Elsevier

Primary Care Diabetes

Volume 7, Issue 3, October 2013, Pages 177-186
Primary Care Diabetes

Review
Original research: Postpartum testing rates among women with a history of gestational diabetes—Systematic review

https://doi.org/10.1016/j.pcd.2013.04.007Get rights and content

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.

Introduction

Women who develop gestational diabetes mellitus (GDM) during their pregnancy have a higher risk of developing overt diabetes mellitus and dysglycemia (impaired fasting glucose, impaired glucose tolerance, or prediabetes) later in life, compared to women without GDM. The prevalence of GDM increased from 2 to 4% in the United States, from 2.9% to 8.8% in Australia, and the number of pregnancies complicated by preexisting diabetes mellitus doubled from 10 to 21% [1], [2], [3]. Obesity, an obvious risk factor for diabetes mellitus and GDM, is also increasing [4]. Because the at-risk population is growing, and postpartum testing of women with GDM will identify the 20–30% with persistent dysglycemia, it is important that an efficient system be in place to identify women with early diabetes mellitus or pre-diabetes for whom evidence based interventions exist [5].

Reported rates of women who follow through with the recommended postpartum testing range from 9 to 95% [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50]. A recent review summarized studies between 2008 and 2010 and, like similar reports, lists conflicting findings regarding the association between specific patient demographics and testing rates, such as Hispanic women being tested 2% more or 10% less than White women [22], [27], [51]. However, because the differences associated with individual demographics are modest, it seems possible that the large variation in screening rates is due to differences in health care delivery that affected the entire population within individual study cohorts. Understanding these differences can help providers design quality improvement initiatives.

This systematic review regarding postpartum testing for women with GDM was designed to determine if factors such as the use of systematic protocols within care systems could explain the variation reported between studies. The specific aim was to identify approaches associated with higher testing rates that could be incorporated into practice models and care-systems.

Section snippets

Search strategy

We referenced the AMSTAR framework and the PRISMA Statement (www.prisma-statement.org) to construct the search and develop the Flowchart (Fig. 1) [52], [53]. We searched major electronic databases: PUBMED (1902 through 2012 Week 29), OVID (1950–2012 Week 29), EMBASE (1947–2012 Week 29), and the Cochrane Database of systematic reviews to identify literature reporting rates of postpartum testing among women with GDM. The search included MeSH terms related to GDM and postpartum screening or

Characteristics of the studies reviewed

Of 307 abstracts reviewed 54 articles met the inclusion criteria and were organized into three groups: 25 reported Usual Care follow-up rates based on retrospective cohort/database reviews, or prospective data collected without (a) allocation of additional staff/resources or (b) systematic changes to the way caregivers practiced. When a proactive system or process was developed to improve follow-up rates, we classified them as Active Care, and 22 articles reported such data. The final group was

Discussion

Organizing this review in terms of Usual vs. Active Care, and the timeframes of the testing, permits the following conclusions: The primary factor associated with higher rates was implementation of an active system-based program designed to improve the postpartum testing rate after the authors observed low rates in a retrospective review, typically allocation of a nurse manager to contact patients. While this might appear to be self evident, to our knowledge this is the first review to

Conflict of interest statement

The authors have no financial or personal relationships with organizations that could bias this work. No funding was provided.

Acknowledgement

MP and MF had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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