1. S. Fatemeh Vasegh Rahimparvar Health Systems Approaches to Diabetes Screening and Prevention in Women with a History of Gestational Diabetes

4. 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.

5. Gestational diabetes (GDM) complicates at least 1 in 20 pregnancies in the USA. The risk for persistent abnormalities in glucose tolerance is high; 30 % of women will continue to have abnormal glucose tolerance postpartum, and up to 10 % will be diagnosed with type 2 diabetes mellitus (T2DM) in the immediate postpartum period. In some cohorts, as many as 70 % develop T2DM in the years following a GDM affected pregnancy, most within the first 10 years postpartum. Multiple professional organizations, including the American College of Obstetrics and Gynecology and the American Diabetes Association, have thus emphasized the importance of diabetes screening in women with GDM.

6. Despite provider awareness of GDM as a risk factor, rates of postpartum screening for T2DM are not optimal. Furthermore, the evidence for preventive strategies after women are screened is limited. This gap between clinical recommendations and practice is a problem relevant not just for patients and providers but also for those that bear the health related costs of the growing diabetes burden, and therefore an opportunity for systems-level approaches to target this high risk population. In this article, we will identify opportunities for quality improvement, review the existing literature on health systems interventions to improve diabetes screening and prevention for women with a history of GDM, and identify areas for future research.

7. women treated for GDM are at high risk for type 2 diabetes and should therefore be screened for glucose abnormalities after pregnancy. Because some women with diabetes first identified in pregnancy will in fact have undiagnosed type 2 diabetes,…..screening at 6–12 weeks postpartum with an OGTT, as well as lifelong screening at every 1–3 years depending on risk factors. Despite these recommendations, published rates of postpartum screening for T2DM are low.

8. In a study including 160 women with GDM who delivered and were subsequently cared for within the same system, nearly all had adequate postpartum care (demonstrated by the 94 % rate of cervical cancer screening at a median of 49 days after delivery), but only 37 % received the recommended postpartum OGTT, and only 50 % were screened for diabetes utilizing any test within the first year after delivery. Other groups have demonstrated similarly low rates of screening in the postpartum period, with the most successful reported rates near 60%.

9. These data may overestimate screening in community practice; a recent study of nearly one million pregnant women who had been tested through a private national laboratory identified postpartum glucose screening in only 19 % of women with laboratory evidence of gestational diabetes. There is less known about screening beyond the initial postpartum period. However, a recent systematic review of postpartum testing explicitly highlighted screening rates beyond the 12-week postpartum time frame and found that the average rate of screening 6 months or more after delivery was 34.5 % in usual care. While many women with GDM will likely be screened eventually due to the presence of other diabetes risk factors, the first years following a GDM-affected pregnancy remain a lost window of opportunity.

10. Providers may also need to be targets for intervention. Several groups have found that women with additional risk factors such as age, BMI, ethnicity, and need for insulin during pregnancy are more likely to be screened, suggesting providers target women they can easily identify as at risk for diabetes outside of a reported history of GDM. A survey of providers in an integrated health system found that while most understood that women with GDM were at risk for diabetes and should be screened, obstetric providers deferred screening to primary care providers, who most often did not receive any information about pregnancy complications and therefore were not aware screening was indicated, highlighting lack of communication as a major barrier to improved quality of care.

11. Patient, provider, and systems factors may limit adherence to recommended glucose screening in women with GDM. Women with GDM may not know or believe they are at elevated risk for future T2DM; in a survey of women with a history of GDM, 90 % recognized GDM as a risk factor for T2DM but only 16 % identified themselves to be at elevated risk. Patient-level barriers may include lack of access to care, reflected by the consistent finding that adequacy of prenatal and postnatal care, socioeconomic status, and education are associated with screening rates. Other studies have identified practical individual-level barriers including lack of childcare, the need for fasting, and the time involved in testing.

12. Systems-level interventions to identify and treat women with GDM beyond pregnancy have thus far been limited. Early work out of Kaiser Permanente examined the impact of systems-based algorithms on the rate of postpartum glucose testing. The programs capitalized on nursing staff to coordinate communication between providers and patients. In a retrospective study of screening rates at Kaiser Northwest after system-wide protocol changes that included a designated nurse coordinator who ensured that clinicians had a standing order for postpartum glucose screening, Dietz et al. observed an increase from 15.9 % in 1999 to 79.3 % ordering testing in 2004 (p<0.01).

