1. Gestational Diabetes: Addressing the Needs of Women in Colorado CityMatCH Conference September 22, 2008

2. Overflowing the System What can we do to change this? What can we do to change this? New GDM Diagnosis Postpartum GDM Woman GDM Tub Type 2 Diabetes Tub

3. Public Health System Improvement Develop clinical care and nutrition guidelines for Gestational Diabetes based on the most current research available Develop clinical care and nutrition guidelines for Gestational Diabetes based on the most current research available Disseminate and offer training on the guidelines to all medical and community health providers to promote the guidelines as the standard of care Disseminate and offer training on the guidelines to all medical and community health providers to promote the guidelines as the standard of care Integrate medical prenatal care with community based-systems Integrate medical prenatal care with community based-systems

4. GDM in Colorado and the US ~7.4% of moms in Colorado have diabetic pregnancies 1 (~5,000 women) ~7.4% of moms in Colorado have diabetic pregnancies 1 (~5,000 women)  Incidence has doubled in the last 7-8 years from 2-5% of population to ~4-12% Estimate about 200,000 women in the US every year (ADA, 2004) Estimate about 200,000 women in the US every year (ADA, 2004) Most likely to develop GDM: Most likely to develop GDM:  Older (35+)  Lower education (< 12 years)  Previous birth  Hispanic  Lower income  Medicaid Source: Colorado Pregnancy Risk Assessment Monitoring System, 2005

5. Age Source: Colorado Pregnancy Risk Assessment Monitoring System, 2004-2006

6. Health Disparities Source: Colorado Pregnancy Risk Assessment Monitoring System, 2004-2006

7. Why Is This A Problem for Mom? Intensive monitoring of blood glucoses, diet restrictions, insulin injections or meds, increased frequency of prenatal visits, financial burden Intensive monitoring of blood glucoses, diet restrictions, insulin injections or meds, increased frequency of prenatal visits, financial burden Higher risk of infections Higher risk of infections Higher risk of C-section Higher risk of C-section ~50-80% Maternal risk of developing Type 2 Diabetes in 5-10 years!!! ~50-80% Maternal risk of developing Type 2 Diabetes in 5-10 years!!! * Slide adapted from Dr. Linda Barbour, 12.6.06

8. Why Is This A Problem for Baby? Babies have central obesity and can’t get through the birth canal  birth trauma Babies have central obesity and can’t get through the birth canal  birth trauma Babies at  risk of stillbirth because they can outgrow their oxygen supply Babies at  risk of stillbirth because they can outgrow their oxygen supply Babies have problems regulating their glucose at birth and may need NICU Babies have problems regulating their glucose at birth and may need NICU Babies develop enlargement of their pancreas, heart, and liver Babies develop enlargement of their pancreas, heart, and liver Babies at  risk for developing childhood obesity and Type 2 “adult onset” diabetes!! Babies at  risk for developing childhood obesity and Type 2 “adult onset” diabetes!! * Slide adapted from Dr. Linda Barbour, 12.6.06

9. Systems Approach Professional Webcasts with Physician Champion Professional Webcasts with Physician Champion Guideline Development Guideline Development GDM Toolkit Development GDM Toolkit Development On-Site Training On-Site Training Provision of Educational Materials Provision of Educational Materials

10. Physician Champion Presented webcast on current recommendations Presented webcast on current recommendations Advisor to guideline development Advisor to guideline development Consultant for trainings, responded to technical questions Consultant for trainings, responded to technical questions Continues to present to professional organizations throughout Colorado and nationally Continues to present to professional organizations throughout Colorado and nationally Linda Barbour, MD, MSPH – Associate Professor in Endocrinology and Maternal-Fetal Medicine at the University of Colorado Health Sciences Center

11. Webcasts Gestational Diabetes: New Concepts, New Guidelines Provided 2 free webcasts in February & March 2007 – 101 active participants, 20 online archive participants Provided 2 free webcasts in February & March 2007 – 101 active participants, 20 online archive participants Presented findings from the recent landmark trials which shaped the recommendations from the 5th International Workshop on Gestational Diabetes Presented findings from the recent landmark trials which shaped the recommendations from the 5th International Workshop on Gestational Diabetes Offered 1.5 CME (through 3/08) - $15 Offered 1.5 CME (through 3/08) - $15 Disk archive still available through DPCP Disk archive still available through DPCP

12. Clinical and Nutrition Guidelines for GDM Partnered with Colorado Clinical Guidelines CollaborativePartnered with Colorado Clinical Guidelines Collaborative More than 6,000 printed and distributed to dateMore than 6,000 printed and distributed to date Distribution to physicians, midwives, community health workers through variety of avenuesDistribution to physicians, midwives, community health workers through variety of avenues Increase knowledge of standard of care for GDM

13. GDM Guideline Recommendations Early screening & education for high-risk women Early screening & education for high-risk women Universal screening between 24-28 weeks of pregnancy Universal screening between 24-28 weeks of pregnancy Follow-up glucose test at the 6-week postpartum appointment to determine if the woman has developed type 2 diabetes, pre-diabetes or has a normal blood sugar. Follow-up glucose test at the 6-week postpartum appointment to determine if the woman has developed type 2 diabetes, pre-diabetes or has a normal blood sugar.

