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Whyler NCA, Krishnaswamy S, Price S, Giles ML. Strategies to improve postpartum engagement in healthcare after high-risk conditions diagnosed in pregnancy: a narrative review. Arch Gynecol Obstet 2024; 310:69-82. [PMID: 38787416 PMCID: PMC11169054 DOI: 10.1007/s00404-024-07562-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024]
Abstract
Transition from antepartum to postpartum care is important, but often fragmented, and attendance at postpartum visits can be poor. Access to care is especially important for individuals diagnosed antepartum with conditions associated with longer-term implications, including gestational diabetes (GDM) and hypertensive disorders in pregnancy (HDP). Strategies to link and strengthen this transition are essential to support people to attend recommended appointments and testing. This narrative review evaluates what is known about postpartum transition of care after higher-risk antepartum conditions, discusses barriers and facilitators to uptake of recommended testing, and outlines strategies trialled to increase both postpartum attendance and testing. Barriers to attendance frequently overlap with general barriers to accessing healthcare. Specific postpartum challenges include difficulties with transport, coordinating breastfeeding and childcare access. Systemic challenges include inadequate communication to women around implications of health conditions diagnosed in pregnancy, and the importance of postpartum follow up. Uptake of recommended testing after a diagnosis of GDM and HDP is variable but generally suboptimal. Strategies which demonstrate promise include the use of patient navigators, focused education and specialised clinics. Reminder systems have had variable impact. Telehealth and technology are under-utilised in this field but offer promising options particularly with the expansion of virtual healthcare into routine maternity care. Strategies to improve both attendance rates and uptake of testing must be designed to address disparities in healthcare access and tailored to the needs of the community. This review provides a starting point to develop such strategies from the community level to the population level.
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Affiliation(s)
- Naomi C A Whyler
- Department of Obstetrics and Gynaecology, Monash University, Wellington Road, Clayton, VIC, 3800, Australia.
| | - Sushena Krishnaswamy
- Department of Obstetrics and Gynaecology, Monash University, Wellington Road, Clayton, VIC, 3800, Australia
| | - Sarah Price
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Royal Parade, Parkville, VIC, 3000, Australia
- Department of Obstetric Medicine, Royal Women's Hospital, 20 Flemington Road, Parkville, VIC, 3000, Australia
| | - Michelle L Giles
- Department of Obstetrics and Gynaecology, Monash University, Wellington Road, Clayton, VIC, 3800, Australia
- Department of Obstetric Medicine, Royal Women's Hospital, 20 Flemington Road, Parkville, VIC, 3000, Australia
- Department of Infectious Diseases, University of Melbourne, Grattan Street, Parkville, VIC, 3000, Australia
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Carter EB, Thayer SM, Paul R, Barry VG, Iqbal SN, Ehrenberg S, Doering M, Mazzoni SE, Frolova AI, Kelly JC, Raghuraman N, Debbink MP. Diabetes Group Prenatal Care: A Systematic Review and Meta-analysis. Obstet Gynecol 2023:00006250-990000000-00958. [PMID: 37944148 PMCID: PMC11078888 DOI: 10.1097/aog.0000000000005442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/05/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To estimate the effect of diabetes group prenatal care on rates of preterm birth and large for gestational age (LGA) among patients with diabetes in pregnancy compared with individual diabetes prenatal care. DATA SOURCES We searched Ovid Medline (1946-), Embase.com (1947-), Scopus (1823-), Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. METHODS OF STUDY SELECTION We searched electronic databases for randomized controlled trials (RCTs) and observational studies comparing diabetes group prenatal care with individual care among patients with type 2 diabetes mellitus or gestational diabetes mellitus (GDM). The primary outcomes were preterm birth before 37 weeks of gestation and LGA (birth weight at or above the 90th percentile). Secondary outcomes were small for gestational age, cesarean delivery, neonatal hypoglycemia, neonatal intensive care unit admission, breastfeeding at hospital discharge, long-acting reversible contraception (LARC) uptake, and 6-week postpartum visit attendance. Secondary outcomes, limited to the subgroup of patients with GDM, included rates of GDM requiring diabetes medication (A2GDM) and completion of postpartum oral glucose tolerance testing (OGTT). Heterogeneity was assessed with the Cochran Q test and I2 statistic. Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean differences. TABULATION, INTEGRATION, AND RESULTS Eight studies met study criteria and were included in the final analysis: three RCTs and five observational studies. A total of 1,701 patients were included in the pooled studies: 770 (45.3%) in diabetes group prenatal care and 931 (54.7%) in individual care. Patients in diabetes group prenatal care had similar rates of preterm birth compared with patients in individual care (seven studies: pooled rates 9.5% diabetes group prenatal care vs 11.5% individual care, pooled RR 0.77, 95% CI, 0.59-1.01), which held for RCTs and observational studies. There was no difference between diabetes group prenatal care and individual care in rates of LGA overall (four studies: pooled rate 16.7% diabetes group prenatal care vs 20.2% individual care, pooled RR 0.93, 95% CI, 0.59-1.45) or by study type. Rates of other secondary outcomes were similar between diabetes group prenatal care and individual care, except patients in diabetes group prenatal care were more likely to receive postpartum LARC (three studies: pooled rates 46.1% diabetes group prenatal care vs 34.1% individual care, pooled RR 1.44, 95% CI, 1.09-1.91). When analysis was limited to patients with GDM, there were no differences in rates of A2GDM or postpartum visit attendance, but patients in diabetes group prenatal care were significantly more likely to complete postpartum OGTT (five studies: pooled rate 74.0% diabetes group prenatal care vs 49.4% individual care, pooled RR 1.58, 95% CI, 1.19-2.09). CONCLUSION Patients with type 2 diabetes and GDM who participate in diabetes group prenatal care have similar rates of preterm birth, LGA, and other pregnancy outcomes compared with those who participate in individual care; however, they are significantly more likely to receive postpartum LARC, and those with GDM are more likely to return for postpartum OGTT. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021279233.
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Affiliation(s)
- Ebony B Carter
- Division of Maternal Fetal Medicine and the Division of Clinical Research, Department of Obstetrics and Gynecology, and the Becker Library, Washington University School of Medicine in St. Louis, St. Louis, Missouri; the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Columbia, Maryland; the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland Ohio; Harborview OB/GYN Generalists, Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington; and the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
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Saldanha IJ, Adam GP, Kanaan G, Zahradnik ML, Steele DW, Chen KK, Peahl AF, Danilack-Fekete VA, Stuebe AM, Balk EM. Delivery Strategies for Postpartum Care: A Systematic Review and Meta-analysis. Obstet Gynecol 2023; 142:529-542. [PMID: 37535967 DOI: 10.1097/aog.0000000000005293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/05/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE To systematically review the effects of postpartum health care-delivery strategies on health care utilization and maternal outcomes. DATA SOURCES We searched Medline, EMBASE, CENTRAL, CINAHL, and ClinicalTrials.gov for studies in the United States or Canada from inception to November 16, 2022. METHODS OF STUDY SELECTION We used duplicate screening for studies comparing health care-delivery strategies for routine postpartum care on health care utilization and maternal outcomes. We selected health care utilization, clinical, and harm outcomes prioritized by stakeholder panels. TABULATION, INTEGRATION, AND RESULTS We found 64 eligible studies (50 randomized controlled trials, 14 nonrandomized comparative studies; N=543,480). For general postpartum care, care location (clinic, at home, by telephone) did not affect depression or anxiety symptoms (low strength of evidence), and care integration (by multiple types of health care professionals) did not affect depression symptoms or substance use (low strength of evidence). Providing contraceptive care earlier (compared with later) was associated with greater implant use at 6 months (summary effect size 1.36, 95% CI 1.13-1.64) (moderate strength of evidence). Location of breastfeeding care did not affect hospitalization, other unplanned care utilization, or mental health symptoms (all low strength of evidence). Peer support was associated with higher rates of any or exclusive breastfeeding at 1 month and any breastfeeding at 3-6 months (summary effect size 1.10-1.22) but not other breastfeeding measures (all moderate strength of evidence). Care by a lactation consultant was associated with higher breastfeeding rates at 6 months (summary effect size 1.43, 95% CI 1.07-1.91) but not exclusive breastfeeding (all moderate strength of evidence). Use and nonuse of information technology for breastfeeding care were associated with comparable rates of breastfeeding (moderate strength of evidence). Testing reminders for screening or preventive care were associated with greater adherence to oral glucose tolerance testing but not random glucose or hemoglobin A 1c testing (moderate strength of evidence). CONCLUSION Various strategies have been shown to improve some aspects of postpartum care, but future research is needed on the most effective care delivery strategies to improve postpartum health. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022309756 .
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Affiliation(s)
- Ian J Saldanha
- Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; the Center for Evidence Synthesis in Health, the Department of Health Services, Policy, and Practice, and the Department of Epidemiology, Brown University School of Public Health, and the Departments of Emergency Medicine, Pediatrics, Medicine, and Obstetrics and Gynecology, Brown University Warren Alpert Medical School, Providence, Rhode Island; the Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan; the Center for Outcomes Research and Evaluation, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; and the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Cronin Á, Noctor E, O' Doherty D, Bowers S, Byrne E, Cremona A. Facilitators and barriers to attending postpartum screening in women with a recent pregnancy complicated by gestational diabetes mellitus: a qualitative study. Public Health 2023; 220:99-107. [PMID: 37290175 DOI: 10.1016/j.puhe.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 04/06/2023] [Accepted: 04/25/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Pregnant women with gestational diabetes mellitus (GDM) are 50% more likely to develop type II diabetes (T2D) within 6 months to 2 years after giving birth. Therefore, international guidelines recommend it is best practice for women diagnosed with GDM to attend screening for T2D 6-12 weeks postpartum and every 1-3 years thereafter for life. However, uptake of postpartum screening is suboptimal. This study will explore the facilitators of and barriers to attending postpartum screening for T2D that women experience. STUDY DESIGN This was a prospective qualitative cohort study using thematic analysis. METHODS A total of 27 in-depth, semistructured interviews were conducted over the telephone with women who had recent GDM. Interviews were recorded and transcribed, and data were analysed using thematic analysis. RESULTS Facilitators of and barriers to attending postpartum screening were identified at three different levels: personal, intervention, and healthcare systems level. The most common facilitators identified were concern for their own health and having the importance of screening explained to them by a health professional. The most common barriers identified were confusion over the test and COVID-19. CONCLUSION This study identified several facilitators of and barriers to attending postpartum screening. These findings will help to inform research and interventions for improving rates of attendance at postpartum screening to reduce the subsequent risk of developing T2D.
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Affiliation(s)
- Á Cronin
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Ireland
| | - E Noctor
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Ireland; Division of Endocrinology, UL Hospital Group, Limerick, Ireland; Health Science Academy, University Hospital Limerick, Limerick, Ireland
| | - D O' Doherty
- School of Medicine, University of Limerick, Ireland
| | - S Bowers
- Department of Clinical Nutrition and Dietetics, UL Hospital Group, Limerick, Ireland; Health Science Academy, University Hospital Limerick, Limerick, Ireland
| | - E Byrne
- School of Medicine, Faculty of Education and Health Sciences, University of Limerick, Ireland
| | - A Cremona
- Discipline of Dietetics, School of Allied Health, Faculty of Education and Health Sciences, University of Limerick, Ireland; Health Research Institute, University of Limerick, Limerick, Ireland; Health Science Academy, University Hospital Limerick, Limerick, Ireland.
