Point-of-need hemoglobin A_1c for evidence-based diabetes care in rural small-world networks: Khumuang community hospital, Buriram, Thailand

Objectives: The objectives of the study were (a) to perform point-of-care (POC) hemoglobin A_1c (HbA_1c) testing at primary care units (PCUs) in rural villages, (b) to devise strategies for improved diabetes control, (c) to improve efficiency managing high-volume diabetic patients, and (d) to implement a small-world network (SWN) of PCUs, a community hospital, and a regional hospital. Methods: Hemoglobin A_1c instruments were rotated through 11 PCUs on diabetes clinic days in the Khumuang Community Hospital SWN, Buriram Province, Isaan, Thailand, then results characterized statistically for demographic differences. Quality control checked instrument consistency and operator competency. Results: Point-of-care HbA_1c brought evidence-based primary care to villages for the first time. Only 17% had HbA_1c of less than 6.5%. Nonnormal distributions were right skewed. Mean (SD), median (range), and third quartile HbA_1c levels (%) were 8.3 (2.1), 7.8 (4-17.5), and 9.3, respectively, for all patients (N = 1188, aged 18-92 years); 8.4 (2.3), 7.8 (4.9-17.5), and 9.5 for 313 males; and 8.2 (2.0), 7.8 (4.1-16.1), and 9.2 for 875 females. Median male/female HbA_1c did not differ significantly. Weighted-average top quartile HbA_1c ranks at PCUs facilitated efficient treatment of patients with poorly controlled diabetes. Conclusions: Rapid on-site HbA_1c testing of up to 150 diabetic PCU patients per day, quickly and efficiently identified those who were poorly controlled. Unexpectedly, elevated HbA_1c changed primary care strategy, pulling together a rotating team of physicians, nurses, and a pharmacist who adjust therapy and accelerate checks for albuminuria to prevent advancing disease, dialysis, and adverse outcomes. This SWN motivates public health leadership to invest in POC HbA_1c monitoring and enables diagnostic screening.