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Clin Chem. Author manuscript; available in PMC 2019 August 14.
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Published in final edited form as:

Clin Chem. 2019 July ; 65(7): 839–848. doi:10.1373/clinchem.2018.296962.

The NGSP: Over 20 Years of Improving HbA1c Measurement

Randie R. Little1, Curt Rohlfing1, David B. Sacks2
1Departmentof Pathology and Anatomical Sciences, University of Missouri School of Medicine,
Columbia, MO, USA
2Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, USA
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Abstract
BACKGROUND: Measurement of hemoglobin A1c (HbA1c) in the blood is integral to and
essential for the management of patients with diabetes mellitus. HbA1c reflects the average blood
glucose concentration over the preceding 8–12 weeks. While the clinical value of HbA1c was
initially limited by very large difference in results among various methods, the investment of
considerable effort to implement standardization has brought about a marked improvement in
analysis.

CONTENT: The focus of this review is on the substantial progress that has been achieved in
enhancing the accuracy and therefore the clinical value of HbA1c assays.

SUMMARY: The interactions between the NGSP and manufacturers of HbA1c methods have
been instrumental in standardizing HbA1c. Proficiency testing using whole blood, thereby
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allowing accuracy-based assessment of methods in individual clinical laboratories, has made an

important contribution to improving the HbA1c measurement in patient samples. These initiatives,
supported by the efforts of the IFCC network, have led to a continuing enhancement of HbA1c
methods.

Many of the factors that previously influenced HbA1c results independently of blood glucose have
been eliminated from most modern methods. These include carbamylation, labile intermediates
and common hemoglobin variants. Nevertheless, some factors (e.g., race and aging), may alter
HbA1c interpretation, but whether these differences have clinical implications remains
contentious. HbA1c has a fundamental role in the diagnosis and management of diabetes. Ongoing
improvements in HbA1c measurement and quality will further enhance the clinical value of this
analyte.
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Keywords
Hemoglobin A1c; standardization; harmonization; calibration; certification; laboratory network;
proficiency testing

Corresponding Author: Randie R. Little, Ph.D., Diabetes Diagnostic Laboratory, Rm. M766, Depts. of Pathology & Anatomical
Sciences and Child Health, University of Missouri School of Medicine, 1 Hospital Dr., Columbia, MO 65212, Phone: 573-882-1257,
FAX: 573-884-4748, LittleR@health.missouri.edu.
 Little et al. Page 2

INTRODUCTION:
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The concentration of hemoglobin A1c (HbA1c), a specific glycated hemoglobin, reflects

average blood glucose concentration over 8–12 weeks. In individuals with diabetes, HbA1c
is used as the primary measure to assess long-term glycemic control and as a predictor for
the risk of developing microvascular complications of diabetes. Landmark clinical trials,
namely the Diabetes Control and Complications Trial (DCCT; published in 1993) and the
United Kingdom Prospective Diabetes Study (UKPDS; published in 1998), conducted in
patients with type 1 and type 2 diabetes, respectively, (1,2) led to recommendations for
specific glycemic targets based on HbA1c. Over the next several years, standardization/
harmonization efforts greatly enhanced the quality of HbA1c analysis. Due to the improved
assay performance, in 2009 an international expert committee concluded that the available
evidence supported the use of HbA1c for the diagnosis of diabetes (3). The improved assay
performance, combined with other positive attributes of HbA1c (4), led the American
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Diabetes Association (ADA) to recommend HbA1c for screening and diagnosis of diabetes
in 2010 (5). Similar recommendations were endorsed by the IDF and WHO the following
year (6,7).

The NGSP was established in 1996 to harmonize HbA1c measurements so that routine
clinical results would be traceable to those in the DCCT (and subsequently the UKPDS),
enabling physicians and patients to achieve glycemic targets recommended by clinical
diabetes societies. Within five years, data from proficiency testing showed that these efforts
had considerably reduced the variability of HbA1c measurements (8). With further
improvement over the years (9), the expanded uses of HbA1c to monitor glycemia, and more
recently to diagnose diabetes, have increased the need for even better accuracy and precision
of results.
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In this review, we describe the NGSP structure and process, collaboration between the
NGSP and IFCC, and the improvements in measurement of HbA1c, particularly in the nine
years since it was recommended for diagnosis.

