service announcement from the Utah Department of Health regarding A1C testing, [https://www.youtube.com/watch?v=vWJkgo8XYNc "Do you wish you could reverse time?"] is available for view in English and Spanish. Diabetes educators play a prominent role in providing information about nutrition, exercise, and blood glucose monitoring. Diabetes education for all people with diabetes is encouraged. The Healthy Environments Active Living (HEAL) program encourages people with diabetes to enroll in a diabetes self-management education class. These classes have been shown to help individuals develop the skills they need to manage their diabetes and are usually taught by dietitians, nurses, or pharmacists, who may also hold the status of Certified Diabetes Educator (CDE). CDEs have considerable expertise in diabetes management and understand what the individual with diabetes is going through. The Utah Arthritis Program supports Chronic Disease Self-Management Programs and Diabetes Self-Management Programs throughout the state, this program is also called the Living Well with Chronic Conditions Program. This six-week program is available throughout the state at no cost and taught by community members. Information is available from Nichole Shepard, 801-538-6259, nshepard@utah.gov. More information is available on the [http://livingwell.utah.gov/ Living Well Utah website]. The HEAL program is working statewide to increase the number of locations that offer DSME and also promote DSME to eligible participants. The National DPP is also an evidence-based program to prevent type 2 diabetes. The HEAL program works with statewide partners to promote the National DPP to eligible Utahns and also is working to expand National DPP sites across the state.

Evidence-based Practices

Diabetes Self-Management Education and Support ([https://www.cdc.gov/diabetes/managing/education.html DSMES]) has been shown to improve blood glucose control in people with diabetes. Education programs may be certified by the American Diabetes Association or the Association of Diabetes Educators. Here is a [https://livingwell.utah.gov/program.php?grp=diab list] of DSMES programs available in Utah.

Available Services

Diabetes care manuals for patients are available in multiple languages are available [http://www.choosehealth.utah.gov/healthcare/physician-resources/diabetes-manuals.php here]. A list of self-management education programs taught by health care professionals is available [http://www.choosehealth.utah.gov/your-health/lifestyle-change/dsme.php here]. A list of free community diabetes self-management workshops taught by members of the community is available at [http://www.choosehealth.utah.gov/your-health/lifestyle-change/living-well.php here]. A diabetes self-management course is also available [http://www.ncoa.org/improve-health/chronic-conditions/better-choices-better-health.html online]. Please see the National Diabetes Education Program for more information about diabetes prevention and management [https://www.cdc.gov/diabetes/ndep/index.html here].

Health Program Information

Individuals seeking more information about diabetes management are welcome to call the toll-free Health Resource Call Center at 1-888-222-2542. Originally known as EPICC, (The Healthy Living through Environment, Policy, and Improved Clinical Care Program), the Healthy Environments Active Living (HEAL) Program is a program within the Utah Department of Health Bureau of Health Promotion. HEAL focuses on enabling education and engaged change for public health by engaging its three main audiences: individuals, partners, and decision-makers. HEAL champions public health initiatives and addresses the challenges of making health awareness and access truly universal and equitable in eight key areas: nutrition, heart health, diabetes, physical activity, schools, child care, community health workers, and worksites. The HEAL Program aims to reduce the incidence of diabetes, heart disease, and stroke by targeting risk factors including reducing obesity, increasing physical activity and nutritious food consumption, and improving diabetes and hypertension control. [[br]] The primary program strategies include: *Increasing healthy nutrition and physical activity environments in K-12 schools *Increasing healthy nutrition and physical activity environments in early care and education (childcare/preschool) *Increasing healthy nutrition and physical activity environments in worksites *Improving awareness of prediabetes and hypertension for Utahns *Improving the quality of medical care for people with diabetes and hypertension *Improving the linkages between health care providers and supporting community programs for Utahns with diabetes and hypertension *Improving access and availability to community health programs for Utahns with diabetes, hypertension, and obesity. *Improving care and management of students with chronic conditions in Utah schools

Relevant Population Characteristics

Members of minority racial and ethnic groups tend to have a higher risk of developing diabetes. The risk of diabetes in the Hispanic/Latino population is twice that for the non-Hispanic White population. The risk in the African American population is 60% higher than the risk for the non-Hispanic White population. The highest risk for developing diabetes is generally seen among Native Americans, where, in some tribes, over half of the adults aged 35 and older have diabetes.

