ATLANTIC DIP: simplifying the follow-up of women with previous gestational diabetes

ArticleObjective: Previous gestational diabetes (GDM) is associated with a significant lifetime risk of type 2 diabetes. In this study, we assessed the performance of HbA1c and fasting plasma glucose (FPG) measurements against that of 75 g oral glucose tolerance testing (OGTT) for the follow- up screening of women with previous GDM.Methods: Two hundred and sixty-six women with previous GDM underwent the follow- up testing (mean of 2.6 years (S.D. 1.0) post- index pregnancy) using HbA1c (100%), and 75 g OGTT (89%) or FPG (11%). American Diabetes Association (ADA) criteria for abnormal glucose tolerance were used.Design, cohort study, and results: The ADA HbA1c high-risk cut-off of 39 mmol/mol yielded sensitivity of 45% (95% CI 32, 59), specificity of 84% (95% CI 78, 88), negative predictive value (NPV) of 87% (95% CI 82, 91) and positive predictive value ( PPV) of 39% (95% CI 27, 52) for detecting abnormal glucose tolerance. ADA high-risk criterion for FPG of 5.6 mmol/ l showed sensitivity of 80% ( 95% CI 66, 89), specificity of 100% (95% CI 98, 100), NPVof 96% (95% CI 92, 98) and PPVof 100% (95% CI 91, 100). Combining HbA1c >= 39 mmol/ mol with FPG >= 5.6 mmol/ l yielded sensitivity of90%(95% CI 78, 96), specificity of 84% (95% CI 78, 88), NPV of 97% (95% CI 94, 99) and PPVof 56% (95% CI 45, 66).Conclusions: Combining test cut- offs of 5.6 mmol/l and HbA1c 39 mmol/mol identifies 90% of women with abnormal glucose tolerance post- GDM ( mean 2.6 years (S. D. 1.0) post- index pregnancy). Applying this follow-up strategy will reduce the number of OGTT tests required by 70%, will be more convenient forwomen and their practitioners, and is likely to lead to increased uptake of long-term retesting by these women whose risk for type 2 diabetes is substantially increased

Perspectives on the provision of GDM screening in general practice versus the hospital setting: a qualitative study of providers and patients

Objective: A novel gestational diabetes mellitus (GDM) screening programme which involved offering screening at the patient\u27s general practitioner (GP) compared with the traditional hospital setting was trialled. This study investigates perspectives of involved stakeholders on the provision of GDM screening at both settings. Design: Thematic analysis of the perspectives of stakeholders involved in the receiving and provision of GDM screening in both the GP and hospital settings drawn from focus groups and interviews. Participants: 3 groups of participants are included in this research-patient participants, GP screening providers and hospital screening providers. All were recruited from a larger sample who participated in a randomised controlled screening trial. Purposeful sampling was utilised to select participants with a wide variety of perspectives on the provision of GDM screening. Setting: Participants were recruited from a geographical area covered by 3 hospitals in Ireland. Results: 4 themes emerged from thematic analysis-namely (1) travel distance, (2) best care provision, (3) sense of ease created and (4) optimal screening. Conclusions: The influence of travel distance from the screening site is the most important factor influencing willingness to attend for GDM screening among women who live a considerable distance from the hospital setting. For patients who live equidistance from both settings, other factors are important; namely the waiting facilities including parking, perceived expertise of screening provider personnel, access to emergency treatment if necessary, accuracy of tests and access to timely results and treatment. Optimal screening for GDM should be specialist led, incorporate expert advice of GDM screening, treatment and management, should be provided locally, offer adequate parking and comfort levels, provide accurate tests, and timely access to results and treatment. Such a service should result in improved rates of GDM screening uptake.PUBLISHEDpeer-reviewe

Short and long-term effects of gestational diabetes mellitus on the health care cost: cross-sectional comparative study in the ATLANTIC DIP Cohort