The NGSP Network:

The NGSP network has been described previously (8,9) and is shown schematically in Fig.
1. The NGSP Steering Committee works with the administrative core to oversee a network
of laboratories. The Central Primary Reference Laboratory (CPRL) maintains the in-house
ion-exchange HPLC method, which is the method that was used by the Reference
Laboratory in the DCCT. This method has been shown to be stable for 34 years in the DCCT
Reference Laboratory (Fig. 2). Two PRLs (Primary Reference Laboratories) use the same
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method as the CPRL and serve as backup laboratories for the CPRL. Secondary Reference
Laboratories (SRLs), currently 10 (3 in the US, 5 in The Netherlands, one in Japan and one
in China), use highly precise commercial methods that are based on several different
methodologies, i.e., ion-exchange HPLC, boronate affinity HPLC, immunoassay, capillary
electrophoresis, and enzymatic. The SRLs are calibrated independently of the manufacturers
so that their results match those of the CPRL. To accomplish this, some SRLs use
commercial calibrators, but set their own calibration values, while other SRLs use in-house

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calibrators composed of pooled whole blood stored at or below −80oC. The CPRL, PRLs
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and SRLs are monitored monthly using ten blinded frozen whole blood pools. Precision of
each network laboratory is assessed by the estimate of the standard deviation of the
difference in sample replicates (9). This estimate must not exceed the 99th percentile of the
sampling distribution around a target SD of 0.15. Bias is assessed by the mean of the
differences (n=10) between the network laboratory and the CPRL and must not exceed
0.35% (3.8 mmol/mol, IFCC units) HbA1c. SRL results must also fall within a defined
acceptance ellipse, which is based on the slope and intercept of the differences between the
results of an individual SRL and the medians of all SRLs (9). The mean between-laboratory
CVs of the network have consistently been below 2% (2.9% calculated at 50mmol/mol
IFCC units (10)) each month for the past 7 years and have been decreasing; all were below
1.6% (2.4% IFCC) over the past year (data not shown). The master equation for the NGSP/
IFCC relationship is NGSP = 0.0915*IFCC + 2.15. This conversion of IFCC to NGSP
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includes a positive y-intercept term, and therefore CVs of converted NGSP are lower (10).
The monthly monitoring samples are different each month. In addition to this monthly
network monitoring, three levels of the same pooled whole blood controls are analyzed
quarterly by all SRLs. These samples are the same each quarter; this allows these results to
be monitored over the long-term in each network laboratory. The mean CVs for these
quarterly monitoring samples have been <1.7% (2.5% IFCC) for the past 7.5 years.

The NGSP network has expanded over the years with the incorporation of additional
laboratories and added updated – and improved - HbA1c methods as they develop. The
network now certifies both manufacturers and selected laboratories worldwide.

The NGSP Process:

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1. Calibration: As shown in Fig. 1, the first component of the process, “calibration”,

includes any support given by a network laboratory to a manufacturer to assist
with initial and confirmatory calibration of their methods. The goal of calibration
is to insure that results from each method are comparable to NGSP/DCCT results
with minimal bias.

2. Certification: The second process is certification, which consists of a blinded

comparison with an SRL of 40 individual whole blood samples. The types of
certification and criteria for certification are shown in table 1. The same
information with IFCC units is shown in Supplementary Table 1. The most
important type of certification for harmonizing HbA1c is manufacturer
certification. A manufacturer is awarded a certificate of traceability to the DCCT
if their results pass certification criteria. Certificates are valid for one year. The
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certificate specifies the method, instrument and lots of both reagents and
calibrators used during the certification process. There is no expectation that
each lot of reagents/calibrators will be certified. Lot to lot comparisons must be
done internally by each manufacturer throughout the year. Variability among lots
will contribute to the variability (%CV) between labs using the same method in
the CAP or other proficiency testing surveys.

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An analogous process is used to certify laboratories that wish to become NGSP certified;
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these laboratories are usually reference or clinical trial laboratories. The criteria for Level II
Laboratory certification is the same as for manufacturers (Table 1). Level I Laboratory
certification criteria are slightly more stringent. Moreover, Level I laboratories are required
to also perform quarterly monitoring comparisons with the NGSP network. Lists of the
certified methods and laboratories are posted on the NGSP website (11) and are updated
monthly.