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Soffer MD, Rekawek P, Pan S, Overbey J, Stone J. Improving Postpartum Attendance among Women with Gestational Diabetes Using the Medical Home Model of Care. Am J Perinatol 2023; 40:313-318. [PMID: 33878773 DOI: 10.1055/s-0041-1727216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Poor attendance at the 6-week postpartum (PP) visit has been well reported. Attendance at this visit is crucial to identify women who have persistent diabetes mellitus (DM) following pregnancies affected by gestational DM (GDM). The medical home model has eliminated barriers to care in various other settings. This study sought to improve PP attendance among women with GDM by jointly scheduling PP visits and the 2-month well infant visits. STUDY DESIGN All patients with a diagnosis of GDM who received care at a New York City-based publicly insured hospital clinic and delivered between October 2017 and June 2019 were eligible. Data were obtained via chart review. The primary outcome was attendance at the PP visit compared with previously published historical controls. Secondary outcomes were rates of PP glucose screening and well infant attendance. RESULTS Of the 74 patients enrolled, 41.9% were Hispanic and 17.6% were Black, mean age was 31.6 years, and 58.1% delivered vaginally. Attendance at the 6-week PP visit was 68.9%, and attendance at the infant visit was 55.1%. PP glucose testing was ordered for 76.5% of attendees at the PP visit, and of those ordered, 43.6% of attendees completed testing. All patients had joint visits requested, though only 70.3% of visits were scheduled jointly. Among those who were jointly scheduled, 71.2% of women attended, 57.7% of infants attended, and 7.7% of pairs attended on the same day. The PP visit attendance rate was not significantly different than the prior attendance rate (p = 0.84). CONCLUSION This study was unable to improve PP visit attendance among women with GDM by jointly scheduling the 6-week PP visit and the 2-month well-infant visit. Future research could be directed toward a shared space where both women and children can be seen to attempt to increase PP visit attendance and monitoring for women with GDM. KEY POINTS · Attendance at the PP visit is poor, and without a visit, women with pregnancies affected by gestational diabetes remain unscreened for PP dysglycemia.. · Jointly scheduling women and their infants to eliminate barriers to care studied by this group, however, were unable to improve attendance.. · Innovative strategies are needed to improve PP attendance among women with pregnancies affected by GDM..
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Affiliation(s)
- Marti D Soffer
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Patricia Rekawek
- Department of Obstetrics and Gynecology, New York University Langone Health, New York University Winthrop Hospital, New York University Long Island School of Medicine, New York, New York
| | - Stephanie Pan
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jessica Overbey
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joanne Stone
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
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Nielsen JH, Fonager K, Kristensen JK, Overgaard C. Effect of an electronic reminder of follow-up screening after pregnancy complicated by gestational diabetes mellitus: a randomized controlled trial. BMC Public Health 2023; 23:153. [PMID: 36690965 PMCID: PMC9872380 DOI: 10.1186/s12889-023-15060-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 01/16/2023] [Indexed: 01/24/2023] Open
Abstract
AIM To determine the effectiveness of despatching an electronic reminder of participation in screening for gestational diabetes. The reminder was sent to the women 1-8 years after delivery. METHODS A registry-based, randomized controlled trial in the North Denmark Region among women with gestational diabetes. Randomization was made, which included seven groups stratified by the child's birth year (2012-2018). The intervention group received standard care supplemented by an electronic reminder through a secure nationwide email system (n = 731), while the control group received only standard care (n = 732). The primary outcome was based on blood testing for diabetes (OGTT, HbA1c or fasting P-glucose). RESULTS A total of 471 (32.1%) women participated in screening. The primary outcome was experienced by 257 women (35.1%) in the intervention group and 214 women (29.2%) in the control group. The effect of the reminder seemed to increase with recipient's age, non-western origin, urban dwelling, and multiparity. Of those who participated in follow-up screening, 56 (3.8%) were diagnosed with type 2 diabetes. CONCLUSION Electronic reminders, based on the principles of informed choice and patient-centred care, to women have been shown to support life-long participation in follow-up screening. Attempts to further stimulation of coverage could however be considered. TRAIL REGISTRATION ISRCTN registry (22/04/2022, ISRCTN23558707).
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Affiliation(s)
- Jane Hyldgaard Nielsen
- Department of Midwifery, University College of Northern Denmark, Aalborg Øst, Denmark.
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
- Research Center for Health and Applied Technology, University College of Northern Denmark, Aalborg, Denmark.
- DECIPH'er, Cardiff School of Social Sciences, Cardiff University, Cardiff, Wales.
| | - Kirsten Fonager
- Department of Social Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Charlotte Overgaard
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Unit of Health Promotion, Department of Public Health, University of Southern Denmark, Esbjerg, Denmark
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Follow-up after gestational diabetes: a qualitative study of perspectives from general practices. BJGP Open 2022; 6:BJGPO.2021.0241. [PMID: 35443978 DOI: 10.3399/bjgpo.2021.0241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/25/2022] [Accepted: 04/05/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Women whose pregnancies are complicated by gestational diabetes mellitus are approximately eight times more likely to develop type two diabetes. Although regular participation in follow-up screening increases the chance of early detection of diabetes, participation rates are often suboptimal. A better understanding of general practice as a key contextual setting for screening could help inform the development and adoption of, for example, electronic reminder interventions to support women's participation. AIM To explore the perspectives of general practitioners and relevant staff members engaged in early detection of diabetes after gestational diabetes in order to identify barriers to and facilitators of follow-up screening. DESIGN & SETTING A qualitative interview study undertaken in general practices in the North Denmark Region. METHOD Based on a purposive sample strategy, 18 semi-structured interviews of 12 general practitioners and six staff members, who were either nurses or midwives, were analysed using a reflexive thematic analytical approach. RESULTS Three main themes were formulated: (1) Challenges of addressing women's risk; (2) Prioritisation of early detection of diabetes; (3) System influence on clinical procedures. CONCLUSION Follow-up screening was facilitated by knowledge of guidelines. We found professional collaboration and adaptation support to lead to successful implementation of guidelines in general practice. Supporting GPs and their staff's reflection and discussion of ways to engage in communication and decision-making processes with women is however important, hence it was found to create an important barrier to follow-up screening. Overall, our findings can help inform the future development of interventions to increase uptake.
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Gomez Slagle HB, Hoffman MK, Caplan R, Shlossman P, Sciscione AC. Validation of a novel mobile phone application for type 2 diabetes screening following gestational diabetes mellitus. Mhealth 2022; 8:12. [PMID: 35449510 PMCID: PMC9014228 DOI: 10.21037/mhealth-21-36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/27/2022] [Indexed: 11/06/2022] Open
Abstract
Background We sought to determine if using fasting blood glucose (FBG) through text-based care is an effective screening tool for type 2 diabetes in the postpartum period compared to in-person, 2-hour oral glucose tolerance testing (2hr OGTT). Methods This was a single-center interventional study that included individuals diagnosed with gestational diabetes. Patients were enrolled in standard, office-based 2hr OGTT in combination with text-based remote diabetes screening. Study participants were instructed to record FBG for 3 consecutive days using a mobile application. We assessed agreement with 2hr OGTT using sensitivity, specificity, positive and negative predictive value with exact binomial 95% confidence intervals. Results A total of 446 individuals diagnosed with gestational diabetes met inclusion criteria, 239 of which were enrolled in standard office-based screening and 207 were enrolled in dual screening using standard 2hr OGTT testing combined with text-based remote FBG screening. A FBG value less than 100 mg/dL had 100% sensitivity (86-100%), 86% specificity (77-93%) with a 100% (94-100%) negative predictive value and 71% (54-85%) positive predictive value. Follow-up was significantly higher among individuals enrolled in remote text-based screening compared to standard in-office screening (48% vs. 25%, respectively; P<0.001). Conclusions Text-based screening may be a feasible alternative to in-office screening. A mobile-based system using FBG successfully screened all patients with type 2 diabetes in the postpartum period with 100% sensitivity and negative predictive value. Remote telehealth screening significantly increased follow-up with type 2 diabetes screening.
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Affiliation(s)
| | - Matthew K. Hoffman
- Department of Obstetrics and Gynecology, Christiana Hospital, Newark, DE, USA
| | - Richard Caplan
- Institute for Research on Equity and Community Health, Christiana Care Health System, Newark, DE, USA
| | - Philip Shlossman
- Department of Obstetrics and Gynecology, Christiana Hospital, Newark, DE, USA
- Delaware Center for Maternal Fetal Medicine, Newark, DE, USA
| | - Anthony C. Sciscione
- Department of Obstetrics and Gynecology, Christiana Hospital, Newark, DE, USA
- Delaware Center for Maternal Fetal Medicine, Newark, DE, USA
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Carter EB, Barbier K, Hill PK, Cahill AG, Colditz GA, Macones GA, Tuuli MG, Mazzoni SE. Pilot Randomized Controlled Trial of Diabetes Group Prenatal Care. Am J Perinatol 2022; 39:45-53. [PMID: 32674202 PMCID: PMC7855154 DOI: 10.1055/s-0040-1714209] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE This study aimed to determine the feasibility and effectiveness of Diabetes Group Prenatal Care to increase patient engagement in diabetes self-care activities. STUDY DESIGN A pilot randomized controlled trial was conducted at two sites. Inclusion criteria were English or Spanish speaking, type 2 or gestational diabetes, 22 to 34 weeks of gestational age at first study visit, ability to attend group care at specified times, and willingness to be randomized. Exclusion criteria included type 1 diabetes, multiple gestation, major fetal anomaly, serious medical comorbidity, and serious psychiatric illness. Women were randomized to Diabetes Group Prenatal Care or individual prenatal care. The primary outcome was completion of diabetes self-care activities, including diet, exercise, blood sugar testing, and medication adherence. Secondary outcomes included antenatal care characteristics, and maternal, neonatal, and diabetes management outcomes. Analysis followed the intention-to-treat principle. RESULTS Of 159 eligible women, 84 (53%) consented to participate in the study and were randomized to group (n = 42) or individual (n = 42) prenatal care. Demographic characteristics were similar between study arms. Completion of diabetes self-care activities was similar overall, but women in group care ate the recommended amount of fruits and vegetables on more days per week (5.1 days/week ± 2.0 standard deviation [SD] in group care vs. 3.4 days ± 2.6 SD in individual care; p < 0.01) and gained less weight per week during the study period (0.2 lbs/week [interquartile range: 0-0.7] vs. 0.5 lbs/week [interquartile range: 0.2-0.9]; p = 0.03) than women in individual care. Women with gestational diabetes randomized to group care were 3.5 times more likely to have postpartum glucose tolerance testing than those in individual care (70 vs. 21%; relative risk: 3.5; 95% confidence interval: 1.4-8.8). Other maternal, neonatal, and pregnancy outcomes were similar between study arms. CONCLUSION Diabetes group care is feasible and shows promise for decreasing gestational weight gain, improving diet, and increasing postpartum diabetes testing among women with pregnancies complicated by diabetes. KEY POINTS · Women with gestational diabetes in group care were 3.5 times more likely to return for postpartum glucose tolerance testing.. · Women with gestational diabetes in group care had less gestational weight gain during the study period.. · Diabetes Group Prenatal Care is a promising intervention to improve outcomes for women with diabetes in pregnancy..
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Affiliation(s)
- Ebony B. Carter
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Kate Barbier
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Pamela K. Hill
- Department of Obstetrics and Gynecology, Denver Health and Hospital, Denver, Colorado
| | - Alison G. Cahill
- Department of Obstetrics and Gynecology, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Graham A. Colditz
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine,, St. Louis, Missouri
| | - George A. Macones
- Department of Obstetrics and Gynecology, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - Methodius G. Tuuli
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sara E. Mazzoni
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
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Gomez HB, Hoffman MK. Text Messaging as a Means to Engage Patients in the Postpartum Period. Clin Obstet Gynecol 2021; 64:366-374. [PMID: 33904842 DOI: 10.1097/grf.0000000000000609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The use of electronic information and telecommunications technologies to support health systems has been increasingly recognized as an important tool in postpartum care. An emerging body of research has suggested that telehealth during the postpartum period may alleviate racial disparities and transportation barriers, while improving access to health resources. Thus, the purpose of this article is to describe current barriers to postpartum health, review prevalence and access to mobile devices, and current uses of text messaging in the postpartum period. We describe key areas of telemedicine utilization including lactation services, blood pressure monitoring, diabetes screening, mental health services, weight loss programs, and access to contraception in the postpartum period. Future research and clinical work should aim to further examine the use of telehealth among postpartum individuals.
