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Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial.


Heather D. Clark, MD, MSc; Ian D. Graham, PhD; Alan Karovitch, MD, MEd; Erin J. Keely, MD. American Journal of Obstetrics & Gynecology, June 2009 

OBJECTIVE: Women with previous gestational diabetes mellitus rarely receive the recommended 2-hour oral glucose tolerance test (OGTT) after delivery. We sought to determine whether postal reminders to be sent after delivery to a patient, her physician, or both would increase screening rates.
STUDY DESIGN: Patients were assigned randomly to 4 groups: reminders sent to both physician and patient, to physician but not patient, or to patient but not physician or no reminders were sent. The primary outcome was the proportion of patients who underwent an OGTT within 1 year after delivery. The secondary outcome was the performance of other postpartum screening tests.
RESULTS: OGTT rates were significantly increased in the physician/patient reminder group (49/81 women; 60.5%), in the patient-only reminder group (42/76 women; 55.3%), and in the physician-only reminder group (16/31 women; 51.6%) compared with the no reminder group (5/35 women; 14.3%; P.05).
CONCLUSION: Postpartum reminders greatly increased screening rates for women with gestational diabetes mellitus.

 

Gestational Diabetes Mellitus and Postpartum Care Practices of Nurse-Midwives.


Jean Y. Ko, PhD, Patricia M. Dietz, DrPH, Elizabeth J. Conrey, RD, PhD, Loren Rodgers, PhD, Cynthia Shellhaas, MD, MPH, Sherry L. Farr, PhD, Cheryl L. Robbins.

Journal of Midwifery & Women’s Health, 
Introduction: Postpartum screening for glucose intolerance among women with recent histories of gestational diabetes mellitus (GDM) is important for identifying women with continued glucose intolerance after birth, yet screening rates are suboptimal. In a thorough review of the literature, we found no studies of screening practices among certified nurse-midwives (CNMs). The objectives of our study were to estimate the prevalence of postpartum screening for abnormal glucose tolerance and related care by CNMs for women with recent histories of GDM and to identify strategies for improvement.
Methods: From October through December 2010, the Ohio Department of Health sent a survey by mail and Internet to all licensed CNMs practicing in Ohio. We calculated prevalence estimates for knowledge, attitudes, clinical practices, and behaviors related to postpartum diabetes screening. Chi-square statistics were used to assess differences in self-reported clinical behaviors by frequency of postpartum screening.
Results: Of the 146 CNMs who provided postpartum care and responded to the survey (62.2% response rate), 50.4% reported screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Of CNMs who screened postpartum, only 48.4% used fasting blood sugar or the 2-hour oral glucose tolerance test. Although 86.2% of all responding CNMs reported that they inform women with recent histories of GDM of their increased risk for type 2 diabetes mellitus, only 63.1% counseled these women to exercise regularly and 23.3% reported referring overweight/obese women to a diet support group or other nutrition counseling. CNMs reported that identification of community resources for lifestyle interventions and additional training in postpartum screening guidelines may help to improve postpartum care.
Discussion: CNMs in Ohio reported suboptimal levels of postpartum diabetes testing and use of a recommended postpartum test. Providing CNMs with additional training and identifying community resources to support needed lifestyle behavior change may improve care for women with recent GDM-affected pregnancies

A system-based intervention to improve postpartum diabetes screening among women with gestational diabetes.
Kimberly K. Vesco, MD, MPH; Patricia M. Dietz, DrPH, MPH; Joanna Bulkley, PhD; F. Carol Bruce, BSN, MPH; William M. Callaghan, MD, MPH; Lucinda England, MD, MSPH; Terry Kimes, MS; Donald J. Bachman, MS; Karen J. Hartinger, RN; Mark C. Hornbrook, PhD.

OBJECTIVE: We sought to determine whether our process improvement program led to increased postpartum diabetes screening rates among women with gestational diabetes mellitus (GDM).
STUDY DESIGN: In early 2009, we conducted obstetrics department staff education sessions, revised GDM patient care protocols, and developed an electronic system to trigger reminder calls to patients who had not completed diabetes mellitus screening by 3 months postpartum. We then evaluated the rates of postpartum glucose test order entry and completion for women with GDM delivering from July 2009 through June 2010 (n 179) and July 2007 through June 2008 (n 200).
RESULTS: After the program’s implementation, the proportion of women receiving an order for a postpartum glucose test within 3 months of delivery increased from 77.5-88.8% (P .004), and test completion increased from 59.5-71.5% (hazard ratio, 1.37; 95% confidence interval, 1.07–1.75).
CONCLUSION: Rates of postpartum diabetes testing can be improved with system changes and reminders.
Am J Obstet Gynecol 2012;207:283.e1-6.