3. Proficiency Testing: The third aspect of the NGSP process is surveillance of

routine clinical laboratories through proficiency testing, specifically the College
of American Pathologists’ (CAP) GH2 and GH5 HbA1c surveys (see “CAP
Proficiency Testing” section below). These surveys use pools of whole blood and
are accuracy-based. Target values are assigned by multiple measurements by US
and European NGSP SRLs. Proficiency testing is essential to monitor the success
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of the NGSP and to evaluate the accuracy of the assays that are used to measure
HbA1c in patient samples. In the US, all laboratories that measure analytes in
human blood samples in non-waived settings are required by law to participate in
proficiency testing. A summary of CAP results with commentary is posted on the
NGSP website after each survey (12).

Changes in NGSP certification criteria over time:

Criteria for passing NGSP certification have tightened over time to encourage the
development and use of better methods and better laboratory practices (Table 1). The NGSP
certification criteria were originally based on EP-5 (precision evaluation) combined with
CLSI EP-9 (bias estimation). EP9 criteria were replaced with Bland/Altman assessment of
agreement criteria in 1999 (9). The separate EP5 imprecision evaluation criterion was
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removed in 2007. Then in 2012, the criteria were modified from an assessment of agreement
to a fixed number of sample results (out of 40 total results) required to be within a defined
percentage of the SRL results (9). This change was related, in part, to pass/fail criteria
initiated by the CAP as described in the next section. In 2012, in order for a method to pass
certification, 37 out of 40 results were required to be within 7% (10.3% IFCC) of the SRL
results. In 2014, this criterion was further tightened to 37/40 results to be within 6% (8.8%
IFCC) of SRL results. In 2019, this will be tightened further to require 36/40 results to be
within 5% (7.4% IFCC) (Table 1). The explanation for these specific changes is in the
following sections.

Changes in CAP Proficiency Testing over time:

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CAP HbA1c proficiency testing began in the mid-1980s and has evolved over the years as
methods have improved and standardization commenced. Grading was initially evaluated by
peer group, i.e. results from an individual laboratory were compared only to other
laboratories that used the same method. In 1998, the CAP introduced pooled whole blood
samples for the HbA1c survey. Eventually, the entire CAP HbA1c survey switched to pooled
human whole blood and target values for each sample were assigned by the NGSP network.
The assigned value was initially used only for educational purposes, but in 2007 the formal

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grading became accuracy-based. Because the PT samples are prepared from human whole
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blood, any bias observed by a laboratory is expected to reliably reflect the bias that exists for
patient samples analyzed with the same method. Initially, the pass/fail criterion was set at
±15% (22.1% IFCC) of the target value. This criterion gradually and progressively
decreased, reaching ±6% (8.8% IFCC) in 2013. The CAP GH surveys currently comprise
three (GH2 survey) or five (GH5 survey) whole blood pools sent 2 or 3 times per year,
respectively, with target values assigned by the mean of multiple measurements from several
NGSP SRLs.

Integration of NGSP and CAP criteria:

In an effort to achieve consistency between the CAP and NGSP criteria, a method of
analysis was developed to compare the two schemes (13) before the adoption of tighter
NGSP criteria in 2012. At that time, the CAP criterion was ±7% (10.3% IFCC) of the target
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value. Simulations were used to determine the probabilities of passing both the CAP and
NGSP criteria at continuously increasing levels of imprecision and bias. Plots were then
constructed to show the results with failure probabilities of 5%, 1% and 0.1% (13). The
measurement uncertainties of both the CAP value assignments and the duplicate SRL results
used for NGSP certification were included in the model for these simulations. Based on
these calculations, the NGSP Steering Committee decided that the appropriate NGSP
criterion was 37 of 40 results within +/−7% (10.3% IFCC) of the SRL results for
certification and this was adopted in 2012. In 2014, these criteria were tightened to +/−6%
(8.8% IFCC) when CAP tightened their criterion to +/−6% (8.8% IFCC). The NGSP
certification criteria for 2019 will require that 36/40 results be within 5% (7.4% IFCC)
(Table 1). At this level, the probability of passing NGSP certification will most closely
match the probability of passing the CAP requirement that results from an individual
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laboratory be ±5% (7.4% IFCC) of the target value (Fig. 3). CAP intends to adopt +/−5%
(7.4% IFCC) as the passing grade in 2020.