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Affiliation(s)
- Helen B Gomez
- Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
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Nielsen JH, Melendez-Torres GJ, Rotevatn TA, Peven K, Fonager K, Overgaard C. How do reminder systems in follow-up screening for women with previous gestational diabetes work? - a realist review. BMC Health Serv Res 2021; 21:535. [PMID: 34074278 PMCID: PMC8167960 DOI: 10.1186/s12913-021-06569-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 05/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women with previous gestational diabetes have an increased risk of developing type 2 diabetes later in life. Recommendations therefore urge these women to participate in follow-up screening, 4-12 weeks postpartum and every 1-3 years thereafter. We sought to theorize how reminder interventions to support early detection of diabetes work, for whom, and in what circumstances. METHODS We used a method informed by realist review and synthesis. A systematic, iterative search in six electronic databases (PubMed, MEDLINE Ovid, The Cochrane Library, CINAHL, EMBASE) had a primary focus on experimental intervention studies and included additional information in relation to identified intervention studies. Analysis inductively identified context-mechanism-outcome configurations present in the evidence. RESULTS We located 16 articles eligible for inclusion. A cross-case comparison identified seven grouped context-mechanism-outcome configurations leading to intervention mechanisms relating to changes in women's reasoning and behavior. Configurations were thematically ordered in relation to Systems Resources, Women's Circumstances, and Continuity of Care. These were mapped onto a socio-ecological model and discussed according to identified middle-range theories. CONCLUSION Our findings adds to the body of evidence, that reminders have the potential to be effective in increasing participation in the recommended follow-up screening. Our study may assist researchers and policy and decision makers to analyze and judge if reminders are feasible and/or likely to succeed in their specific context. Further research into the perspective of socially disadvantaged and overweight women is needed to avoid unintended consequences such as social inequality in service use and stigmatization in future programs.
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Affiliation(s)
- Jane Hyldgaard Nielsen
- Department of Midwifery, University College of Northern Denmark, Selma Lagerløfs Vej 2, 9220, Aalborg Øst, Denmark.
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Niels Jernes Vej, 14, 9220, Aalborg Øst, Denmark.
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.
- DECIPHer, Cardiff School of Social Sciences, Cardiff University, Cardiff, Wales.
| | - G J Melendez-Torres
- Peninsula Technology Assessment Group, University of Exeter Medical School, Exeter, UK
| | - Torill Alise Rotevatn
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Niels Jernes Vej, 14, 9220, Aalborg Øst, Denmark
| | - Kimberly Peven
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Department of Child and Family Health Nursing, Kings College London, London, UK
| | - Kirsten Fonager
- Department of Social Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Charlotte Overgaard
- Public Health and Epidemiology Group, Department of Health Science and Technology, Aalborg University, Niels Jernes Vej, 14, 9220, Aalborg Øst, Denmark
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Zahmatkeshan M, Zakerabasali S, Farjam M, Gholampour Y, Seraji M, Yazdani A. The use of mobile health interventions for gestational diabetes mellitus: a descriptive literature review. J Med Life 2021; 14:131-141. [PMID: 34104235 PMCID: PMC8169150 DOI: 10.25122/jml-2020-0163] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/02/2021] [Indexed: 11/23/2022] Open
Abstract
This study attempted to review the evidence for or against the effectiveness of mobile health (m-health) interventions on health outcomes improvement and/or gestational diabetes mellitus (GDM) management. PubMed, Web of Science, Scopus, and Embase databases were searched from 2000 to 10 July 2018 to find studies investigating the effect of m-health on GDM management. After removing duplications, a total of 27 articles met our defined inclusion criteria. m-health interventions were implemented by smartphone, without referring to its type, in 26% (7/27) of selected studies, short message service (SMS) in 14.9% (4/27), mobile-based applications in 33.3% (9/27), telemedicine-based on smartphones in 18.5% (5/27), and SMS reminder system in 7.1% (2/27). Most of the included studies (n=23) supported the effectiveness of m-health interventions on GDM management and 14.3% (n=4) reported no association between m-health interventions and pregnancy outcomes. Based on our findings, m-health interventions could enhance GDM patients' pregnancy outcomes. A majority of the included studies suggested positive outcomes. M-health can be one of the most prominent technologies for the management of GDM.
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Affiliation(s)
- Maryam Zahmatkeshan
- Noncommunicable Diseases Research Center, School of Medicine, Fasa University of Medical Sciences, Fasa, Iran
| | - Somayyeh Zakerabasali
- Department of Health Information Management, Health Human Resources Research Center, School of Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mojtaba Farjam
- Noncommunicable Diseases Research Center, School of Medicine, Fasa University of Medical Sciences, Fasa, Iran
- Clinical Research Development Unit, Valie-Asr Hospital, Fasa University of Medical Sciences, Fasa, Iran
| | | | - Maryam Seraji
- Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Azita Yazdani
- Department of Health Information Management, Health Human Resources Research Center, School of Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
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The use of an automated call to elicit and characterize postpartum concerns after hospital discharge. Am J Obstet Gynecol MFM 2019; 1:128-135. [PMID: 33345818 DOI: 10.1016/j.ajogmf.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/02/2019] [Accepted: 06/04/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The postpartum period is a high-risk time for women, but most women do not have an opportunity to discuss concerns with providers until 4-6 weeks after delivery. OBJECTIVE The purpose of this study was to evaluate the use of an automated call system to contact postpartum patients within 72 hours of hospital discharge and to identify characteristics that are associated with postpartum concerns. STUDY DESIGN A prospective cohort of 2948 women in the postpartum period were contacted via an automated call within 72 hours of discharge to elicit concerns. We compared likelihood of successful call and presence of concerns by maternal demographic and medical characteristics using univariate analysis and multivariable logistic regression. RESULTS Of the participants, 2479 (84.1%) responded to a call after discharge, and 723 (29.1%) reported a concern. Primiparous women were more likely to be contacted successfully than were multiparous women (87.8% vs 79.0%; P<.005) and more likely to have an issue (31.5% vs 25.6%; P=.002). White women were more likely to be contacted successfully than were black, Latina, and Asian or Pacific Islander women (87.1% white, 72.1% black, 80.6% Latina, 85.8% Asian/Pacific Islander; P<.001) but were less likely to report a concern (25.2% white, 33.9% black, 26.5% Latina, 38.3% Asian/Pacific Islander; P<.001). Women with public insurance and those whose neonates were admitted to the intensive care nursery were less likely to be contacted, but these factors were not associated with increased concerns once a successful call was made. When controlling for cofounders, being primiparous and identifying as white were positive predictors of being contacted; having a neonate in the intensive care nursery was a negative predictor. Being primiparous and identifying as non-white were predictors of having a concern. CONCLUSION Most women responded to a call after hospital discharge, and nearly one-third of them had concerns. The system was not as effective at reaching women with public insurance, women with neonates in the intensive care nursery, and women of color, despite equal or greater numbers of concerns in these groups.
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Balaji B, Ranjit Mohan A, Rajendra P, Mohan D, Ram U, Viswanathan M. Gestational Diabetes Mellitus Postpartum Follow-Up Testing: Challenges and Solutions. Can J Diabetes 2019; 43:641-646. [PMID: 31230979 DOI: 10.1016/j.jcjd.2019.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 04/05/2019] [Accepted: 04/30/2019] [Indexed: 12/19/2022]
Abstract
One in every 4 pregnancies is affected by hyperglycemia, of which 90% is gestational diabetes mellitus (GDM). Women with GDM are at a high risk of developing both short- and long-term complications. Various studies have shown the heightened risk of type 2 diabetes among women with GDM. Despite clear evidence from published literature about the substantial risk that GDM imposes on women after delivery, rates of postpartum follow up have been low in most parts of the world. Several reasons, such as lack of awareness among health-care professionals and patient-related barriers, such as emotional stress and adjusting to motherhood, have been cited as reasons for poor follow-up rates. To address these issues and come up with solutions to improve postpartum follow-up rates, it is important to understand these barriers both from the patient and the health-care system points of view. In this review, we have summarized some of the key issues contributing to the low postpartum follow-up rates and have discussed possible strategies to tackle them. Use of proactive reminder systems, such as postal service, telephone call, short messaging service and e-mail, recall registries for GDM and utilization of mobile health technology are some of the key strategies that have been discussed in this review. A brief note on the Women in India with GDM Strategy project, which developed a model of care for GDM in resource-constrained settings and adopted several strategies that led to a 95.8% postpartum follow up, has also been presented.
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Affiliation(s)
| | - Anjana Ranjit Mohan
- Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, Tamil Nadu, India
| | - Pradeepa Rajendra
- Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, Tamil Nadu, India
| | - Deepa Mohan
- Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, Tamil Nadu, India
| | - Uma Ram
- Seethapathy Clinic and Hospital, Chennai, Tamil Nadu, India
| | - Mohan Viswanathan
- Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, Tamil Nadu, India
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O'Reilly SL, Dunbar JA, Best JD, Versace V, Ford D, Young D, Shih S, Bills R, Shepherdley W, Janus ED. GooD4Mum: A general practice-based quality improvement collaborative for diabetes prevention in women with previous gestational diabetes. Prim Care Diabetes 2019; 13:134-141. [PMID: 30448412 DOI: 10.1016/j.pcd.2018.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 10/11/2018] [Accepted: 10/22/2018] [Indexed: 10/27/2022]
Abstract
AIMS Gestational diabetes (GDM) and Type 2 diabetes pose tremendous health and economic burdens as worldwide incidence increases. Primary care-based systematic diabetes screening and prevention programs could be effective in women with previous GDM. GooD4Mum aimed to determine whether a Quality Improvement Collaborative (QIC) would improve postpartum diabetes screening and prevention planning in women with previous GDM in general practice. METHODS Fifteen general practices within Victoria (Australia) participated in a 12-month QIC, consisting of baseline and four quarterly audits, guideline-led workshops and Plan-Do-Study-Act feedback cycles after each audit. The primary outcome measures were the proportion of women on local GDM registers completing a diabetes screening test and a diabetes prevention planning consultation within the previous 15 months. RESULTS Diabetes screening increased with rates more than doubled from 26% to 61% and postpartum screening increased from 43%-60%. Diabetes prevention planning consultations did not show the same level of increase (0%-10%). The recording of body mass index improved overall (51%-69%) but the number of women with normal body mass index did not. CONCLUSIONS GooD4Mum supported increased diabetes screening and the monitoring of high risk women with previous GDM in general practice.
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Affiliation(s)
- S L O'Reilly
- Institute of Physical Activity and Nutrition, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia.
| | - J A Dunbar
- Deakin Rural Health, School of Medicine, Faculty of Health, Deakin University, Warrnambool, VIC 3280, Australia.
| | - J D Best
- Lee Kong Chian School of Medicine, Imperial College London and Nanyang Technological University, 11 Mandalay Road, 308232, Singapore.
| | - V Versace
- Deakin Rural Health, School of Medicine, Faculty of Health, Deakin University, Warrnambool, VIC 3280, Australia.
| | - D Ford
- Improvement Foundation, 8/19 Grenfell St, Adelaide, SA 5000, Australia.
| | - D Young
- Faculty of Medicine, Dentistry and Health Sciences, Building 181, University of Melbourne, Grattan Street, Melbourne, VIC 3010, Australia.
| | - S Shih
- Centre for Population Health Research, Deakin University, 221 Burwood Highway, Burwood, VIC 3125, Australia.
| | - R Bills
- Brooke Street Medical Centre, 14 Brooke Street, Woodend, VIC 3422, Australia.
| | - W Shepherdley
- Brooke Street Medical Centre, 14 Brooke Street, Woodend, VIC 3422, Australia.
| | - E D Janus
- General Internal Medicine Unit, Western Health, Sunshine Hospital, 176 Furlong Rd, St Albans, VIC 3021, Australia; Department of Medicine, Melbourne Medical School - Western Precinct, University of Melbourne, 176 Furlong Rd, St Albans, VIC 3021, Australia.
