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Article 1: A physician reminder to improve postpartum diabetes screening in women with gestational
diabetes mellitus
- Lega, Mclaughlin, Coroneos, Handley-Derry, Donovan, & Lipscombe. (2012). A physician
reminder to improve postpartum diabetes screening in women with gestational diabetes mellitus.
- http://www.sciencedirect.com/science/article/pii/S0168822711005663
Method
The hypothesis of this article is that a reminder system in a context where prenatal and
postpartum care is provided by the same team of physicians, would improve postpartum screening rates.
The main study population of this study are women with GDM seen at the academic endocrine clinic in
Toronto, Canada between 2006 and 2010 with a sample size of 314 women. The statistical power seen
through this study was a with a 3 fold increase in odds of being screened postpartum, and nearly 4 fold
increase in postpartum follow up visits when assigning checklist to each participant.
Assignment
The process of this assignment is on the basis of conducting and following a retrospective chart
review of women at an endocrine center during pregnancy; where they are attended to regularly for
diabetes management. Postpartum, there was implementation of a physician follow-up system where
physicians were asked to chart specific guidelines and values regarding the mothers. The main process of
this assignment is to improve postpartum diabetes screening rates using a physician-targeted reminder
system. This study is done through a pre-test post-test manner where participants are evaluated before and
after the reminder system is implemented with physicians. Some confounding factors that play a role in
this assignment would be that sometimes the role of the physician in providing that physician-patient
relationship varied because of the individuals contributed. Some mothers were charted (144) while some
mothers were uncharted (173). Some masking effects of this assignment would be identifying the actual
problem and addressing a change in system in response. The primary care and support for the
consideration of gestation diabetes in expectant mothers, before and after the birth, is blurred between the
endocrinologist and physician. Usually what is seen is that during the pregnancy, the mother will be
follow-up by a specialist or endocrinologist but after pregnancy, the mothers are to return back to the
physician.
Assessment
The appropriateness of the assessment was valid and consistent for the study. There was
elimination of women who had previous history of diabetes or had impaired glucose tolerance.
Participants of this study were seen regularly during pregnancy and were offered postpartum visits to
review their diabetes screening results between six weeks and six months postpartum. The precision of
this assessment is seen in the detailed requirements asked of the physicians in this study to evaluate,
including the following: postpartum OGTT requisition given to patient, postpartum appointment made,
postpartum package given (providing information on diabetes screening, risk, and prevention), and labour
and delivery orders written. The measurement during this study was seen in the various charts that were
conducted for each participant. There were charts that were completed by the endocrinologist or specialist
during pregnancy and then charts that were completed after pregnancy by the physician. Data was
recorded by the physician at least 6 months after postpartum and included age, ethnicity, parity, obstetric
history, smoking, number of clinics attended, family history of type 2 diabetes or GDM, personal medical
history, and pregnancy weight gain was collected from each participant. All of the items mentioned were
to be completed within 36 weeks of postpartum. Furthermore, a multivariate logistic regression analyses,
using both unadjusted and adjusted models were used to decipher participants with and without a
checklist. OGTT was completed more frequently (62% vs 36%) in participants that had a checklist and
were more likely to attend follow-up visits with physician (58% vs 30%).
Results
When reviewing the results, participants that had a checklist had a “three-fold increase in odds of
postpartum diabetes testing and a close to four-fold increase in odds of follow-up appointments, even
after adjusting for maternal age, insulin use, weight gain in pregnancy, and number of prenatal clinic
visits.” 1 What is ultimately inferred from these findings is that participants that had a checklist were more
likely to be successful in following up with appointments and necessary blood glucose testing, after
pregnancy. The adjustments made per group went into consideration of whether or not they had a
checklist, if they had previous history of diabetes and if they were impaired glucose tolerance.
Interpretation. The outcomes affect participants in this study by following a close supervision and
monitoring of blood glucose values in each participant after pregnancy. Careful monitoring of these
values can suggest better control and outcomes of blood glucose values after gestational diabetes
diagnosis; lowering the incidence of glucose abnormalities and improving screening rates. In terms of
effectiveness, it was concluded that the reminder system implemented in this study is an easy and
effective way to overcome some of the barriers that limit postpartum diabetes screening rates. There may
be harms proposed in multiple healthcare providers to each individuals and the different techniques used
to assess and review the participant’s blood glucose history and prognosis. The interactions seen in this
study are primarily noted between the participant and the healthcare team that contribute to the care and
monitoring of the gestational diabetes prognosis during pregnancy and at least 6 weeks after pregnancy.