Traceability to the IFCC network:

The EU Directive 98/79EC, published in 1998 and implemented in 2005, states that “The
traceability of values assigned to calibrators and/or control materials must be assured
through available reference measurement procedures and/or available reference materials of
a higher order” (14). At the time of implementation of the NGSP in 1996, there was no
higher order reference method or reference material available for HbA1c. In 2004, the IFCC
Working Group on HbA1c developed a Reference System for HbA1c (15). The IFCC
reference measurement procedure for HbA1c is calibrated with certified reference materials
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consisting of pure HbA1c and HbA0, and quantifies the glycated and nonglycated
hexapeptides by mass spectrometry or by capillary electrophoresis. HbA1c is thus defined
and measured based on its molecular structure. This reference method is then used to assign
values to secondary reference materials that can be used to transfer accuracy to routine
methods. Both the NGSP and IFCC reference measurement procedures are listed on the
JCTLM database as “higher order to a manufacturer’s method”, but the IFCC method is
considered a higher order method than the NGSP CPRL method. Although there was an
excellent linear correlation (r>0.99) between results of the two networks (NGSP and IFCC),

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the values were not the same (15). An International consensus statement on the worldwide
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standardization of HbA1c recognized that the IFCC reference system should be the anchor
for worldwide standardization and that results should be reported in both “standardized”
IFCC (mmol/mol) and “harmonized” NGSP/DCCT (%) units (16). Notwithstanding the
consensus statement, individual countries are deciding how HbA1c should be reported.
Since all clinical trial data and diabetes recommendation had been based on NGSP/DCCT/
UKPDS HbA1c values, many countries have elected to report HbA1c only in NGSP/DCCT
(%) units. By contrast, some countries (predominantly in Europe) have chosen to report
results only in mmol/mol. A few countries are reporting results in both units. Since
comparability of the two systems is essential for worldwide use, a master equation was
developed between results of the two networks, to allow patient results to easily be
converted from one system to the other (17). This relationship is monitored by twice-yearly
comparisons to insure consistency in the relationship over time (17).
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The NGSP and IFCC approaches to the standardization of HbA1c results serve different, but
complimentary, purposes. The primary objective of IFCC standardization is to ensure that
manufacturers are traceable to an accuracy base. Each manufacturer must document
traceability to a method of higher order through an unbroken traceability chain, and the
uncertainty of each step must be documented (18). However, there is no limit on the degree
of uncertainty allowed between a manufacturer’s method and a reference method-assigned
value. As outlined above, the NGSP defines acceptable limits for method performance that
are based on clinical need, i.e. recommendations for diabetes care by clinical societies.

Status of HbA1c Measurement

The considerable improvement in the comparability of HbA1c results within and among
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assay methods that are used to measure patient samples is shown in Fig. 4. These data are
derived from the CAP GH surveys. At the time the DCCT was published in 1993, the state
of HbA1c testing made it difficult, if not impossible, for clinicians to employ the specific
HbA1c targets recommended by the ADA (19) and other clinical organizations. Examination
of CAP survey data revealed that, in 1993, only ~50% of glycated hemoglobin (GHB)
results were being reported as HbA1c, the rest being reported as either HbA1 or total GHB.
Moreover, even methods reporting HbA1c values demonstrated considerable variability (Fig.
4). One of the initial goals of the NGSP was to have all GHB results reported as HbA1c,
regardless of methodology; this aim was largely achieved by 2004. A second objective of the
NGSP is to improve accuracy of HbA1c assays. Analysis of imprecision shows that all-
method CVs have improved considerably since 2000, declining from ~5–6% (7–9% IFCC)
in 2000 to ~3.5% (5.1% IFCC) by 2013–2014 (Fig. 5). These CVs have consistently been
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below 3.5% (5.1% IFCC) (for 4/5 or 5/5 samples) over the last 8 surveys; CVs were ≤ 3.0 %
(4.4% IFCC) for all five samples in the most recent survey. Some commercial methods
demonstrated substantial variability (between-laboratory, within-method CVs ≥3.5% (5.1%
IFCC)) on one or more samples in the 2018 GH5B CAP survey (20); these methods are used
by only about 4% of all the laboratories participating in that survey. Approximately 33 % of
laboratories in the 2018 GH5B survey were using methods with between-lab, within-method
CVs ≤2% (2.9% IFCC) for at least 3/5 samples. Moreover, the all-method CV for the 2018

