Short Communication A study of the differences in the request of glycated hemoglobin in primary care in Spain: A global, significant, and potentially dangerous under-request Maria Salinas a,b, ⁎, Maite López-Garrigós a , Joaquín Uris c , Carlos Leiva-Salinas d , on behalf of the Pilot Group of the Appropriate Utilization of Laboratory Tests (REDCONLAB) working group a Clinical Laboratory, Hospital Universitario de San Juan, San Juan de Alicante, Spain b Department of Biochemistry and Molecular Pathology, Universidad Miguel Hernandez, Elche, Spain c Department of Public Health, Universidad de Alicante, Alicante, Spain d Department of Radiology, University of Virginia, Charlottesville, VA, USA abstract article info Article history: Received 10 February 2014 Received in revised form 15 April 2014 Accepted 16 April 2014 Available online xxxx Keywords: Glycated hemoglobin Laboratory management Test request appropriateness Patient safety Outcome results Objectives: The study was performed to compare the variability and appropriateness in the request of glycated hemoglobin (HbA1c) in primary care in Spain. Design and methods: 76 Spanish laboratories from diverse regions across Spain filled out the number of HbA1c tests requested by general practitioners (GPs) during the year 2012. Every patient seen at the different pri- mary care centers was included in the study. Each participating laboratory was required to provide organizational data. The number of HbA1c requests per 1000 inhabitants was calculated and compared between regions. To in- vestigate whether HbA1c was appropriately requested to manage and to diagnose Diabetes Mellitus (DM), the number of necessary HbA1c was calculated, according to the disease prevalence in Spain (6.9%) and the guide- lines regarding DM management and diagnosis. Results: 17 679 195 patients were included in the study. A total of 1 544 551 HbA1c tests were ordered. No sig- nificant difference in the number of HbA1c requests per 1000 inhabitants was seen according to hospital setting (rural, urban or rural–urban). No significant differences were noticed between 3 Spanish regions, except the Valencian Community that presented higher values. Regarding the request appropriateness, 3 280 183 additional tests would have been necessary to manage diabetic patients and to diagnose new patients with the disease. Conclusion: There was a high variability regarding the request of HbA1c; the test was under-requested in all the participating health departments. This emphasizes the need to accomplish interventions to improve an ap- propriate use. © 2014 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved. Introduction Diabetes Mellitus (DM) is the most common endocrine disease and its incidence is increasing [1]. It is crucial to detect this high prevalent disorder early in its clinical course, as timely treatment delays progres- sion and prevents its devastating complications, thus improving prog- nosis [2,3]. Traditionally, glycated hemoglobin (HbA1c) has been used for the management of patients with DM [4]. Besides its pivotal role in the man- agement of the disease, HbA1c has been recently shown to be a valid test in the initial diagnosis [5]. This renders it in one of the most powerful lab- oratory parameters, a screening tool that has begun to being used in adults above 45 years old, independently of their risk factors [6]. Great efforts should be accomplished in order to use this test appropriately in this new scenario to improve DM diagnosis and prognosis. Prior studies have shown a high variability in the request pattern of HbA1c [7], and demonstrated that the test may be under-requested in some regions [8]. Other investigations suggest that HbA1c may be over-used in non-diabetic patients [9] although this was, however, per- formed prior to the recommendation of HbA1c as a tool to diagnose DM. Other authors demonstrated that although HbA1c over-requesting was common, under-requesting was more prevalent, potentially affecting longer-term health outcomes [10]. In all, new strategies and recommen- dations regarding the use of HbA1c are needed [11].A first step will be to investigate the real variability in the test request, trying to identify the root causes of inappropriateness. Clinical Biochemistry xxx (2014) xxx–xxx Abbreviations: DM, Diabetes Mellitus; HbA1c, glycated hemoglobin; GPs, general prac- titioners; PCC, primary care center patients. ⁎ Corresponding author at: Hospital Universitario de San Juan, Carretera Alicante- Valencia, s/n, 03550 San Juan de Alicante, Alicante, Spain. Fax: +34 965938383. E-mail address: salinas_mar@gva.es (M. Salinas). CLB-08699; No. of pages: 4; 4C: http://dx.doi.org/10.1016/j.clinbiochem.2014.04.020 0009-9120/© 2014 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Clinical Biochemistry journal homepage: www.elsevier.com/locate/clinbiochem Please cite this article as: Salinas M, et al, A study of the differences in the request of glycated hemoglobin in primary care in Spain: A global, sig- nificant, and potentially ..., Clin Biochem (2014), http://dx.doi.org/10.1016/j.clinbiochem.2014.04.020