Gestational Diabetes: Addressing the Needs of Women in Colorado

1
Gestational DiabetesAddressing the Needs of
Women in Colorado
CityMatCH Conference September 22, 2008
2
Overflowing the System

• What can we do to change this?

New GDM Diagnosis
GDM Tub
Postpartum GDM Woman
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
• 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

4
GDM in Colorado and the US

• 7.4 of moms in Colorado have diabetic
  pregnancies1 (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)
• Most likely to develop GDM
• Older (35)
• Lower education (lt 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
• Higher risk of infections
• Higher risk of C-section
• 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 cant get through
  the birth canal?birth trauma
• 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 develop enlargement of their pancreas,
  heart, and liver
• 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
• Guideline Development
• GDM Toolkit Development
• On-Site Training
• Provision of Educational Materials

10
Physician Champion
Linda Barbour, MD, MSPH Associate Professor in
Endocrinology and Maternal-Fetal Medicine at the
University of Colorado Health Sciences Center

• Presented webcast on current recommendations
• Advisor to guideline development
• Consultant for trainings, responded to technical
  questions
• Continues to present to professional
  organizations throughout Colorado and nationally

11
Webcasts

• Gestational Diabetes New Concepts, New
  Guidelines
• 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
• Offered 1.5 CME (through 3/08) - 15
• Disk archive still available through DPCP

12
Clinical and Nutrition Guidelines for GDM
Increase knowledge of standard of care for GDM

• Partnered with Colorado Clinical Guidelines
  Collaborative
• More than 6,000 printed and distributed to date
• Distribution to physicians, midwives, community
  health workers through variety of avenues

13
GDM Guideline Recommendations

• Early screening education for high-risk women
• 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.

14
GDM Tool Kit Development

• 1-hour and 3-hour Instruction Sheet
• My Diabetes Record
• GDM Flowsheet
• Weight Gain Grid
• Postpartum Flyer Reminder Card
• Educational Materials
• BASIC Materials
• Web Resources

15
Regional On-Site Trainings

• Recognize Risk Factors for GDM
• Learn to relate all Guidelines to GDM practice
• Recognize client challenges and barriers to
  adequate care
• 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
• 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
• 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.
• 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
• 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
• 23 of workshop participants reordered
  educational materials

18
Educational Materials

• Free to training participants
• International Diabetes Center
• National Diabetes Education Program

19
Challenges

• Changing medical practice is difficult to achieve
• 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
• 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

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
• 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?

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
• 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
• 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
• 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.
• 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 303-692-2495 mandy.
mcculloch_at_state.co.us http//www.cdphe.state.co.u
s/pp/diabetes/index.html