ArticlePrevious gestational diabetes (GDM) is associated with a significant lifetime risk of type 2 diabetes. We assessed the performance of HbA1c and fasting plasma glucose (FPG) against 75g oral glucose tolerance testing (OGTT) for follow-up screening of these women

Factors influencing lifestyle behaviours during and after a gestational diabetes mellitus pregnancy

Objective: This qualitative study examined the healthy lifestyle behaviours undertaken during and after a pregnancy complicated by gestational diabetes mellitus (GDM) and the factors that influenced the likelihood of undertaking of such behaviours. Methods: Semi-structured telephone interviews were conducted with women who had a pregnancy complicated by GDM in the previous 3-7 years. Interviews were analysed using a theoretical thematic analysis approach. Results: Thirteen women provided interviews as part of this study. Women typically engaged in healthy behaviours in terms of diet, physical activity and glucose monitoring during their GDM pregnancy, but generally these behaviours were not maintained postpartum. Women appear not to be intrinsically motivated to engage in healthy lifestyle behaviours, but rather require the support of an extrinsic motivator such as their unborn child or the support of healthcare professionals. A gap exists between women\u27s knowledge of their increased longterm diabetes risk and the behaviours which they undertake to reduce this risk in the postpartum period. Conclusion: Women with previous GDM need increased support in the postpartum period to assist them to develop self-management and prioritisation skills to take control of their increased type 2 diabetes mellitus risk

A mixed-methods study of the causes and impact of poor teamwork between junior doctors and nurses

Objectives This study aimed to collect and analyse examples of poor teamwork between junior doctors and nurses; identify the teamwork failures contributing to poor team function; and ascertain if particular teamwork failures are associated with higher levels of risk to patients. Design Critical Incident Technique interviews were carried out with junior doctors and nurses. Setting Two teaching hospitals in the Republic of Ireland. Participants Junior doctors (n = 28) and nurses (n = 8) provided descriptions of scenarios of poor teamwork. The interviews were coded against a theoretical framework of healthcare team function by three psychologists and were also rated for risk to patients by four doctors and three nurses. Results A total of 33 of the scenarios met the inclusion criteria for analysis. A total of 63.6% (21/33) of the scenarios were attributed to ‘poor quality of collaboration’, 42.4% (14/33) to ‘poor leadership’ and 48.5% (16/33) to a ‘lack of coordination’. A total of 16 scenarios were classified as high risk and 17 scenarios were classified as medium risk. Significantly more of the high-risk scenarios were associated with a ‘lack of a shared mental model’ (62.5%, 10/16) and ‘poor communication’ (50.0%, 8/16) than the medium-risk scenarios (17.6%, 3/17 and 11.8%, 2/17, respectively). Conclusion Poor teamwork between junior doctors and nurses is common and places patients at considerable risk. Addressing this problem requires a well-designed complex intervention to develop the team skills of doctors and nurses and foster a clinical environment in which teamwork is supported.This research was partially supported through funding from the Intern Education and Training Service Level Agreement, National Doctors Training and Planning, Health Services Executive

An evaluation of MyAction, a community-based lifestyle and medical risk factor modification programme, in women with prior gestational diabetes mellitus: study protocol for a randomised controlled trial

Journal articleUniversal screening using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria has identified a prevalence of gestational diabetes mellitus (GDM) of 12.4% in women living in Ireland. Women with prior GDM are at increased risk of developing type 2 diabetes later in life. A number of risk factors linked to the development of type 2 diabetes are potentially modifiable through lifestyle and behaviour changes, and medical management. No previous Irish studies have adequately investigated the efficacy of lifestyle intervention programmes in reducing these risk factors in women with prior GDM. Through a two-group, parallel randomised controlled trial (RCT), this study aims to assess the clinical impact, cost-effectiveness and psychological experience of the Croí MyAction intensive lifestyle modification programme for women with prior GDM.HRB Ireland (Health Research Board