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Klassing HM, Ruisinger JF, Prohaska ES, Melton BL. Evaluation of Pharmacist-Initiated Interventions on Vaccination Rates in Patients with Asthma or COPD. J Community Health 2019; 43:297-303. [PMID: 28852915 DOI: 10.1007/s10900-017-0421-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To determine if pharmacy-initiated interventions improved the rate of influenza and pneumococcal vaccinations in adult patients with asthma and/or chronic obstructive pulmonary disease (COPD). Adult patients who filled prescriptions at one of three community pharmacies, who had a dispensing history indicative of an asthma and/or COPD diagnosis were randomized to receive a personal phone call or standardized mailed letter recommending influenza and pneumococcal vaccinations, or control with no vaccination information. The rate of influenza and pneumococcal vaccinations was measured for each group and measured using Chi square. Of 831 eligible participants, 210 patients completed the study, and self-reported a diagnosis of asthma and/or COPD. The influenza vaccine was administered to 56 (72.7%), 55 (87.3%), and 62 (88.6%) patients (p = 0.019); pneumococcal vaccine was administered to 46 (59.7%), 39 (61.9%), and 39 (55.7%) patients in the phone call, letter, and control groups, respectively. While the control group had significantly more influenza vaccinations, between the interventions the letter showed a higher rate of influenza vaccination over the phone call. Reviewing patients under age 65, the letter had a significantly higher rate of influenza vaccination than the phone call (p = 0.021). No significant improvement was found for the pneumococcal vaccination. Patients under age 65 who received a mailed letter had a significantly higher rate of influenza vaccination than those who received a phone call, and had a higher rate of pneumococcal vaccination. A standardized, mailed letter may help community pharmacists improve vaccination rates in patients with asthma and/or COPD.
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Affiliation(s)
| | | | - Emily S Prohaska
- Balls Food Stores Hen House Pharmacy, Olathe, KS, USA
- Adjunct Faculty, University of Kansas School of Pharmacy, Lawrence, KS, USA
| | - Brittany L Melton
- University of Kansas School of Pharmacy, Lawrence, KS, USA.
- University of Kansas Medical Center, 3901 Rainbow Blvd, Mailstop 4047, Kansas City, KS, USA.
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Pastore I, Chiefari E, Vero R, Brunetti A. Postpartum glucose intolerance: an updated overview. Endocrine 2018; 59:481-494. [PMID: 28808874 DOI: 10.1007/s12020-017-1388-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 07/28/2017] [Indexed: 12/19/2022]
Abstract
The prevalence of type 2 diabetes mellitus has increased worldwide over the past three decades, as a consequence of the more westernized lifestyle, which is responsible for the increasing obesity rate in the modern adult's life. Concomitant with this increase there has been a gradual rise in the overall prevalence of gestational diabetes mellitus, a condition that strongly predisposes to overt diabetes later in life. Many women with previous gestational diabetes mellitus show glucose intolerance in the early postpartum period. Although the best screening strategy for postpartum glucose intolerance is still debated, numerous evidences indicate that identification of these women at this time is of critical importance, as efforts to initiate early intensive lifestyle modification, including hypocaloric diet and physical activity, and to ameliorate the metabolic profile of these high-risk subjects can prevent or delay the onset of type 2 diabetes mellitus. Nevertheless, less than one fifth of women attend the scheduled postpartum screening following gestational diabetes mellitus and they are at increased risk to develop type 2 diabetes mellitus later in their lives. Unsatisfying results have also come from early intervention strategies and tools that have been developed during the last few years to help improving the rate of adherence to postpartum glycemic testing, thereby indicating that more effective strategies are needed to improve women's participation in postpartum screening.
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Affiliation(s)
- Ida Pastore
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Viale Europa (Loc. Germaneto), Catanzaro, 88100, Italy
| | - Eusebio Chiefari
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Viale Europa (Loc. Germaneto), Catanzaro, 88100, Italy
| | - Raffaella Vero
- Complex Operative Structure Endocrinology-Diabetology, Hospital Pugliese-Ciaccio, Catanzaro, 88100, Italy
| | - Antonio Brunetti
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, Viale Europa (Loc. Germaneto), Catanzaro, 88100, Italy.
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18
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Early versus 6-12 week postpartum glucose tolerance testing for women with gestational diabetes. J Perinatol 2018; 38:118-121. [PMID: 29048411 PMCID: PMC5790595 DOI: 10.1038/jp.2017.159] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 07/20/2017] [Accepted: 08/29/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The objective of this study is to estimate the accuracy of early oral glucose tolerance testing (GTT), to predict impaired glucose tolerance. STUDY DESIGN This was a prospective cohort study. Women received an early 75 g 2 h GTT between postpartum days 2-4 and again 6-12 weeks postpartum. The ability of the early GTT to accurately detect impaired glucose tolerance and diabetes was assessed by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPVs). The routine 6-12-week postpartum GTT was considered the gold standard. RESULTS The early GTT was completed by 100% of subjects, whereas only 31 of 58 (53%) women returned to complete the 6-12-week postpartum GTT. The early GTT had modest sensitivity for impaired glucose tolerance (62.5%) and overt diabetes (50%). However, it had excellent specificity (100%), PPV (100%) and NPV (96.7%) for diabetes. The NPV for impaired glucose tolerance with the early GTT was 80%. CONCLUSION Rates of 6-12 week postpartum GTT completion among patients with gestational diabetes is poor. Appropriate postpartum management may improve by using the early GTT as a screening test.
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Cabizuca CA, Rocha PS, Marques JV, Costa TFLR, Santos ASN, Schröder AL, Mello CAG, Sousa HD, Silva ESG, Braga FO, Abi-Abib RC, Gomes MB. Postpartum follow up of gestational diabetes in a Tertiary Care Center. Diabetol Metab Syndr 2018; 10:2. [PMID: 29308091 PMCID: PMC5751834 DOI: 10.1186/s13098-017-0303-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 12/20/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Gestational diabetes is a risk factor for future development of type 2 diabetes. The primary aim of this study was to estimate the prevalence of postpartum glucose tolerance status evaluation in pregnancies complicated by gestational diabetes 6-12 weeks after delivery. The secondary one was to identify the factors that are implicated with postpartum glucose retesting. METHODS This was a retrospective study performed with a cohort of women with gestational diabetes, with prenatal care and delivery at a tertiary care center, from January 2013 to April 2017. The diagnosis of gestational diabetes was based on IADPSG criteria (Fasting ≥ 92 mg/dl, 1 h ≥ 180 mg/dl and/or 2 h ≥ 153 mg/dl, respectively) and the diagnosis of type 2 diabetes and prediabetes were made using the 2016 ADA's criteria (fasting and 2 h after glucose load ≥ 126 mg/dl and/or ≥ 200 and 100-125 mg/dl and/or 140 and 199 mg/dl, respectively). All women had an appointment scheduled 6-12 weeks postpartum with the results of a 75-g oral glucose tolerance test (OGTT). RESULTS Of the 152 evaluated women, 21 (13.8%) returned with the postpartum OGTT results. Of these, 9 (45.0%) had a diagnosis of prediabetes. The use of insulin during gestation was the only factor implicated in a higher adherence rate to postpartum testing OR 6.33 (p 0.002). No significance was found for other demographic and clinical variables (age, family income, years of study, parity, gestational age at first visit, smoking, family history of type 2 diabetes, diagnosis of gestational diabetes before the third trimester, pregestational body mass index, previous history of gestational diabetes and ethnicity). CONCLUSION The majority of patients with gestational diabetes did not return postpartum to perform OGTT and in our study the only factor implicated in a higher postpartum return was the use of insulin during pregnancy. Considering that 45.0% were diagnosed with prediabetes, diabetes care teams should initially identify non-adherent patients.
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Affiliation(s)
- C. A. Cabizuca
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
- Rua Cinco de Julho 63/504 Copacabana, Rio de Janeiro, CEP 22051-030 Brazil
| | - P. S. Rocha
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - J. V. Marques
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - T. F. L. R. Costa
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - A. S. N. Santos
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - A. L. Schröder
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - C. A. G. Mello
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - H. D. Sousa
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - E. S. G. Silva
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - F. O. Braga
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - R. C. Abi-Abib
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - M. B. Gomes
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
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Ghajari H, Nouhjah S, Shahbazian H, Valizadeh R, Tahery N. Postpartum glucose testing, related factors and progression to abnormal glucose tolerance in a rural population with a known history of gestational diabetes. Diabetes Metab Syndr 2017; 11 Suppl 1:S455-S458. [PMID: 28404514 DOI: 10.1016/j.dsx.2017.03.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 03/31/2017] [Indexed: 01/04/2023]
Abstract
AIMS Gestational diabetes is a strong risk factor for postpartum progression to glucose intolerance. The aims of the study were to determine rate of postpartum glucose testing , its related factors and rate of progression to glucose intolerance in women who underwent postpartum glucose testing after pregnancy that complicated by gestational diabetes. MATERIALS this is a retrospective study and women with gestational diabetes who received prenatal care during 2005-2015 in 3 rural health centers of Khuramshahr (southwestern of Iran) were enrolled. Gestational diabetes mellitus diagnosed by FPG test only, 75g OGTT or GCT. The American Diabetes Association(ADA) criteria applied for definition of postpartum glucose intolerance (pre-diabetes or diabetes) . RESULTS Mean duration of follow-up was 29.7 months. BMI≥ 25 was detected in 73.3% and 78.7% of women during pre-pregnancy and postpartum respectively. Overall 45.8% (60/131) of women received postpartum glucose testing. Rate of progression to abnormal glucose tolerance was 23.3% (8.5% pre-diabetes and 15.2% diabetes). Advanced maternal age was associated with postpartum glucose testing (OR 1.066, CI 1.008-1.128, p=0.02). DISCUSSION high rate of overweight and obesity, sub optimal rate of postpartum glucose testing and high prevalence of glucose intolerance, highlights the importance of postpartum screening with a more sensitive test and implementation of an intervention program to prevent type 2 diabetes in rural population particularly older women with prior gestational diabetes.
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Affiliation(s)
| | - Sedigheh Nouhjah
- Diabetes Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Hajieh Shahbazian
- Diabetes Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Rohollah Valizadeh
- Student Research Committee, Urmia University of Medical Sciences, Urmia, Iran
| | - Noorollah Tahery
- Faculty of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran & Abadan School of Medical Sciences, Abadan, Iran.
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Aziz S, Munim TF, Fatima SS. Post-partum follow-up of women with gestational diabetes mellitus: effectiveness, determinants, and barriers. J Matern Fetal Neonatal Med 2017; 31:1607-1612. [PMID: 28423981 DOI: 10.1080/14767058.2017.1321630] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Despite the recommendations for postpartum blood glucose monitoring post gestational diabetes mellitus (GDM); scientific evidence reveals that these recommendations may not be fully complied to. This study aimed to follow-up women up to 2 years post-delivery with pregnancies complicated by GDM and healthy controls to assess this fact. METHODS Women with GDM (n = 78) and normal glucose tolerant (n = 89) delivered in 2014 were followed up for 2 years. They were informed and enquired via telephone about their blood glucose screening, physical activity, postpartum complications, and current weight status of mother and baby. RESULTS Women with previous GDM were older and reported higher body weight 2 years post-delivery. At the 2 year follow-up, n = 11 (14.1%) participants had developed diabetes, all with previous GDM. Both weight at birth (3.8 ± 0.5 kg) and at 2-year (10.7 ± 2.3 kg) for the babies born to GDM mothers was significantly higher than the NGT group babies (2.6 ± 0.63 and 7.1 ± 1.4 kg; p < .05). Only 27 women regularly opted for T2DM screening via monitoring blood glucose or HbA1c levels postpartum. The top reason for failed screening included: believing that GDM would disappear after delivery, and being occupied with the baby. CONCLUSIONS The high incidence of T2DM in women with previous GDM is an alarming finding. Given this trend, systematic follow-up programs are needed to reduce obesity and diabetes risk.