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GH5B survey was ≤3.0% (4.4% IFCC) for all samples, which is below the recommended
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between-laboratory CV of 3.5% (5.1% IFCC) (20).

Inspection of the data in Fig. 4 reveals that the mean bias of most methods has decreased
considerably. While six methods had mean biases ≥0.3% (3.3 mmol/mol) HbA1c in 1999,
by 2010 only three methods had biases ≥0.3% (3.3 mmol/mol) HbA1c, even though the total
number of methods had increased substantially. Improvements have continued since that
time, and by 2014 only one method exhibited a bias ≥0.3% (3.3 mmol/mol) HbA1c.

Approval of HbA1c methods for Diagnosing Diabetes

In 2009, an expert committee reconsidered the use of HbA1c for diagnosis (3). They
concluded that compared with measurement of glucose, HbA1c was at least as good at
defining the level of hyperglycemia at which retinopathy increases, had superior technical
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attributes, and was more convenient to use. This led to the recommendation in 2010 by the
ADA to use HbA1c as a diagnostic tool (5). The following year other influential clinical
organizations also accepted HbA1c as a criterion for diagnosis of diabetes (6,7)

Despite these guidelines, in 2010 no HbA1c methods were approved by the FDA in the US
for diagnosis of diabetes. FDA approval was restricted to monitoring patients with diagnosed
diabetes. Subsequently for manufacturers to obtain a diagnostic claim, the FDA developed
new criteria that are more stringent than those required for monitoring of glycemic control.
At the time of writing, 17 laboratory assay methods have this designation (22). In June 2018,
one point-of-care (POC) method, designated as moderate complexity (not CLIA-waived),
was included in this list.

POC HbA1c
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Many POC methods for measuring HbA1c are now commercially available. Some studies
have suggested that having a HbA1c result available at the time of the patient visit can be
beneficial, while others have shown little benefit (23,24). Over 30 POC HbA1c methods are
currently NGSP-certified (not all of these are available in the US) and a few have
consistently demonstrated excellent overall performance on the CAP surveys. However,
POC methods are CLIA-waived in the U.S., meaning that users who measure patient
samples are not required to participate in proficiency testing and the vast majority do not.
Thus, there are no data available for most of these methods to enable assessment of their
performance in the hands of users. It is primarily for this reason that the ADA does not
recommend that POC methods be used to diagnose diabetes, although they do suggest that
POC HbA1c results can be useful for monitoring diabetes in some situations (25).
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Interferences with HbA1c

For the vast majority of patients with diabetes, HbA1c is a useful indication of mean
glycemia and risks for diabetes complications. However, some hemoglobin variants can
interfere with HbA1c measurement; these interferences are method-specific. Although this
was a major concern in previous years, at this time, only a few methods show interference
from one or more of the most common heterozygous hemoglobin variants (HbAS, HbAC,

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HbAE, HbAD) and/or HbF<15%. The NGSP regularly evaluates HbA1c methods to
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determine the degree of interference from these variants; results of these studies (and those
from other authors) are summarized and posted on the NGSP web site (26). Based on the
most recent CAP data, only about 15% of participating laboratories are using methods that
show clinically significant interference from one or more of the four most common
heterozygous hemoglobin variants. Most current methods are not affected by HbF<15%;
some methods can measure HbA1c in the presence of HbF as high as 30% (26). While some
methods can detect the presence of Hb variants (e.g. most ion-exchange HPLC and Capillary
Electrophoresis methods), others (e.g. immunoassays, boronate affinity and enzymatic
methods) cannot. Several rare Hb variants have been reported to interfere with HbA1c
testing. Interference from rare variants is also method-specific, with a few exceptions where
glycation may be reduced. One study evaluated 49 rare variants using eight different
methods (27); almost all of these rare variants were recognized as such by the ion-exchange
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HPLC methods evaluated. Nevertheless, inaccurate results would still be reported by some
methods. Carbamylated Hb, elevated in renal disease, affected some older charge-based
methods, but this analytical interference has essentially been eliminated in recent years (28).