An evaluation of Croi MyAction community lifestyle modification programme compared to standard care to reduce progression to diabetes/pre-diabetes in women with prior gestational diabetes mellitus (GDM): study protocol for a randomised controlled trial

Background: Universal screening using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria has identified a prevalence of gestational diabetes mellitus (GDM) of 12.4% in women living in Ireland. Women with prior GDM are at increased risk of developing type 2 diabetes later in life. A number of risk factors linked to the development of type 2 diabetes are potentially modifiable through lifestyle and behaviour changes, and medical management. No previous Irish studies have adequately investigated the efficacy of lifestyle intervention programmes in reducing these risk factors in women with prior GDM. Through a two-group, parallel randomised controlled trial (RCT), this study aims to assess the clinical impact, cost-effectiveness and psychological experience of the Croi MyAction intensive lifestyle modification programme for women with prior GDM. Methods/Design: A total of 54 women with a history of GDM and persistent post-partum glucose dysfunction (impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)), are randomly assigned to a control arm (n = 27) or to the Croi MyAction intervention group (n = 27). The control arm receives usual health care advice - written information on diet and lifestyle changes for reducing diabetes risks and visits with general practitioners as required. The intervention group receives usual health care as per the control group in addition to attending a 12-week intensive lifestyle modification programme known as Croi MyAction. Croi MyAction involves 2.5 hour sessions once per week (for 12 weeks) comprising a group exercise programme, group health promotion or education seminars, and one-to-one meetings with a multidisciplinary health care team to personalise risk factor reductions. Randomisation and allocation to the intervention arms is carried out by an independent researcher, ensuring that the allocation sequence is concealed from study researchers until the interventions are assigned. The primary analysis is based on glucose dysfunction, comparing a mean reduction in fasting plasma glucose (FPG) levels on a 75 gram oral glucose tolerance test (OGTT) in the two groups at a one-year, post-intervention follow-up. The trial is funded by the Irish Health Research Board (HRB). Ethics approval was obtained on 27 March 2012 from the Clinical Research Ethics Committee, Galway University Hospitals, Health Service Executive of Ireland (Ref: C.A. 691).PUBLISHEDpeer-reviewe

Screening uptake rates and the clinical and cost effectiveness of screening for gestational diabetes mellitus in primary versus secondary care: study protocol for a randomised controlled trial

Background: The risks associated with gestational diabetes mellitus (GDM) are well recognized, and there is increasing evidence to support treatment of the condition. However, clear guidance on the ideal approach to screening for GDM is lacking. Professional groups continue to debate whether selective screening (based on risk factors) or universal screening is the most appropriate approach. Additionally, there is ongoing debate about what levels of glucose abnormalities during pregnancy respond best to treatment and which maternal and neonatal outcomes benefit most from treatment. Furthermore, the implications of possible screening options on health care costs are not well established. In response to this uncertainty there have been repeated calls for well-designed, randomised trials to determine the efficacy of screening, diagnosis, and management plans for GDM. We describe a randomised controlled trial to investigate screening uptake rates and the clinical and cost effectiveness of screening in primary versus secondary care settings. Methods/Design: This will be an unblinded, two-group, parallel randomised controlled trial (RCT). The target population includes 784 women presenting for their first antenatal visit at 12 to 18 weeks gestation at two hospitals in the west of Ireland: Galway University Hospital and Mayo General Hospital. Participants will be offered universal screening for GDM at 24 to 28 weeks gestation in either primary care (n = 392) or secondary care (n = 392) locations. The primary outcome variable is the uptake rate of screening. Secondary outcomes include indicators of clinical effectiveness of screening at each screening site (primary and secondary) including gestational week at time of screening, time to access antenatal diabetes services for women diagnosed with GDM, and pregnancy and neonatal outcomes for women with GDM. In addition, parallel economic and qualitative evaluations will be conducted. The trial will cover the period from the woman\u27s first hospital antenatal visit at 12 to 18 weeks gestation, until the completion of the pregnancy.PUBLISHEDpeer-reviewe