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Affiliation(s)
- Saleha Aziz
- a Medical College, Aga Khan University , Karachi , Pakistan
| | - Tazeen Fatima Munim
- b Department of Obstetrics and Gynecology , Abassi Shaheed Hospital , Karachi , Pakistan
| | - Syeda Sadia Fatima
- c Department of Biological and Biomedical Sciences , Aga Khan University , Karachi , Pakistan
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Procrastination as a Key Factor in Postpartum Screening for Diabetes: A Qualitative Study of Iranian Women with Recent Gestational Diabetes. IRANIAN RED CRESCENT MEDICAL JOURNAL 2017. [DOI: 10.5812/ircmj.44833] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Hamel MS, Werner EF. Interventions to Improve Rate of Diabetes Testing Postpartum in Women With Gestational Diabetes Mellitus. Curr Diab Rep 2017; 17:7. [PMID: 28150160 DOI: 10.1007/s11892-017-0835-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. In the USA, four million women are screened annually for GDM in pregnancy in part to improve pregnancy outcomes but also because diagnosis predicts a high risk of future type 2 diabetes mellitus (T2DM). Therefore, among women with GDM, postpartum care should be focused on T2DM prevention. This review describes the current literature aimed to increase postpartum diabetes testing among women with GDM. RECENT FINDINGS Data suggest that proactive patient contact via a health educator, a phone call, or even postal mail is associated with higher rates of postpartum diabetes testing. There may also be utility to changing the timing of postpartum diabetes testing. Despite the widespread knowledge regarding the importance of postpartum testing for women with GDM, testing rates remain low. Alternative testing strategies and large randomized trials addressing postpartum testing are warranted.
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Affiliation(s)
- Maureen S Hamel
- Department of Obstetrics & Gynecology, Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI, 02905, USA.
| | - Erika F Werner
- Department of Obstetrics & Gynecology, Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI, 02905, USA
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Soffer MD, Factor SH, Rosenman A, Levy C, Stone J. Improving postpartum glucose monitoring in women with gestational diabetes. J Matern Fetal Neonatal Med 2017; 30:3014-3019. [PMID: 27936990 DOI: 10.1080/14767058.2016.1271411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To improve 6-week postpartum visit attendance, glucose test ordering and test completion among postpartum patients with a history of gestational diabetes (GDM). METHODS Pre- and post-intervention GDM women at Mount Sinai Hospital were studied via chart review. Interventions included advanced order sets for glucose monitoring at the 35-week pregnancy visit, educational modules, and nutritionist phone calls reminding patients to attend postpartum visits fasting. RESULTS One hundred and seven pre-intervention and 42 post-intervention women were studied. Percentages of orders placed for postpartum testing was higher post-intervention vs. pre-intervention (57% vs. 42%, p = 0.03). There were higher test completion rates post-intervention vs. pre-intervention (36% vs. 17%, p = 0.01). Postpartum visit attendance rates did not vary between the groups (73% vs. 69% p = 0.60). Six percent of patients pre-intervention fasted for postpartum visits vs. 60% post-intervention. CONCLUSION There was no observed increase in women attending their 6-week postpartum visits, yet rates of completed orders for postpartum testing, women attending visits fasting, and postpartum test completions were higher post-intervention. More research may identify the barriers to attendance at 6-week postpartum visits.
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Affiliation(s)
- M D Soffer
- a Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Hospital , New York , NY , USA
| | - S H Factor
- a Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Hospital , New York , NY , USA.,b Department of Infectious Disease, Mount Sinai Hospital , New York , NY , USA
| | - A Rosenman
- a Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Hospital , New York , NY , USA
| | - C Levy
- a Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Hospital , New York , NY , USA.,c Department of Endocrinology, Diabetes, and Bone Disease Mount Sinai Hospital , New York , NY , USA
| | - J Stone
- a Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Hospital , New York , NY , USA.,d Department of Maternal Fetal Medicine, Mount Sinai Hospital , New York , NY , USA
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Bhavadharini B, Anjana RM, Mahalakshmi MM, Maheswari K, Kayal A, Unnikrishnan R, Ranjani H, Ninov L, Pastakia SD, Usha S, Malanda B, Belton A, Uma R, Mohan V. Glucose tolerance status of Asian Indian women with gestational diabetes at 6weeks to 1year postpartum (WINGS-7). Diabetes Res Clin Pract 2016; 117:22-7. [PMID: 27329018 DOI: 10.1016/j.diabres.2016.04.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 03/12/2016] [Accepted: 04/26/2016] [Indexed: 01/18/2023]
Abstract
AIM To determine postpartum glucose tolerance status among women with gestational diabetes mellitus (GDM) recruited under the Women In India with GDM Strategy (WINGS) Model of Care (MOC). METHODS Through the WINGS MOC programme, 212 women with GDM were followed till delivery between November 2013 and August 2015. All women were advised to return for a postpartum oral glucose tolerance test (OGTT) 6-12weeks after delivery. A multivariate logistic regression (MLR) model was developed to identify the risk factors for postpartum dysglycemia which was defined as presence of diabetes (DM) or prediabetes. RESULTS 203/212(95.8%) women completed their postpartum OGTT. Of the 161 women (79.3%) who came back for the test between 6 and 12weeks, 2(1.2%) developed DM, 5(3.1%), isolated IFG, 13(8.1%), isolated IGT and 5(3.1%) combined IFG/IGT [dysglycemia 25(15.5%)]. 136 women (84.5%) reverted to normal glucose tolerance (NGT). Of the 42 women who came back between 12weeks and a year, 5(11.9%) developed DM, 10(23.8%), isolated IFG and 1(2.4%) combined IFG/IGT [dysglycemia 16(38.1%)]. 26/42 women (61.9%) reverted to NGT. Thus overall dysglycemia occurred in 41/203 women (20.2%). MLR showed that BMI ⩾25kg/m(2) was significantly associated with postpartum dysglycemia (odds ratio: 4.47; 95% confidence interval: 1.8-11.2, p=0.001). CONCLUSION Among Asian Indian women with GDM, over 20% develop dysglycemia within one year postpartum, and BMI ⩾25kg/m(2) increased this risk four-fold. Early postpartum screening can identify high risk women and help plan strategies for prevention of type 2 diabetes in the future.
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Affiliation(s)
| | | | | | | | | | | | | | - Lyudmil Ninov
- International Diabetes Federation, Brussels, Belgium
| | | | - Sriram Usha
- Associates in Clinical Endocrinology Education and Research (ACEER), Chennai, India
| | - Belma Malanda
- International Diabetes Federation, Brussels, Belgium
| | - Anne Belton
- International Diabetes Federation, Brussels, Belgium
| | - Ram Uma
- Seethapathy Clinic and Hospital, Chennai, India
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Huynh T, Ghaffari N, Bastek J, Durnwald C. Prenatal care in a specialized diabetes in pregnancy program improves compliance with postpartum testing in GDM women . J Matern Fetal Neonatal Med 2016; 30:1075-1079. [PMID: 27296556 DOI: 10.1080/14767058.2016.1201472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate whether prenatal care in a specialized diabetes in pregnancy program (DMC) improves compliance with completion of the 2-h 75 g oral glucose tolerance test (2HrOGTT) in GDM women. METHODS A retrospective cohort study of GDM women delivering in a university health system between January 2011 and March 2014 was performed. Women were divided into two groups: those receiving care in prenatal clinics over an 18-month period prior to the establishment of the diabetes in pregnancy clinic (pre-DMC) and those receiving prenatal care in a specialized diabetes in pregnancy clinic (post-DMC). The primary outcome was completion of the 2HrOGTT postpartum. Clinical characteristics associated with 2HrOGTT completion were evaluated. Time trend analysis was performed to evaluate month to month variation in 2HrOGTT compliance for secular trends. RESULTS A total of 292 women were analyzed, 147 post-DMC and 118 pre-DMC. The 2HrOGTT was ordered more frequently in the post-DMC compared to pre-DMC (90.0 versus 53.0%, p < 0.0001). Rates of completion of the 2HrOGTT were 49.2% post-DMC and 25.0% pre-DMC, p = 0.007. After adjusting for potential confounders, women who received prenatal care post-DMC were 2.98 times more likely to complete the 2HrOGTT compared to those receiving care pre-DMC (OR 2.98 [1.34, 6.62], p = 0.007). CONCLUSIONS Providers were 5.9 times more likely to order the recommended testing for GDM women who attended the postpartum visit in the post-DMC period. GDM women who receive prenatal care in a specialized diabetes in pregnancy program are more likely to complete the 2HrOGTT in the postpartum period.
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Affiliation(s)
- Terri Huynh
- a Maternal and Child Health Research Program, Department of OB/GYN, University of Pennsylvania, Perelman School of Medicine , Philadelphia , PA , USA
| | - Neda Ghaffari
- a Maternal and Child Health Research Program, Department of OB/GYN, University of Pennsylvania, Perelman School of Medicine , Philadelphia , PA , USA
| | - Jamie Bastek
- a Maternal and Child Health Research Program, Department of OB/GYN, University of Pennsylvania, Perelman School of Medicine , Philadelphia , PA , USA
| | - Celeste Durnwald
- a Maternal and Child Health Research Program, Department of OB/GYN, University of Pennsylvania, Perelman School of Medicine , Philadelphia , PA , USA
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Yarrington C, Zera C. Health Systems Approaches to Diabetes Screening and Prevention in Women with a History of Gestational Diabetes. Curr Diab Rep 2015; 15:114. [PMID: 26458385 DOI: 10.1007/s11892-015-0687-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Gestational diabetes (GDM) is associated with a high risk of future type 2 diabetes. Despite multiple clinical guidelines highlighting the importance of screening in this high-risk population, many health systems report that fewer than 50 % of eligible women are screened in the postpartum period, and little is known about screening beyond the first postpartum year. Systems-level approaches to screening for and prevention of type 2 diabetes in women with a history of GDM are therefore an opportunity for quality improvement. This review will discuss the literature on interventions to improve screening at the systems level and highlight successful strategies as well as gaps in the existing literature. Future directions for intervention research are suggested.
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Affiliation(s)
- Christina Yarrington
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Boston Medical Center, One Boston Medical Center Place, Boston, MA, USA
| | - Chloe Zera
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Boston Medical Center, One Boston Medical Center Place, Boston, MA, USA.
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The forgotten risk? A systematic review of the effect of reminder systems for postpartum screening for type 2 diabetes in women with previous gestational diabetes. BMC Res Notes 2015; 8:373. [PMID: 26306499 PMCID: PMC4548707 DOI: 10.1186/s13104-015-1334-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 08/12/2015] [Indexed: 11/13/2022] Open
Abstract
Background Screening for type 2 diabetes is recommended for women with previous gestational diabetes (GDM). However, the screening rates remain low. We aimed to evaluate the reminders and reminder systems for women with previous GDM and the health professionals in primary and secondary health care with screening rate among postpartum women as primary outcome. Methods Observational and intervention studies were included and the PRISMA guidelines were followed for the literature extraction. Results Six studies were included: two long-term follow up studies and four early terms. Five studies focused on secondary care settings and one on primary care. Three studies focused on reminders to postpartum women only, two studies to both the women and health care professional, and one study on the health care provider only. Types of reminders varied from letters, emails, and personal telephone calls to the women to register-based reminders or letters to the health care professionals. Reminders were efficient but efficiency varied between studies. Two studies found that direct telephone calls strengthened the reminding of the women. The effect of reminding both the women and the health professional screening rates decreased compared to reminding either health professionals or reminding the women separately. Conclusions Reminders have a potential for early detection and prevention of type 2 diabetes in this high risk group of women; however, the kind of reminder and the frequency of reminders should be carefully considered accordingly to the target group.