Extrapolation
What these findings ultimately mean for the general population is that when a checklist or a
reminder system is implemented for postpartum GDM mothers, there is an increase in blood glucose
monitoring, follow-ups and surveillance of blood glucose management and care of these mothers. Outside
of this study, it is usually noted that after birth for mothers who were classified as GDM, the change in
role from the endocrinologist or specialist to the physician did not yield good follow-up rates for the
participants. This change in primary care provider for the GDM prognosis has played a significant role in
the screening rates and follow-up visits of each participant after pregnancy.2,3,4.5
Article 2: Dietetic practice in the management of gestational diabetes mellitus: A survey of Australian
dietitians.
- Morrison, M., Collins, C., & Lowe, J. (2011). Dietetic practice in the management of gestational
diabetes mellitus: A survey of Australian dietitians. Nutrition & Dietetics, 68(3), 189-194.
- http://onlinelibrary.wiley.com.libproxy.csun.edu/doi/10.1111/j.1747-0080.2011.01537.x/full
Method
The hypothesis of this article is that there is a difference between current Australian dietetic
practice in the management of gestational diabetes and the national evidence-based dietetic practice
guidelines for gestational diabetes. The study population was focused on Australian dietitians practicing
in the area of gestational diabetes who were recruited through the dietitians association of Australia.
About 3295 electronic surveys were emailed out and 295 written invitation were mailed out; 220 eligible
dietitians participated in the survey. The statistical power could be the lack of responsiveness from the
total emails and letters mailed out compared to the total responses. Of the total 220 responses, 77% said
that their services for GDM were based upon references to a dietitian, 54% felt they met adequate services
to their patients, and 8% had a follow-up visit post-pregnancy. What was the most significant was that
86% of the participants said they felt there was a need for GDM dietetic practice guidelines and 87%
Assignment
The appropriateness in this study was noted in the elevated rates of prognosis of expecting
mothers. In Australia, 5% of pregnancies are GDM and 14% are placed in a high-risk category, suffer
from adverse effects after pregnancy such as type 2 diabetes and perinatal risks.6,7 The precision of this
assignment is seen in the complete and concise answers provided from the surveys. There was fault in
precision when assessing the open-ended questions that provided an array of responses. The measurement
of this assignment was executed as a cross-sectional survey between March and June of 2009. The
surveys were reviewed once completed and reviewed in its entirety for answers recorded on the multiple
choice section and the open-ended responses that allowed for thoughts, opinions and feedback form each
of the 220 dietitians that participated. The observational effect of the outcomes was that despite having
reached out to several services, only an estimated 6% of the individuals reached out to, responded. What
was consistently noted from the 220 responses was that majority of the dietitians (87%) were working
within a multidisciplinary service and could be classified as diabetes educator (92%), endocrinologist/
Assessment
With the motive of evaluating the dietitian's practices with a rise in GDM prognosis in Australia,
the appropriateness of this cross-sectional study is supported by the conclusive evidence that surfaced and
new knowledge that has been provided from the 220 participants. When taking a look at the precision of
this study, the assessment of each multiple choice answer was precise because there was no other options
made available for participants outside of the ones made available for them. Precision of each assessment
becomes confusing when reviewed the open-ended questions proposed because each participant yields
their own unique thoughts and opinions that can make it challenging to categorize into precise responses
or categories. Completion of the online survey or return of the paper questionnaire was considered
implied consent from each participant. These participants were from states all around Australia, further
hindering precision. Measurement of each assessment was reviewed in order of the questions proposed in
the survey which were as follows, “multiple-choice, open-ended questions or used Likert scale responses
to report demographics (12 questions), GDM service provision (12 questions), dietetic assessment and
interventions (11 questions), screening and management guidelines (5 questions), postnatal management
practices (8 questions), as well as information on current guideline use and perceived need for Australian
evidence-based guidelines.” 9 The observational effect of outcomes for the assessment in this study was
seen through the honest responses that these dietitians completed the survey with. Dietitians who
responded yielded a variety of positions such as full-time, DAA membership and DAA interest groups
and were from states representing NSW, VIC and QLD responded; allowing an array of opinions from
Australian states.
Results
Estimation during this study was precise and uniform,with little ambiguity with the multiple
choice responses and higher variability in the open-ended responses. On the end of the observers, there
was a high amount of estimation needed when categorizes the written responses from each participant.