In addition to analytical interference, laboratorians and clinicians need to be aware of

potential interferences that can influence the interpretation of HbA1c results. Severe iron-
deficiency anemia, renal failure or any condition that alters erythrocyte lifespan, such as
hemolytic anemia or major blood loss, can affect HbA1c results regardless of assay
methodology (28–30).

Several recent studies have suggested that HbA1c results are slightly higher in African-
Americans compared to whites with equivalent glucose concentrations (31). Whether this
difference is clinically relevant remains highly controversial (32–34). One study claimed
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0.29% (3.2 mmol/mol) higher HbA1c results in African Americans with sickle cell trait
compared to those without this trait (35). However, this difference was most likely due to the
use of a HbA1c method that shows a method-specific, statistically significant interference
from sickle-cell trait (36).

Several factors complicate interpretation of HbA1c in pregnancy (37). HbA1c

concentrations decline in early pregnancy due to increased turnover of erythrocytes. Later in
gestation, women develop insulin resistance, leading to a slight increase in HbA1c values.
While a few studies have evaluated reference intervals for HbA1c in different trimesters of
pregnancy (37), there is no consensus and clinical decision thresholds for HbA1c have not
been established in pregnancy. HbA1c is not accepted as a diagnostic criterion for
gestational diabetes, which is identified exclusively by measurement of glucose.
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Nevertheless, HbA1c has clinical value in some pregnant women. Current ADA guidelines
recommend that women who have risk factors for type 2 diabetes should be screened at their
initial prenatal visit, using standard diagnostic criteria, namely glucose or HbA1c. In
addition, women with pre-existing diabetes who are planning pregnancy should maintain
HbA1c <6.5% (48 mmol/mol) to reduce the risk of congenital malformations (38). Due to
the limitations in HbA1c summarized above, self-monitoring of blood glucose should be
used as the primary measure of glycemic control in pregnancy, with HbA1c as a secondary
measure.

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Summary
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There has been considerable improvement in the quality of HbA1c testing since the NGSP
was initiated over 20 years ago. Virtually all laboratories in developed countries now report
all glycated hemoglobin results exclusively as HbA1c. Moreover, overall variability within
and among methods and among individual laboratories has been considerably reduced. In
2009, international experts from the ADA, the IDF, and the EASD joined to recommend the
use of HbA1c for the diagnosis of diabetes (3). This recommendation was due in large part
to advances in HbA1c assay standardization.

The IFCC reference method system allows manufacturers to achieve and maintain
traceability to a higher order reference method, enabling compliance with the EU IVD
Directive (14). The decision as to which units are used to report HbA1c results, IFCC
mmol/mol or NGSP %, is being made on a country-by-country basis. Equations have been
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established that allow easy conversion between HbA1c units (11), and the ongoing
collaboration between the IFCC and NGSP networks that includes twice-yearly monitoring
exchanges ensures that the relationship between the networks remains constant over time.

The FDA requires manufacturers to meet additional requirements in order to make a

diagnostic claim for their method(s). POC methods are generally CLIA-waived in the U.S.,
and are therefore not recommended for use in diagnosing diabetes at this time. Better
monitoring of the performance of POC methods in the field would help to ensure that these
methods are consistently producing reliable results that are adequate for the intended use in
clinical settings.

There is still some room for improvement in HbA1c testing, especially given its use in
diagnosis. A few methods still show sub-optimal variability on CAP surveys; we encourage
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laboratories to use methods that are NGSP certified and that show good performance on
CAP surveys. The further tightening of the NGSP and CAP limits in 2019 and 2020,
respectively, will help to maintain continued improvement in HbA1c testing methods and
ensure that the quality of HbA1c remains sufficient to meet clinical needs.