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Kumar S, Shewade HD, Vasudevan K, Durairaju K, Santhi VS, Sunderamurthy B, Krishnakumari V, Panigrahi KC. Effect of mobile reminders on screening yield during opportunistic screening for type 2 diabetes mellitus in a primary health care setting: A randomized trial. Prev Med Rep 2015; 2:640-4. [PMID: 26844130 PMCID: PMC4721301 DOI: 10.1016/j.pmedr.2015.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective. We wanted to study whether mobile reminders increased follow-up for definitive tests resulting in higher screening yield during opportunistic screening for diabetes. Methods. This was a facility-based parallel randomized controlled trial during routine outpatient department hours in a primary health care setting in Puducherry, India (2014). We offered random blood glucose testing to non-pregnant non-diabetes adults with age >30 years (667 total, 390 consented); eligible outpatients (random blood glucose ≥ 6.1 mmol/l, n = 268) were requested to follow-up for definitive tests (fasting and postprandial blood glucose). Eligible outpatients either received (intervention arm, n = 133) or did not receive mobile reminder (control arm, n = 135) to follow-up for definitive tests. We measured capillary blood glucose using a glucometer to make epidemiological diagnosis of diabetes. The trial was registered with Clinical Trial Registry of India (CTRI/2014/10/005138). Results. 85.7% of outpatients in intervention arm returned for definitive test when compared to 53.3% in control arm [Relative Risk = 1.61, (0.95 Confidence Interval — 1.35, 1.91)]. Screening yield in intervention and control arm was 18.6% and 10.2% respectively. Etiologic fraction was 45.2% and number needed to screen was 11.9. Conclusion. In countries like India, which is emerging as the diabetes capital of the world, considering the wide prevalent use of mobile phones, and real life resource limited settings in which this study was carried out, mobile reminders during opportunistic screening in primary health care setting improve screening yield of diabetes. First RCT to determine the effect of mobile reminders on screening yield for diabetes mellitus. Operational research conducted in real world primary health care setting. Outpatients with random blood glucose ≥ 6.1 mmol/l among adults >30y were eligible for definitive tests. Mobile reminders for eligible outpatients was introduced as a reminder system.
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Key Words
- CI, confidence interval
- CTRI, Clinical Trial Registry of India
- Diabetes mellitus, type 2
- FBG, fasting blood glucose
- HbA1C, glycosylated hemoglobin
- India
- Loss to follow-up
- NNS, number needed to screen
- NPCDCS, National Programme for Prevention and Control of Diabetes, Cardiovascular diseases and Stroke
- OPD, Out Patient Department
- Operational research
- Opportunistic screening
- Outpatients
- PHC, Primary Health Centre
- PPBG, postprandial blood glucose
- Primary Health Centre
- Primary health care
- RBG, random blood glucose
- RCT, randomized controlled trial
- Randomized controlled trial
- Reminder system
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Affiliation(s)
- Sathish Kumar
- Indira Gandhi Medical College and Research Institute (IGMCRI), Puducherry, India
| | | | - Kavita Vasudevan
- Indira Gandhi Medical College and Research Institute (IGMCRI), Puducherry, India
| | - Kathamuthu Durairaju
- Primary Health Centre, Lawspet, Department of Health and Family Welfare, Puducherry, India
| | - V S Santhi
- Primary Health Centre, Lawspet, Department of Health and Family Welfare, Puducherry, India
| | | | - Velavane Krishnakumari
- Primary Health Centre, Lawspet, Department of Health and Family Welfare, Puducherry, India
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Halperin IJ, Sehgal P, Lowe J, Hladunewich M, Wong BM. Increasing Timely Postpartum Oral Glucose Tolerance Test Completion in Women with Gestational Diabetes: A Quality-Improvement Initiative. Can J Diabetes 2015; 39:451-6. [PMID: 26277221 DOI: 10.1016/j.jcjd.2015.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 06/09/2015] [Accepted: 06/09/2015] [Indexed: 12/31/2022]
Affiliation(s)
- Ilana J Halperin
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Prateek Sehgal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Julia Lowe
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Hladunewich
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brian M Wong
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Peticca P, Shah BR, Shea A, Clark HD, Malcolm JC, Walker M, Karovitch A, Brazeau-Gravelle P, Keely EJ. Clinical predictors for diabetes screening in the first year postpartum after gestational diabetes. Obstet Med 2014; 7:116-20. [PMID: 27512435 PMCID: PMC4934972 DOI: 10.1177/1753495x14528487] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Postpartum screening for diabetes in women with gestational diabetes (GDM) improves with use of reminder systems. Our primary objective was to identify predictors of diabetes screening in the first year after delivery. METHODS A retrospective study was performed of 556 women with GDM who received outpatient prenatal care between 2007 and 2009. A mailed reminder system was utilized at two sites. Rates of postpartum glucose testing at 6 and 12 months postpartum were measured. RESULTS Site of care and non-smoking status were identified as the only predictors of postpartum diabetes screening (p<0.001 and p = 0.02, respectively). Rates of OGTT completion at one year (38% vs. 19% p<0.001) were higher in women who attended clinics with postpartum reminders. CONCLUSIONS The site of diabetes care in pregnancy is a major predictor of adherence to diabetes screening postpartum. Health care delivery should be considered in the development of strategies to increase screening rates.
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Affiliation(s)
- Patricia Peticca
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Baiju R Shah
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alison Shea
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Heather D Clark
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Janine C Malcolm
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Mark Walker
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Obstetrics and Gynecology, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Alan Karovitch
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
- Department of Obstetrics and Gynecology, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | | | - Erin J Keely
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Obstetrics and Gynecology, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
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Capula C, Chiefari E, Vero A, Foti DP, Brunetti A, Vero R. Prevalence and predictors of postpartum glucose intolerance in Italian women with gestational diabetes mellitus. Diabetes Res Clin Pract 2014; 105:223-30. [PMID: 24931701 DOI: 10.1016/j.diabres.2014.05.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 04/25/2014] [Accepted: 05/18/2014] [Indexed: 02/07/2023]
Abstract
AIMS To determine the prevalence of both prediabetes and type 2 diabetes mellitus (T2DM) by postpartum oral glucose tolerance test (ppOGTT) in Italian women diagnosed with gestational diabetes mellitus (GDM), and identify antepartum predictors of glucose intolerance. METHODS Retrospective study of 454 Caucasian women that underwent a 75g OGTT between 6 and 12 weeks postpartum in Calabria (Southern Italy) between 2004 and 2012. Prediabetes and T2DM were diagnosed according to the American Diabetes Association (ADA) criteria. Data were examined by univariate analysis and multiple regression analysis. RESULTS 290 women (63.9%) were normal, 146 (32.1%) had prediabetes (85 impaired fasting glycemia; 61 impaired glucose tolerance), and 18 (4.0%) had T2DM. Of the continuous variables, pre-pregnancy body mass index (BMI), age at pregnancy, fasting plasma glucose (FPG) at gravid OGTT, and week at diagnosis of GDM were associated with prediabetes and T2DM, whereas the parity was associated with T2DM only. For categorical traits, pre-pregnancy BMI ≥ 25 and previous diagnosis of polycystic ovary syndrome (PCOS) emerged as the strongest predictors of prediabetes whereas the strongest predictors of T2DM were FPG ≥ 100 mg/dl (5.6 mmol/l) at GDM diagnosis and pre-pregnancy BMI ≥ 25. Moreover, FPG at GDM screening was a good predictor of T2DM after receiver-operating-characteristic analysis. CONCLUSIONS Our findings confirm the high prevalence of glucose intolerance in the early postpartum period in women with previous GDM. PCOS emerges as a new strong antepartum predictor of prediabetes.
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Affiliation(s)
- Carmelo Capula
- Complex Operative Structure of Endocrinology-Diabetology, Pugliese-Ciaccio Hospital, 88100 Catanzaro, Italy
| | - Eusebio Chiefari
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, 88100 Catanzaro, Italy
| | - Anna Vero
- Complex Operative Structure of Endocrinology-Diabetology, Pugliese-Ciaccio Hospital, 88100 Catanzaro, Italy
| | - Daniela P Foti
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, 88100 Catanzaro, Italy
| | - Antonio Brunetti
- Department of Health Sciences, University "Magna Græcia" of Catanzaro, 88100 Catanzaro, Italy.
| | - Raffaella Vero
- Complex Operative Structure of Endocrinology-Diabetology, Pugliese-Ciaccio Hospital, 88100 Catanzaro, Italy
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Paez KA, Eggleston EM, Griffey SJ, Farrar B, Smith J, Thompson J, Gillman MW. Understanding Why Some Women with a History of Gestational Diabetes Do Not Get Tested for Diabetes. Womens Health Issues 2014; 24:e373-9. [DOI: 10.1016/j.whi.2014.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Revised: 04/11/2014] [Accepted: 04/21/2014] [Indexed: 12/11/2022]
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McCloskey L, Bernstein J, Winter M, Iverson R, Lee-Parritz A. Follow-up of gestational diabetes mellitus in an urban safety net hospital: missed opportunities to launch preventive care for women. J Womens Health (Larchmt) 2014; 23:327-34. [PMID: 24707899 PMCID: PMC3991991 DOI: 10.1089/jwh.2013.4628] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Our study assessed the follow-up of gestational diabetes mellitus (GDM) in the postpartum period among a racially and ethnically diverse group of women receiving care in a major urban medical center. METHODS We conducted cross-sectional analysis of clinical and administrative data on women aged 18-44 years who gave birth at Boston Medical Center (BMC) between 2003 and 2009, had GDM, and used BMC for regular care. We calculated the rate of glucose testing by 70 days and by 180 days after delivery and used logistic regression to assess the predictors of testing. RESULTS By 6 months postpartum, only 23.4% of GDM-affected women received any kind of glucose test. Among these, over half had been completed by 10 weeks but only 29% were the recommended oral glucose tolerance test (OGTT). After accounting for sociodemographic and health service factors, women aged ≤ 35 years of age and women with a family practice provider were significantly less likely to be tested than their counterparts (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.32, 0.83 and OR 0.36; 95% CI 0.19, 0.71 respectively). Women who attended a primary care visit within 180 days after birth had three times higher odds of being tested than those without such a visit (OR 3.10; 95% CI 1.97, 4.87). CONCLUSIONS Despite widely disseminated clinical guidelines, postpartum glucose testing rates are exceedingly low, marking a critical missed opportunity to launch preventive care for women at high risk of type 2 DM. Failed follow-up of GDM by providers of prenatal and postpartum care also reflects a broader systems failure: the absence of a well-supported transition from pregnancy care to ongoing primary care for women.