13. This change in systems also resulted in an increase in patient test completion from 9 % in 1999 to 7.8 % in 2004 (p<0.01). Analogously, Ferrara et al. examined data from Kaiser Northern California and observed an increase in an age- and ethnicity-adjusted proportion of women who received postpartum screening after GDM from 20.7 % in 1995 to 53.8 % in 2006. They attributed this rise to the impact of organization-wide initiation of a nurse managed care program targeting women with a history of GDM. Both successes relied on designated nurses, underscoring the importance of skilled personal contact to facilitate system success. Notably, even with this improvement in infrastructure, roughly 40 % of women in each cohort were still not screened. This observational work spurred interventional trials.

14. Multiple groups have looked prospectively at the potential for clinical quality improvement programs targeting both patients and providers to improve screening rates, with mixed results. Lega and colleagues studied the impact of a checklist that was attached a patient’s chart upon diagnosis of GDM and transfer to an endocrine clinic. The checklist included reminders to give the patient a requisition for a GTT, schedule a postpartum appointment, and give her written educational materials about diabetes. The effects …………………………………………………………………………………….

15. Similarly, a protocol change incorporating intensive face-to- face and written counseling from a certified diabetes educator prior to delivery was associated with increased odds of postpartum follow-up. The effects ……………………………………… Clinical decision support, commonly implemented as reminders or prompts within electronic medical record systems, has been proposed as a potential quality improvement intervention.

16. A passive reminder on EHR may not be sufficient to spur clinical action. Clinicians may agree that additional reminders on the EHR front page come across as visual noise and do not effect a meaningful pause in workflow. However, when integrated with direct patient contact, HER based reminders did seem to have an impact. Future studies focused on the effective utilization of EHR-based interventions may need to explore not just provider prompts but also patient-facing technologies, such as smartphone apps that allow patients to view and interact with their own medical records. Indeed, patient-directed access to their own health information and ability to communicate with their health team have been identified as a critical component of meaningful use of the electronic health record being implemented nationwide. The nearly ubiquitous use of mobile technology and explosion of access across socioeconomic strata offer a promising platform for engaging the patient in decisions and action.

17. The goal of screening is to identify women who benefit most from intervention; one could argue that in fact all women with GDM are at high risk for diabetes and therefore should be eligible for interventions to reduce the risk of type 2 diabetes. The Diabetes Prevention Program established the potential for intensive lifestyle modification to delay or prevent progression to type 2 diabetes in adults at risk. A secondary analysis of the 350 subjects with a history of GDM showed that women with a history of GDM were more likely than parous women without a history of GDM to develop T2DM, and also that lifestyle modification reduced the risk by 50 %. Multiple randomized controlled trials have been performed in the past 15 years testing lifestyle interventions on metabolic parameters for women after gestational diabetes, although none have been implemented at the systems level.

18. Ongoing studies are examining the ability of mobile device enabled applications to engage women with a history of pregnancy complications in disease prevention. In the USA, the national transition to larger health care organizations and mandatory health insurance may improve patient access and utilization. Additionally, larger health care organizations may be able to harness the tools of meaningful use of an electronic health record in a more cost-effective manner than is available to smaller health plans, paving the way for interventions that can improve quality of postpartum screening and ultimately lead to diabetes prevention on a large scale.

19. A pregnancy complicated by gestational diabetes is an opportunity to identify and prevent type 2 diabetes. As the diabetes epidemic worsens, effective interventions targeting high-risk groups are urgently needed. Enhancement of provider awareness will not only address the gap in laboratory screening but may also result in improved patient awareness. As reflected in a recent study demonstrating behavioral change among patients who are aware of their elevated A1c, greater knowledge and ownership of individual risk may facilitate incorporation of habits, diet, and medication that could additionally mitigate disease progression. Prior efforts to bridge the gap between obstetrics and primary care have found the greatest success when built upon a structure of clinical person to person outreach such as a nurse coordinator. Systems- level interventions arising from electronic health records or health plans have the potential to build upon existing clinical resources and are a promising direction for future study.

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