Higher costs and utilization occurs among patients with diabetes mellitus when HbA1c results are not present in the electronic health record: a retrospective analysis (Preprint)

BACKGROUND Clinical information may frequently be missing from the electronic health record (EHR), and contributes to delayed care, adverse events, and additional services, which may be costly. Missing laboratory data might be valuable marker for population-level risk stratification to help identify patients at risk of high cost and utilization. OBJECTIVE To determine whether absent hemoglobin HbA1c results in the EHR stratifies risk of high healthcare costs and utilization among adults with diabetes mellitus (DM). METHODS Retrospective U.S. cohort with EHR and claims data (2012-2013) of 6,270 continuously insured and care-engaged patients with DM who had ≥1 ambulatory visit in 2012. HbA1c availability defined as “HbA1c present” if ≥1 HbA1c EHR result was available in 2012 and otherwise as “HbA1c absent.” Patient’s annual healthcare costs, presence of any inpatient hospitalization, and presence of any emergency department (ED) visit in 2012 (concurrent) and 2013 (prospective).We used linear and logistic regression analyses, adjusting for age, gender and comorbidity, to determine associations with concurrent and prospective healthcare costs, emergency department (ED) visit, and hospitalization. RESULTS Overall, HbA1c result was absent from the EHR in 20.2%. Absent HbA1c status had significantly greater healthcare costs than HbA1c present (Concurrent difference: $5,081, p<0.001; Prospective difference: $5,489, p<0.001). Absent HbA1c status was significantly more likely to have an ED visit than HbA1c present (Concurrent: OR 1.44, p<0.001; Prospective: OR 1.29, p=0.01). No significant differences in hospitalization existed between groups. CONCLUSIONS Markers indicating absent laboratory results in the EHR, such as HbA1c availability, may be a promising population-level risk stratification approach. HbA1c availability appears to offer clinically relevant information associated with high healthcare costs and utilization. Future research might use markers identifying HbA1c or other laboratory results absent from the EHR to trigger various quality improvement interventions, such as health information exchange, clinical decision support, or care management.