14. GDM Tool Kit Development 1-hour and 3-hour Instruction Sheet 1-hour and 3-hour Instruction Sheet My Diabetes Record My Diabetes Record GDM Flowsheet GDM Flowsheet Weight Gain Grid Weight Gain Grid Postpartum Flyer & Reminder Card Postpartum Flyer & Reminder Card Educational Materials Educational Materials BASIC Materials BASIC Materials Web Resources Web Resources

15. Regional On-Site Trainings Recognize Risk Factors for GDM Recognize Risk Factors for GDM Learn to relate all Guidelines to GDM practice Learn to relate all Guidelines to GDM practice Recognize client challenges and barriers to adequate care Recognize client challenges and barriers to adequate care Be aware of educational resources and tools for GDM Be aware of educational resources and tools for GDM Understand long term risk of GDM in the development of type 2 diabetes in mother/child Understand long term risk of GDM in the development of type 2 diabetes in mother/child Discuss GDM network and current systems within each community and ways to expand these systems Discuss GDM network and current systems within each community and ways to expand these systems

16. Training Success 8 regional trainings were completed with 254 individuals attending the 6 hour workshop 8 regional trainings were completed with 254 individuals attending the 6 hour workshop 66% of the workshop participants completed a personal action plan 66% of the workshop participants completed a personal action plan Of those who completed a personal action plan, 85% took actions in their work as a result of attending the training. Of those who completed a personal action plan, 85% took actions in their work as a result of attending the training. Differences from pre  post knowledge in the areas addressed in the objectives was statistically significant based on self assessment Differences from pre  post knowledge in the areas addressed in the objectives was statistically significant based on self assessment

17. Training Success (cont.) 3-6 months after the training, participants working in a clinical setting, related that they were following the recommendations in the clinical guidelines regarding: 3-6 months after the training, participants working in a clinical setting, related that they were following the recommendations in the clinical guidelines regarding:  Early Risk Assessment at Initial Visit - 78%  Universal Screening at 24-28 weeks - 68%  Postpartum Follow-up with 2-hour OGTT - 56% 25% of individuals from the training contacted another participant who could be a resource 25% of individuals from the training contacted another participant who could be a resource 23% of workshop participants reordered educational materials 23% of workshop participants reordered educational materials

18. Educational Materials Free to training participants Free to training participants International Diabetes Center International Diabetes Center National Diabetes Education Program National Diabetes Education Program

19. Challenges Changing medical practice is difficult to achieve Changing medical practice is difficult to achieve Specialty medical care for GDM can be difficult to obtain in rural areas Specialty medical care for GDM can be difficult to obtain in rural areas

20. Lessons Learned Having a physician champion was an integral component of our success Having a physician champion was an integral component of our success Developing a standard of care brought together a network of providers offering the same message Developing a standard of care brought together a network of providers offering the same message Using multiple methods of distribution helped us to reach as many providers as possible Using multiple methods of distribution helped us to reach as many providers as possible

21. Future Data on GDM in Colorado Starting in 2009: New PRAMS Questions added to monitor universal screening rates, postpartum follow-up and adequacy of GDM education Starting in 2009: New PRAMS Questions added to monitor universal screening rates, postpartum follow-up and adequacy of GDM education During this pregnancy, did you have a blood test that required you to drink a very sweet liquid at 6-7 months of pregnancy? During this pregnancy, did you have a blood test that required you to drink a very sweet liquid at 6-7 months of pregnancy? Since you new baby was born, have you been tested for diabetes or high blood sugar? Since you new baby was born, have you been tested for diabetes or high blood sugar?

22. Future Data on GDM in Colorado (cont.) During this pregnancy, when you were told that you had GDM, did a doctor, nurse or other health care worker do any of the things listed below: During this pregnancy, when you were told that you had GDM, did a doctor, nurse or other health care worker do any of the things listed below:  Refer you to a nutritionist/dietitian  Talk to you about the importance of exercise/being physically active  Talk to you about getting to and staying at a healthy weight after delivery  Suggest that you breastfeed your new baby  Talk to you about your risk for developing type 2 diabetes

23. Continued GDM Work Update to the Guidelines based on review of recently released studies Update to the Guidelines based on review of recently released studies  Hyperglycemia and Adverse Pregnancy Outcome Study (HAPO)  National Institute of Child Health and Human Development (NICHD)  MiG Trial Additional webcasts addressing GDM Clinical Guidelines and Nutrition Guidelines Additional webcasts addressing GDM Clinical Guidelines and Nutrition Guidelines Potential online learning module for clients Potential online learning module for clients

24. Conclusion Create a standard of care for women at risk for, and diagnosed with, GDM to improve the health status of women during pregnancy and their birth outcomes. Create a standard of care for women at risk for, and diagnosed with, GDM to improve the health status of women during pregnancy and their birth outcomes. Use a systems approach to establish a powerful network of healthcare professionals and community workers that speak uniformly to women with GDM for improved access and quality care in Colorado. Use a systems approach to establish a powerful network of healthcare professionals and community workers that speak uniformly to women with GDM for improved access and quality care in Colorado.

25. THANK YOU! Mandy McCulloch, RD 303-692-2495mandy.mcculloch@state.co.us http://www.cdphe.state.co.us/pp/diabetes/index.html