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Affiliation(s)
- Lois McCloskey
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Judith Bernstein
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Michael Winter
- Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts
| | - Ronald Iverson
- Department of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Aviva Lee-Parritz
- Department of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
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Middleton P, Crowther CA. Reminder systems for women with previous gestational diabetes mellitus to increase uptake of testing for type 2 diabetes or impaired glucose tolerance. Cochrane Database Syst Rev 2014; 2014:CD009578. [PMID: 24638998 PMCID: PMC11095846 DOI: 10.1002/14651858.cd009578.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The early postpartum period is an important time in which to identify the risk of diabetes in women with a history of gestational diabetes mellitus (GDM). Oral glucose tolerance and other tests can help guide lifestyle management and monitoring to reduce the future risk of type 2 diabetes mellitus. OBJECTIVES To assess whether reminder systems increase the uptake of testing for type 2 diabetes or impaired glucose tolerance in women with a history of GDM. SEARCH METHODS We searched MEDLINE and EMBASE (last searched 1 June 2013) and The Cochrane Library (last searched April 2013). SELECTION CRITERIA We included randomised trials of women who had experienced GDM in the index pregnancy and who were then sent any modality of reminder (or control) to complete a test for type 2 diabetes after giving birth. DATA COLLECTION AND ANALYSIS Two authors independently screened titles and abstracts for relevance. One author extracted the data, carried out 'Risk of bias' assessments and evaluated the overall study quality according to GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria; the other author double-checked these procedures. Meta-analysis was not possible as only one study was eligible for inclusion. MAIN RESULTS Only one trial with an unclear risk of bias in the majority of domains was included in the study; the overall study quality was judged to be low. This factorial trial of 256 women compared three types of postal reminder strategies (in a total of 213 women) with usual care (no postal reminder, 43 women) and reported on the uptake of four possible types of glucose tests. The three strategies investigated were: reminders sent to both the woman and the physician; reminder sent to the woman only; and reminder sent to the physician only, all issued approximately three months after the woman had given birth.There was low-quality evidence that all three reminder interventions increased uptake of oral glucose tolerance tests compared with usual care (no reminder system): reminders to the woman and the physician (uptake 60% versus 14%): risk ratio 4.23 (95% confidence interval (CI) 1.85 to 9.71); 116 participants); reminder to the woman only (uptake 55% versus 14%): RR 3.87 (95% CI 1.68 to 8.93); 111 participants); reminder to the physician only (uptake 52% versus 14%): RR 3.61 (95% CI 1.50 to 8.71); 66 participants). This represented an increase in uptake from 14% in the no reminder group to 57% across the three reminder groups. There was also an increase in uptake of fasting glucose tests in the reminder group compared with the usual care group: reminders to the woman and the physician versus no reminder (uptake 63% versus 40%): RR 1.57 (95% CI 1.01 to 2.44); reminder to the woman only (uptake 71% versus 40%): RR 1.78 (95% CI 1.16 to 2.73); reminder to the physician only (uptake 68% versus 40%): RR 1.69 (95% CI 1.06 to 2.72). Uptake of random glucose and glycated haemoglobin A1c tests was low, and no statistically significant differences were seen between the reminder and no reminder groups for these tests. Uptake of any test was higher in each of the reminder groups compared with the no reminder group (RR 1.65 (95% CI 1.12 to 2.41); 1.73 (95% CI 1.18 to 2.52); and 1.55 (95% CI 1.01 to 2.38) in the respective reminder groups.The trial did not report this review's other primary outcomes (proportion of women diagnosed with type 2 diabetes or showing impaired glucose tolerance or impaired fasting glucose after giving birth; or health-related quality of life). Nor did it report any secondary review outcomes such as diabetes-associated morbidity, lifestyle changes, need for insulin, recurrence of GDM or women's and/or health professionals' views of the intervention. No adverse events of the intervention were reported.Subgroup interaction tests gave no indication that dual reminders (to both women and physicians) were more successful than single reminders to either women or physicians alone. It was also not clear if test uptakes between women in the reminder and no reminder groups differed by type of glucose test undertaken. AUTHORS' CONCLUSIONS Results from the only trial that fulfilled our inclusion criteria showed low-quality evidence for a marked increase in the uptake of testing for type 2 diabetes in women with previous GDM following the issue of postal reminders. The effects of other forms of reminder systems need to be assessed to see whether test uptake also increases when email and telephone reminders are deployed. We also need a better understanding of why some women fail to take opportunities to be screened postpartum. As the ultimate aim of increasing postpartum testing is to prevent the subsequent development of type 2 diabetes, it is important to determine whether increased test uptake rates also increase women's use of preventive strategies such as lifestyle modifications.
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Affiliation(s)
- Philippa Middleton
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, The Robinson Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Caroline A Crowther
- The University of AucklandLiggins InstitutePrivate Bag 9201985 Park RoadAucklandNew Zealand
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Nielsen KK, Kapur A, Damm P, de Courten M, Bygbjerg IC. From screening to postpartum follow-up - the determinants and barriers for gestational diabetes mellitus (GDM) services, a systematic review. BMC Pregnancy Childbirth 2014; 14:41. [PMID: 24450389 PMCID: PMC3901889 DOI: 10.1186/1471-2393-14-41] [Citation(s) in RCA: 170] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 01/06/2014] [Indexed: 12/25/2022] Open
Abstract
Background Gestational diabetes mellitus (GDM) – a transitory form of diabetes first recognised during pregnancy complicates between < 1% and 28% of all pregnancies. GDM has important short and long-term health consequences for both the mother and her offspring. To prevent adverse pregnancy outcomes and to prevent or delay future onset of type 2 diabetes in mother and offspring, timely detection, optimum treatment, and preventive postpartum care and follow-up is necessary. However the area remains grossly under-prioritised. Methods To investigate determinants and barriers to GDM care from initial screening and diagnosis to prenatal treatment and postpartum follow-up, a PubMed database search to identify quantitative and qualitative studies on the subject was done in September 2012. Fifty-eight relevant studies were reviewed. Results Adherence to prevailing GDM screening guidelines and compliance to screening tests seems sub-optimal at best and arbitrary at worst, with no clear or consistent correlation to health care provider, health system or client characteristics. Studies indicate that most women express commitment and motivation for behaviour change to protect the health of their unborn baby, but compliance to recommended treatment and advice is fraught with challenges, and precious little is known about health system or societal factors that hinder compliance and what can be done to improve it. A number of barriers related to health care provider/system and client characteristics have been identified by qualitative studies. Immediately following a GDM pregnancy many women, when properly informed, desire and intend to maintain healthy lifestyles to prevent future diabetes, but find the effort challenging. Adherence to recommended postpartum screening and continued lifestyle modifications seems even lower. Here too, health care provider, health system and client related determinants and barriers were identified. Studies reveal that sense of self-efficacy and social support are key determinants. Conclusions The paper identifies and discusses determinants and barriers for GDM care, fully recognising that these are highly dependent on the context.
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Affiliation(s)
- Karoline Kragelund Nielsen
- Department of International Health, Immunology and Microbiology, University of Copenhagen, Oester Farimagsgade 5, Building 9, Copenhagen DK-1014, K, Denmark.
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Nerenberg K, Daskalopoulou SS, Dasgupta K. Gestational diabetes and hypertensive disorders of pregnancy as vascular risk signals: an overview and grading of the evidence. Can J Cardiol 2014; 30:765-73. [PMID: 24726053 DOI: 10.1016/j.cjca.2013.12.030] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 12/02/2013] [Accepted: 12/09/2013] [Indexed: 01/11/2023] Open
Abstract
The occurrence of common pregnancy-related medical disorders identifies women at high risk of developing future vascular disease. Systematic reviews of cohort studies demonstrate that gestational diabetes confers a 7-fold risk increase for type 2 diabetes, and preeclampsia confers a 1.8-fold risk increase for type 2 diabetes and 3.4-fold risk increase for hypertension. Gestational diabetes and hypertensive disorders of pregnancy (HDP) increase the risk of premature vascular disease, but the 2-fold risk increase associated with preeclampsia is only partially explained by the development of traditional vascular risk factors. Despite the compelling evidence for gestational diabetes and HDP as vascular risk indicators, there are no published Canadian vascular prevention guidelines that recognize these postpartum women. In contrast, the 2011 American Heart Association guidelines on cardiovascular disease in women include gestational diabetes and HDP in their vascular risk assessment. Studies indicate that the importance surveillance of vascular risk factors in these women after pregnancy is underappreciated by the women themselves and their physicians. Although a prudent diet and physically active lifestyle were demonstrated to reduce diabetes risk in women with a gestational diabetes history in the American Diabetes Prevention Program trial, adoption of these health behaviours is low; qualitative studies confirm a need for tailored strategies that address barriers and provide social support. Further research is also needed on approaches to reduce vascular risk in women with a history of gestational diabetes and HDP. Otherwise, an early window of opportunity for chronic disease prevention in young, high-risk women will be missed.
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Affiliation(s)
- Kara Nerenberg
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Stella S Daskalopoulou
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada; Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Kaberi Dasgupta
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada; Department of Medicine, McGill University, Montreal, Québec, Canada.
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Gupta Y, Gupta A. Response to Lie et al. Preventing Type 2 diabetes after gestational diabetes: women's experiences and implications for diabetes prevention interventions. Diabet Med 2013; 30:1509-10. [PMID: 23952364 DOI: 10.1111/dme.12304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Y Gupta
- Department of Medicine, Government Medical College and Hospital, Chandigarh, India
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Carson MP, Frank MI, Keely E. Original research: postpartum testing rates among women with a history of gestational diabetes--systematic review. Prim Care Diabetes 2013; 7:177-186. [PMID: 23684416 DOI: 10.1016/j.pcd.2013.04.007] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 04/13/2013] [Accepted: 04/16/2013] [Indexed: 01/08/2023]
Abstract
AIMS Gestational diabetes mellitus (GDM) is increasing and 30% have persistent postpartum dysglycemia. Reported compliance with recommended postpartum testing ranges 9-95% without a clear explanation for this wide variation. Small and conflicting differences in testing rates are associated with some demographics (race, use of insulin), but system factors likely play a larger role. A systematic literature review was performed to identify system based factors that could explain the broad variation in postpartum GDM testing rates. METHODS Original articles reporting postpartum testing rates among women with GDM were identified within PubMed, OVID, EMBASE, and the Cochrane Database of systematic reviews. Articles that did not report rates for the entire GDM cohort were excluded. RESULTS 54/307 citations met inclusion criteria. The use of proactive patient contact programs increased postpartum testing rates from an average of 33% (range 9-71%) up to 60% (range 14-95%). CONCLUSIONS Proactively contacting patients via phone calls, education programs, or postal reminders was associated with higher postpartum testing rates. Rather than working to identifying individual demographic factors, systems based approaches were associated with a larger potential impact, and appear easily generalizable. Clinicians should think beyond individual habits and consider systematic approaches to improving testing rates.
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Affiliation(s)
- Michael P Carson
- UMDNJ-Robert Wood Johnson Medical School, Jersey Shore University Medical Center, Department of Medicine, Ackerman 3, 1945 Route 33, Neptune, NJ 07753, United States.
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Smith GN, Pudwell J, Roddy M. The Maternal Health Clinic: A New Window of Opportunity for Early Heart Disease Risk Screening and Intervention for Women with Pregnancy Complications. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2013; 35:831-839. [DOI: 10.1016/s1701-2163(15)30841-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Predictors of postpartum glucose tolerance testing in italian women with gestational diabetes mellitus. ISRN ENDOCRINOLOGY 2013; 2013:182505. [PMID: 23956870 PMCID: PMC3730210 DOI: 10.1155/2013/182505] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 06/30/2013] [Indexed: 01/19/2023]
Abstract
Postpartum screening is critical for early identification of type 2 diabetes in women previously diagnosed with gestational diabetes mellitus (GDM). Nevertheless, its rate remains disappointingly low. Thus, we plan to examine the rate of postpartum glucose tolerance test (ppOGTT) for Italian women with GDM, before and after counseling, and identify demographic, clinical, and/or biochemical predictors of adherence. With these aims, we retrospectively enrolled 1159 women with GDM, in Calabria, Southern Italy, between 2004 and 2011. During the last year, verbal and written counseling on the importance of followup was introduced. Data were analyzed by multiple regression analysis. A significant increase of the return rate was observed following introduction of the counseling [adjusted odds ratio (AOR) 5.17 (95% CI, 3.83–6.97), P < 0.001]. Interestingly, previous diagnosis of polycystic ovary syndrome (PCOS) emerged as the major predictor of postpartum followup [AOR 5.27 (95% CI, 3.51–8.70), P < 0.001], even after stratification for the absence of counseling. Previous diagnosis of GDM, higher educational status, and insulin treatment were also relevant predictors. Overall, our data indicate that counseling intervention is effective, even if many women fail to return, whereas PCOS represents a new strong predictor of adherence to postpartum testing.
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Ko JY, Dietz PM, Conrey EJ, Rodgers LE, Shellhaas C, Farr SL, Robbins CL. Strategies associated with higher postpartum glucose tolerance screening rates for gestational diabetes mellitus patients. J Womens Health (Larchmt) 2013; 22:681-6. [PMID: 23789581 DOI: 10.1089/jwh.2012.4092] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Most women with histories of gestational diabetes mellitus do not receive a postpartum screening test for type 2 diabetes, even though they are at increased risk. The objective of this study was to identify factors associated with high rates of postpartum glucose screening. METHODS This cross-sectional analysis assessed characteristics associated with postpartum diabetes screening for patients with gestational diabetes mellitus (GDM)-affected pregnancies self-reported by randomly sampled licensed obstetricians/gynecologists (OBs/GYNs) in Ohio in 2010. RESULTS Responses were received from 306 OBs/GYNs (56.5% response rate), among whom 69.9% reported frequently (always/most of the time) screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Compared to infrequent screeners, OBs/GYNs who frequently screen for postpartum glucose tolerance were statistically (p<0.05) more likely to have a clinical protocol addressing postpartum testing (67.2% vs. 26.7%), an electronic reminder system for providers (10.8% vs. 2.2%) and provide reminders to patients (16.4% vs. 4.4%). Frequent screeners were more likely to use recommended fasting blood glucose or 2-hour oral glucose tolerance test (61.8% vs. 34.6%, p<0.001) than infrequent screeners. CONCLUSIONS Strategies associated with higher postpartum glucose screening for GDM patients included clinical protocols for postpartum testing, electronic medical records to alert providers of the need for testing, and reminders to patients.