The effectiveness of implementing a reminder system into routine clinical practice: does it increase postpartum screening in women with gestational diabetes?
A.K. Shea, PhD, MSc; B.R. Shah, MD, PhD; H.D. Clark, MD, MSc; J. Malcolm, MD; M. Walker, MD, MSc; A. Karovitch, MD, MEd; E.J. Keely, MD                                                        Vol 31, No 2, March 2011 – Chronic Diseases in Canada
Introduction: During regular care, women with previous gestational diabetes mellitus (GDM) rarely receive the recommended screening test for type 2 diabetes, a 2-hour oral glucose tolerance test (OGTT), in the postpartum period. The current study examined whether the implementation of a reminder system improved screening rates.
Methods: Based on our previous randomized control trial, we implemented a postpartum reminder (letter or phone call) protocol into routine care at two of three clinical sites. We verified postpartum testing by searching hospital laboratory databases and by linking to the provincial physician service claims database. The primary outcome was the proportion of patients who underwent an OGTT within 6 months of delivery.
Results: Women who received care in a setting using a reminder system were more likely to receive an OGTT within 6 months postpartum (28%) compared with usual care (14%). The OGTT rates for both reminder groups were lower than that found in our randomized control trial (28% vs. 60%).
Conclusion: Although the screening rates remain low, postpartum reminders doubled screening rates using the recommended test, the OGT.
Patient counseling increases postpartum follow-up in women with gestational diabetes mellitus.
Marina Stasenko, BA; Jennifer Liddell, RN, CDE; Yvonne W. Cheng, MD, MPH; Teresa N. Sparks, MD; Molly Killion, RN; Aaron B. Caughey, MD, PhD                                                                                                                                                                                         American Journal of Obstetrics & Gynecology JUNE 2011
OBJECTIVE: The objective of the study was to evaluate the efficacy of an educational intervention at increasing the rates of postpartum (PP) follow-up for women with gestational diabetes mellitus (GDM).
STUDY DESIGN: A retrospective cohort study of all patients with GDM delivering during 2002-2009 was conducted. The primary outcome was obtaining PP  diabetes testing. The 2002-2006 cohort was advised to obtain PP testing by their providers. The 2007-2009 cohort received educational counseling at the 37-38 week visit by a nurse educator. Univariate and multivariable statistical tests were utilized.
RESULTS: The PP testing frequency was 53% for the 2007-2009 cohort, compared with 33% for the 2002-2006 cohort (P!.001). When stratified by race/ethnicity, increased rates of testing were seen in whites (28% to 53%, P ! .001), Latinas (15% to 50%, P! .001), and Asians (43% to 59%, P " .005). There was a nonsignificant decrease in the African American follow-up, 28% to 17% (P " .414).
CONCLUSION: GDM precedes the development of type 2 diabetes. Antepartum education counseling increases postpartum diabetes testing. More efforts are needed to obtain universal screening.
Physician Care Patterns and Adherence to Postpartum Glucose Testing after Gestational Diabetes Mellitus in Oregon.
Monica L. Hunsberger, Rebecca J. Donatelle, Karen Lindsay, Kenneth D. Rosenberg                                                                                                                                 PLoS ONE 7(10): e47052. doi:10.1371/journal.pone.0047052

Objective: This study examines obstetrician/gynecologists and family medicine physicians’ reported care patterns, attitudes and beliefs and predictors of  adherence to postpartum testing in women with a history of gestational diabetes mellitus.
Research Design and Methods: In November–December 2005, a mailed survey went to a random, cross-sectional sample of 683 Oregon licensed physicians in obstetrician/gynecologists and family medicine from a population of 2171.
Results: Routine postpartum glucose tolerance testing by both family physicians (19.3%) and obstetrician/gynecologists physicians (35.3%) was reportedly low among the 285 respondents (42% response rate). Factors associated with high
adherence to postpartum testing included physician stated priority (OR 4.39, 95% CI: 1.69–7.94) and physician beliefs about norms or typical testing practices (OR 3.66, 95% CI: 1.65–11.69). Specialty, sex of physician, years of practice, location, type of practice, other attitudes and beliefs were not associated with postpartum glucose tolerance testing.
Conclusions: Postpartum glucose tolerance testing following a gestational diabetes mellitus pregnancy was not routinely practiced by responders to this survey. Our findings indicate that physician knowledge, attitudes and beliefs may in part explain suboptimal postpartum testing. Although guidelines for postpartum care are established, some physicians do not prioritize these guidelines in practice and do not believe postpartum testing is the norm among their peers.
Window of Opportunity: Postpartum Screening of Women with Gestational Diabetes for Early Detection of Prediabetes and Type 2 Diabetes.
Cassandra E. Henderson, Jan Kavookjian, Harris Leitstein, June M. McKoy, Wambui Jane Murage, and Ruth d. Lipman
The Open Diabetes Journal, 2012, 5, 25-28
Abstract: Gestational diabetes is a condition characterized by glucose intolerance during pregnancy, with defined approaches for screening, treatment, and follow-up. It is associated with a variety of adverse birth outcomes, including excessive fetal weight gain and related increases in the rate of cesarean delivery and perinatal injury as well as increased risk for developing type 2 diabetes for women who have had gestational diabetes. A diagnosis of gestational diabetes may also be a manifestation of pre-existing type 2 diabetes. Nonetheless, a substantial proportion of women with a history of gestational diabetes fail to receive the recommended postpartum glucose screening. This failure to conduct follow-up
screening of women with gestational diabetes after delivery represents a missed opportunity for earlier diagnosis of diabetes, and chance to increase the awareness of women of their future risk for developing diabetes. This paper explores the barriers contributing to the lack in follow-up screening and makes recommendations about addressing these problems.