The inference from this study is that while 54% of participants expressed their services to the GDM
patients being adequate, 86-87% of participants also felt a strong need for GDM dietetic guidelines and
nutrition recommendations. “When asked to describe their level of confidence in GDM management, 33%
were very confident, 50% confident, 16% somewhat confident and 1% not confident.9 ” While the goal of
this study to to further understand the role of a dietitian in GDM prognosis and management, what is
noted in this study is that there are a variety of dietitians that feel on different scales on confidents. With
that in mind, the observer should take into consideration this variability between participants and the
Interpretation
What is included in this study is that there are differences in the implementation of MNT
practices and guidelines for GDM management. Two-thirds of participants reported that only one to two
consults per client were provided per week, a value lower than what is recommended in ADA guidelines
(which recommends a minimum of 3 consultations). Additionality, less than half of the participants were
able to provide a consultation within a week’s time, also a standard recommendation in the ADA
guidelines. The efficacy of this study is addressed in gaining a better understanding a dietitian’s role in
GDM. The main difference noted through this study is that there are inconsistencies with the guidelines
that are currently available and the practices that are currently being executed by dietitians. The absence
of specific guidelines hinders efficacy in glycemic control, clinical judgement, staffing levels, specific
issues related to literacy, language spoken and health care services.9 The survey concluded a variability in
reported glycemic targets, as noted in the efficacy section. This places the patients and participants of this
study in a varied range of harm, as some are receiving care and services that might be missed by another.
The interactions of this study are seen in the role of the dietitian with GDM and GDM management for
each patient; providing greater emphasis in nutrition education, consultation and meeting ADA
guidelines.
Extrapolation
From this survey, it could be said that future patients of these registered dietitians will be
receiving services that range in terms of MNT confidence, assessing glycemic values and overall success.
What can be drawn from this study is that there is a demand for specific guidelines for proper gestational
diabetes care. It is suggested by the majority of the 220 participants that these guidelines should be met by
the national DAA endorsed dietetic practice guidelines and nutrition. The services that will be provided to
future patients depend on the MNT quality and personal efforts exerted by the RD. While there has been
limited research for dietetic interventions specific for patients diagnosed with gestational diabetes, there
have been larger prevention trials that confirm benefits for the patient’s lifestyle and wellbeing.11 There
have also been other studies that have suggest the need for additional resources in addressing gestational
diabetes and a guideline for proper management.12 The previous studies mentioned are similar to this
study in the sense of addressing an absence in quality and efficiency for GDM management and care.
Rather than having studies that have shown similarities, the studies mentioned previously further validate
the need for more investigation of the implementation of specific guidelines for GDM nutrition
management. This relates to our research in allowing further insight into the role of the RD with GDM
care, considering areas needing improvement and areas that favor the role over the primary physician.
Citations
1. Lega, Mclaughlin, Coroneos, Handley-Derry, Donovan, & Lipscombe. (2012). A physician
reminder to improve postpartum diabetes screening in women with gestational diabetes mellitus.
Diabetes Research and Clinical Practice, 95(3), 352-357.
2. M.A. Russell, M.G. Phipps, C.L. Olson, H.G. Welch, M.W. (2006) Carpenter Rates of
postpartum glucose testing after gestational diabetes mellitus. Obstet Gynecol, 108, pp.
1456-1462
3. C. Kim, B.P. Tabaei, R. Burke, L.N. McEwen, R.W. Lash, S.L. Johnson, et al. (2006) Missed
opportunities for type 2 diabetes mellitus screening among women with a history of gestational
diabetes mellitus. Am J Public Health, 96 , pp. 1643-1648
4. L.R. Greenberg, T.R. Moore, H. Murphy. (1995) Gestational diabetes mellitus: antenatal
variables as predictors of postpartum glucose intolerance. Obstet Gynecol, 86, pp. 97-101
5. K.J. Hunt, S.L. Logan, D.L. Conway, J.E. Korte (2010). Postpartum screening following GDM:
how well are we doing? Curr Diab Rep, 10, pp. 235-241
6. Templeton M, Pieris-Caldwell I. Gestational Diabetes Mellitus in Australia, 2008. Canberra:
Australian Institute of Health and Welfare.
7. Anderson K, Barbeau M-C, Blagrave P et al. (2006) Recommendations for nutrition best practice
in the management of gestational diabetes mellitus. Can J Diet Pract Res, 67: 206–8.
8. Weintrob N, Karp M, Hod M. (1996) Short- and long-range complications in offspring of diabetic
mothers. J Diabetes Complications. 10: 294–301.
9. Morrison, M., Collins, C., & Lowe, J. (2011). Dietetic practice in the management of gestational
diabetes mellitus: A survey of Australian dietitians. Nutrition & Dietetics, 68(3), 189-194.
10. Reader D, Splett P, Gunderson EP. (2006) For the Diabetes Care and Education Dietetic Practice
Group. Impact of gestational diabetes mellitus nutrition practice guidelines implemented by
registered dietitians on pregnancy outcomes. J Am Diet Assoc, 106: 1426–33.
11. The Diabetes Prevention Program Research Group (2002). Reduction in the incidence of type 2
diabetes with lifestyle intervention or metformin. N Engl J Med, 346: 393–403.
12. Hoffman L, Nolan C, Wilson JD, Oats JN, Simmons D. (1998). Gestational diabetes
mellitus—management guidelines. Med J Aust, 169: 93–7.