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Affiliation(s)
- Jean Y Ko
- Epidemic Intelligence Service, Scientific Education, and Professional Development Program Office, Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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Carson MP, Lewis BG, Pagan ER, Evers M. Evaluation of home testing to improve follow up after gestational diabetes (Fingerstick Assessments of Sugar Two-months postpartum or FAST). Obstet Med 2013; 6:120-124. [PMID: 27708703 DOI: 10.1177/1753495x13479346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Historically the rates of postpartum glucose tolerance testing for women with gestational diabetes (GDM) average a suboptimal 33%. Barriers include the need for new mothers to miss work and/or arrange for childcare in order to engage in a two-hour test at a commercial lab. This pilot study was initiated to test the theory that a home testing regimen would be accepted by patients and increase the rate of postpartum glucose assessments relative to published rates, without requiring additional health-care staff or resources to achieve this goal. STUDY DESIGN Six weeks postpartum, women with GDM from an academic private practice were asked to check fingerstick blood glucose (FAST Protocol) four times a day for two days, and then obtain an oral glucose tolerance test (OGTT). The physician consultants saw the women each month during pregnancy and arranged the postpartum testing. RESULTS Two of 69 refused to be consented. Twelve of the remaining 67(18%) women completed both the FAST regimen and the OGTT, three completed only the OGTT and five completed only the FAST regimen for a final follow-up rate of 20/67 (30%). The demands of caring for a newborn, or the annoyance of fingersticks, were barriers to compliance. CONCLUSIONS In spite of intense physician involvement, this home testing regimen was not associated with an increase in the rates of women participating in postpartum glucose assessments.
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Affiliation(s)
- Michael P Carson
- Jersey Shore University Medical Center, Neptune; UMDNJ - Robert Wood Johnson Medical School, Piscataway
| | - Beth G Lewis
- Saint Peter's University Hospital; Drexel University College of Medicine, New Brunswick, NJ
| | | | - Martin Evers
- Medical Director Bon Secours Charity Medical Group, Bon Secours Community Hospital , Port Jervis, NY, USA
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Heatley E, Middleton P, Hague W, Crowther C. The DIAMIND study: postpartum SMS reminders to women who have had gestational diabetes mellitus to test for type 2 diabetes: a randomised controlled trial - study protocol. BMC Pregnancy Childbirth 2013; 13:92. [PMID: 23587090 PMCID: PMC3626874 DOI: 10.1186/1471-2393-13-92] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 04/08/2013] [Indexed: 12/11/2022] Open
Abstract
Background Postpartum follow up of women who have been found to have gestational diabetes during pregnancy is essential because of the strong association of gestational diabetes with subsequent type 2 diabetes. Postal reminders have been shown to increase significantly attendance for oral glucose tolerance testing postpartum. It is possible that a short message service (text) reminder system may also be effective. This trial aims to assess whether a text message reminder system for women who have experienced gestational diabetes in their index pregnancy will increase attendance for oral glucose tolerance testing within six months after birth. Methods/Design Design: Single centre (Women’s and Children’s Hospital, South Australia), parallel group randomised controlled trial. Inclusion criteria: Women diagnosed with gestational diabetes in their index pregnancy (oral glucose tolerance test with fasting glucose ≥ 5.5 mmol/L and/or two hour glucose ≥ 7.8 mmol/L), with access to a mobile phone, whose capillary blood glucose profile measurements prior to postnatal discharge are all normal (fasting glucose < 6.0 mmol/L, postprandial glucoses < 8.0 mmol/L). Exclusion criteria: Pregestational diabetes mellitus, triplet/higher order multiple birth or stillbirth in the index pregnancy, requirement for interpreter. Trial entry and randomisation: Allocation to intervention will be undertaken using a telephone randomisation service (computer-generated random number sequence generation, with balanced variable blocks, and stratification by insulin requirement). Study groups: Women in the intervention group will receive a text reminder to attend for an oral glucose tolerance test at 6 weeks postpartum, with further reminders at 3 months and 6 months if they do not respond to indicate test completion. Women in the control group will receive a single text message reminder at 6 months postpartum. Blinding: Baseline data collection will be undertaken blinded. Blinding of participants and blinded collection of primary outcome data will not be possible for this study. Primary study outcome: Attendance for the oral glucose tolerance test within 6 months postpartum. Sample size: 276 subjects will be required to show an 18% absolute increase in the rate of attendance (α=0.05 two tailed, β=80%, 5% loss to follow up) from 37% to 55% in the intervention group. Discussion Given the heightened risk of impaired glucose tolerance and type 2 diabetes in women who have had gestational diabetes, ensuring the highest possible rate of attendance for postpartum glucose tolerance testing, so that early diagnosis and intervention can occur, is important. A text message reminder system may prove to be an effective method for achieving improved attendance for such testing. This randomised controlled trial will assess whether such a system will increase rates of attendance for postpartum oral glucose tolerance testing in women who have experienced gestational diabetes. Trial Registration Australian New Zealand Clinical Trials Registry - ACTRN12612000621819
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Affiliation(s)
- Emer Heatley
- Australian Research Centre for Health of Women and Babies, Robinson Institute, The University of Adelaide, 72 King William Road North, Adelaide, SA 5006, Australia.
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Austad B, Hetlevik I, Bugten V, Wennberg S, Olsen AH, Helvik AS. Implementing guidelines for follow-up after surgery with ventilation tube in the tympanic membrane in Norway: a retrospective study. BMC EAR, NOSE, AND THROAT DISORDERS 2013; 13:2. [PMID: 23295016 PMCID: PMC3585735 DOI: 10.1186/1472-6815-13-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 01/04/2013] [Indexed: 11/10/2022]
Abstract
Background When clinical guidelines are being changed a strategy is required for implementation. St. Olavs University Hospital in Norway modified their guidelines for the follow-up care of children after insertion of ventilation tubes (VT) in the tympanic membrane, transferring the controls of the healthiest children to General Practitioners (GPs). This study evaluates the implementation process in the hospital and in general practice by exploring two issues: 1) Whether the hospital discharged the patients they were supposed to and 2) whether the children consulted a GP for follow-up care. Methods A retrospective observational study was performed at St. Olavs University Hospital, Norway and general practice in Mid-Norway. Children under the age of 18 who underwent insertion of VT between Nov 1st 2007 and Dec 31st 2008 (n = 136) were included. Degree of guideline adherence at the hospital and in general practice was measured. Results The hospital adhered to the guidelines in two-thirds (68.5%) of the patients, planning more patients for follow-up by their GP than recommended in the guidelines (25.8% vs. 12.4%). All except one contacted their GP for control. In total 60% were referred back to specialist health services within two years. Conclusions The methods for guideline implementation were successful in securing consultations for follow-up care in general practice. Lack of guideline adherence in the hospital can partly be explained by the lack of quality of the guideline. Further studies are needed to evaluate the quality of controls done by the GPs in order to consider implications for follow-up after VT surgery.
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Affiliation(s)
- Bjarne Austad
- General Practice Research Unit, Department of Public Health and General Practice, Norwegian University of Science and Technology (NTNU), Trondheim, Norway and Sjøsiden Medical Centre, 7491, Trondheim, Norway.
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Lega IC, McLaughlin H, Coroneos M, Handley-Derry F, Donovan N, Lipscombe LL. A physician reminder to improve postpartum diabetes screening in women with gestational diabetes mellitus. Diabetes Res Clin Pract 2012; 95:352-7. [PMID: 22099149 DOI: 10.1016/j.diabres.2011.10.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 09/29/2011] [Accepted: 10/17/2011] [Indexed: 01/11/2023]
Abstract
AIMS Women with gestational diabetes (GDM) have a 20% risk of developing diabetes in the 10 years following pregnancy, but the risk may be as high as 70% in higher risk populations. Guidelines recommend screening for diabetes postpartum, but screening rates are low. We evaluated the effect of a physician reminder on postpartum screening and in women with GDM. METHODS We conducted a retrospective chart review among women with GDM seen at our urban, academic endocrine clinic in Toronto, Canada between 2006 and 2010. Our primary outcome was to evaluate the effect of a reminder checklist on postpartum diabetes screening rates. RESULTS We included 314 women in our study, 173 had a checklist on their chart. Women had a mean age of 34.9 years, 45% were Caucasian and 23% had a previous GDM. The checklist was associated with a 3 fold increase in odds of being screened postpartum, and nearly 4 fold increase in postpartum follow up visits (OR 2.99, 95% CI 1.84-4.85 and OR 3.71, 95% CI 2.26-6.11). CONCLUSION A physician based reminder system is an effective way to improve postpartum screening rates. To further increase screening rates, a multilevel approach targeting both patients and physicians is required.
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Affiliation(s)
- Iliana C Lega
- Women's College Hospital, Women's College Research Institute, Toronto, Ontario, Canada.
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Clark HD, Keely E. Getting mothers with gestational diabetes to return for postpartum testing: what works and what does not. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/dmt.11.64] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Korpi-Hyövälti E, Laaksonen DE, Schwab U, Heinonen S, Niskanen L. How can we increase postpartum glucose screening in women at high risk for gestational diabetes mellitus? Int J Endocrinol 2012; 2012:519267. [PMID: 22536233 PMCID: PMC3320005 DOI: 10.1155/2012/519267] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 01/14/2012] [Accepted: 01/17/2012] [Indexed: 01/21/2023] Open
Abstract
Women with a history of gestational diabetes mellitus (GDM) are at increased risk for diabetes mellitus but postpartum followup is problematic for frequent nonattendance. Our aim was to increase coverage of postpartum oral glucose tolerance tests (ppOGTTs) and examine associated factors. This was a prospective observational study of altogether 266 high-risk women for GDM from 2005 to 2008 in four Finnish municipalities. The groups were as follows: women (n = 54) who had previously participated in early pregnancy lifestyle intervention study and high-risk women (n = 102) from the same municipalities studied within one-year after delivery. Furthermore, in two neighboring municipalities nurses were reminded to perform a ppOGTT on high-risk women (n = 110). The primary outcome was the prevalence of ppOGTT performed and associated factors. Overall the ppOGTT was performed in 35.7% of women. Only 14.7% of women returned for testing to health care centers, 30.9% after a reminder in municipalities, and 82.5% to the central hospital, respectively. The most important explaining factor was a special call or reminder from the central hospital (OR 13.4 (4.6-38.1), P < 0.001). Thus, additional reminders improved communication between primary care and secondary care and more attention to postpartum oral glucose testing in primary care are of great importance.
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Affiliation(s)
- Eeva Korpi-Hyövälti
- Department of Internal Medicine, Seinäjoki Central Hospital, 60220 Seinäjoki, Finland
- *Eeva Korpi-Hyövälti:
| | - David E. Laaksonen
- Physiology Department, Institute of Biomedicine, University of Eastern Finland, Kuopio Campus, 70211 Kuopio, Finland
- Institute of Clinical Medicine, Internal Medicine, Kuopio University Hospital, 70211 Kuopio, Finland
| | - Ursula Schwab
- Institute of Clinical Medicine, Internal Medicine, Kuopio University Hospital, 70211 Kuopio, Finland
- Department of Clinical Nutrition, Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio Campus, 70211 Kuopio, Finland
| | - Seppo Heinonen
- Department of Obstetrics and Gynecology, Kuopio University Hospital, 70211 Kuopio, Finland
| | - Leo Niskanen
- Department of Internal Medicine, Central Finland Hospital District, 40620 Jyväskylä, Finland
- Faculty of Health Sciences, University of Eastern Finland, Kuopio Campus, 70211 Kuopio, Finland
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