There are some analytical and biological limitations of HbA1c measurements that physicians
need to be aware of. These limitations notwithstanding, the role of HbA1c in monitoring and
diagnosis of diabetes is well established and measurement of HbA1c is appropriate for the
majority of individuals with, or at risk of developing, diabetes.

Supplementary Material
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Refer to Web version on PubMed Central for supplementary material.

Acknowledgements
Work in the laboratory of DBS is supported by the National Institutes of Health Clinical Center Intramural
Program. Work in the laboratory of RRL and CLR is supported by NIH/NIDDK Grant Number 1UC4DK096587–
01. We thank CAP for permission to use data from their proficiency testing program.

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Abbreviations:
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HbA1c Hemoglobin A1c

DCCT Diabetes Control and Complications Trial

UKPDS United Kingdom Prospective Diabetes Study

CPRL Central Primary Reference Laboratory

PRL Primary Reference Laboratory

SRL Secondary Reference Laboratory

CAP College of American Pathologists

CLSI Clinical and Laboratory Standards Institute

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GHB Glycated Hemoglobin

POC Point of Care

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Figure 1.
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NGSP Network and process: CPRL, Central Primary Reference Laboratory; PRL, Primary
Reference Laboratory; SRL, Secondary Reference Laboratory; IFCC, International
Federation of Clinical Chemistry
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 Little et al. Page 14
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Figure 2.
Mean HbA1c measured by the CPRL for nine quality control specimens. Each point
represents the mean during each year of use. For each point the CV was <3% (4.4% IFCC).
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 Little et al. Page 15
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Figure 3.
The 2019 NGSP certification criterion (36/40 results within ±5%) compared to the proposed
2020 CAP criterion of ±5%. The lines represent the bias and CV combinations required to
pass the NGSP (solid lines) and CAP (dashed lines) criteria with 0.95 (top, light gray), 0.99
(middle, dark gray) and 0.999 (bottom, black) probabilities.
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 Little et al. Page 16
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Figure 4.
Improvement in HbA1c over time. CAP data from a single sample in 1993, 1999, 2004,
2010, 2014 and 2018. The dashed line is the NGSP/DCCT Reference value for that sample.
Each point is the mean of a single method; bars are 2SD ranges. Results were reported as
HbA1c ▇, HbA1 ◆, and Total GHB ●.
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 Little et al. Page 17
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Figure 5.
All method CVs over time in CAP samples from 2000 to 2018. A. Samples with target
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values; A. 4–6% (20–42 mmol/mol) HbA1c, B. 6–8% (42–64 mmol/mol) HbA1c and C. 8–
10% (64–86 mmol/mol) HbA1c. Note that the NGSP/IFCC %CV relationships on the y-axes
are different for each graph since the conversion is based on specific HbA1c levels. The
HbA1c levels used for the conversion are 5% (31 mmol/mol), 7% (53 mmol/mol) and 9%
(75 mmol/mol) for A, B, and C, respectively (10).
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Table 1:

NGSP Certification and monitoring, changes in criteria 1996–2019 (NGSP % HbA1c)

Certification Certification criteria 1996–1998 Certification criteria 1999–2012 Certification criteria 2013– Certification criteria Monitoring
Little et al.

type 2018 2019 protocol

Manufacturer EP-5 precision (≤5%) EP-5 precision (≤5% to ≤4% in 2002, dropped in 37 of 40 results within ±7% in 36 of 40 results within None
EP-9: 95%CI for predicted bias must 2007) 2013 to ±6% in 2014 ±5%
overlap ±5% of SRL at 6% and 9% Bland/Altman assessment of agreement: 95% CI of
HbA1c differences within ±1.0% HbA1c in 1999 to ±0.75%
in 2010
Level II Lab

EP-5 precision (≤3%)
EP-9: 95%CI for predicted bias must
Level I Lab
overlap ±3% of SRL at 6% and 9%
HbA1c
EP-5 precision (≤3%, dropped in 2007) 38 of 40 results within ±7% in 37 of 40 results within 10 samples
95% CI of differences within ±0.75% HbA1c in 2013 to ±6% in 2014 ±5% quarterly
1999 to ±0.70% in 2010

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