Health Care System Factors

Equipment is available to measure A1C levels in as little as eight minutes. Some companies have developed portable A1C monitors that can be used to test individuals' A1C levels outside of a physician's office.

Risk Factors

As A1C levels increase, the risk of cardiovasular failure increases, for both people with and without diabetes (Arch Intern Med. 2008 Aug 11;168(15):1699-704). A one percentage decrease in A1C level can reduce to the risk of microvascular (eye, kidney, nerve disease) by as much as 40 percent (2012 Diabetes Report Card).

Health Status Outcomes

Tight control of A1C levels (i.e., maintaining a level of less than 7%) has been shown to be associated with substantial reductions in kidney disease and blindness among people with diabetes. Regular A1C exams can help people with diabetes maintain better blood sugar control. Regular A1C exams can lead to early detection and treatment for poor blood sugar control and help prevent complications.

The figure above shows age-adjusted rates of adults with diabetes who had 2 or more A1C tests in the past year by local health district. Weber-Morgan Local Health District has the highest rate of A1C testing at 87.8%. Utah County Local Health District has the lowest rate at 45.4%.

Data Notes

Beginning in 2011, BRFSS data include both landline and cell phone respondent data along with a new weighting methodology called iterative proportional fitting, or raking. This methodology utilizes additional demographic information (such as education, race, and marital status) in the weighting procedure. Both of these methodology changes were implemented to account for an increased number of U.S. households without landline phones and an under-representation of certain demographic groups that were not well-represented in the sample. This graph is based on the new methodology. More details about these changes can be found at the following [https://ibis.health.utah.gov/pdf/opha/resource/brfss/RakingImpact2011.pdf link].   Prior to 2015 San Juan County was part of the Southeast Local Health District. In 2015 the San Juan County Local Health District was formed.

There hasn't been any significant changes in the last decade of the percent of people with diabetes reporting having their A1C checked twice a year. In addition, the U.S. and Utah have statistically similar rates.

Data Notes

Beginning in 2011, BRFSS data include both landline and cell phone respondent data along with a new weighting methodology called iterative proportional fitting, or raking. This methodology utilizes additional demographic information (such as education, race, and marital status) in the weighting procedure. Both of these methodology changes were implemented to account for an increased number of U.S. households without landline phones and an under-representation of certain demographic groups that were not well-represented in the sample. This graph is based on the new methodology. More details about these changes can be found at the following [https://ibis.health.utah.gov/pdf/opha/resource/brfss/RakingImpact2011.pdf link].   Rates are age-adjusted and standardized to 2000 U.S. population. This question wasn't asked in Utah in 2014, 2016, and 2018. In addition, this question is not asked consistently from state to state. The following years of the U.S. data are suppressed because less than 25 states asked the question: 2011, 2014, 2016, 2018, and 2019.

References and Community Resources

The American Diabetes Association provides a current listing of free or low-cost screening services, updated monthly. Click on this [http://www.diabetes.org link] or call 1-800-DIABETES. This organization is a great resource for all types of diabetes information for patients, family members, and health care professionals. American Association of Diabetes Educators [[br]] [http://www.diabeteseducator.org][[br]] Local Chapter Facebook Page: [https://www.facebook.com/aadeutah] References: Utah: [http://apps.nccd.cdc.gov/DDTSTRS/Index.aspx?stateId=49&state=Utah&cat=preventive&Data=data&view=TO&trend=a1ctests&id=7 Utah Behavioral Risk Factor Surveillance System 2000-2006] U.S.: U.S. Behavioral Risk Factor Surveillance System 2013 Gerstein HC, Swedberg K, Carlsson J, McMurray JJ, Michelson EL, Olofsson B, Pfeffer MA, Yusuf S. The hemoglobin A1c level as a progressive risk factor for cardiovascular death, hospitalization for heart failure, or death in patients with chronic heart failure: an analysis of the Candesartan in Heart failure: Assessment of Reduction in Mortality and Morbidity (CHARM) program. Arch Intern Med. 2008 Aug 11;168(15):1699-704.