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Perspectives on postpartum diabetes screening among patients with gestational diabetes in an integrated healthcare system

Published:February 12, 2022DOI:https://doi.org/10.1016/j.ajog.2022.02.010

      Objective

      Gestational diabetes mellitus (GDM) affects 7% of pregnancies in the United States (US), raises the risk of type 2 diabetes (T2D) by nearly 10-fold, and impacts racial and ethnic minority groups disproportionately.
      • Vounzoulaki E.
      • Khunti K.
      • Abner S.C.
      • Tan B.K.
      • Davies M.J.
      • Gillies C.L.
      Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis.
      Guidelines recommend an oral glucose tolerance test (OGTT) to screen for T2D by 12 weeks postpartum. However, only 7% of US patients complete this, potentially delaying T2D prevention and early treatment.
      • Eggleston E.M.
      • LeCates R.F.
      • Zhang F.
      • Wharam J.F.
      • Ross-Degnan D.
      • Oken E.
      Variation in postpartum glycemic screening in women with a history of gestational diabetes mellitus.
      We examined the patient perceptions of postpartum screening to identify modifiable barriers in a setting where postpartum screening via OGTT is standard care and is actively promoted.

      Study Design

      In 2019, we surveyed patients in an integrated health system with existing strategies to promote screening as standard care (eg, centralized ordering of OGTTs in electronic health records and mailed patient reminders)
      • Ferrara A.
      • Hedderson M.M.
      • Ching J.
      • Kim C.
      • Peng T.
      • Crites Y.M.
      Referral to telephonic nurse management improves outcomes in women with gestational diabetes.
      and a screening rate of 48%.
      • Brown S.D.
      • Tsai A.L.
      • Hedderson M.M.
      • Quesenberry C.
      • Ferrara A.
      350-OR: Disparities in uptake of guideline-recommended postpartum diabetes screening after GDM.
      The inclusion criteria were diagnosis of GDM, age ≥18 years, and being pregnant and at ≤38 weeks’ gestation or 12–52 weeks postpartum if an OGTT had not been completed. The eligible patients (n=608) received a single recruitment email (97.9%) or letter (2.1%) and a $25 gift card after completing an online survey. Across 36 survey items derived from previous research, we assessed the descriptive norms
      • Rulison K.L.
      • Milroy J.J.
      • Wyrick D.L.
      A randomized iterative approach to optimizing an online substance use intervention for collegiate athletes.
      (perceived frequency of screening among others with GDM); perceived barriers and benefits of screening
      • Van Ryswyk E.
      • Middleton P.
      • Shute E.
      • Hague W.
      • Crowther C.
      Women’s views and knowledge regarding healthcare seeking for gestational diabetes in the postpartum period: A systematic review of qualitative/survey studies.
      • Van Ryswyk E.M.
      • Middleton P.F.
      • Hague W.M.
      • Crowther C.A.
      Women’s views on postpartum testing for type 2 diabetes after gestational diabetes: six month follow-up to the DIAMIND randomised controlled trial.
      • Keely E.
      • Clark H.
      • Karovitch A.
      • Graham I.
      Screening for type 2 diabetes following gestational diabetes: family physician and patient perspectives.
      ; recall of clinician advice
      • Ferrara A.
      • Hedderson M.M.
      • Albright C.L.
      • et al.
      A pragmatic cluster randomized clinical trial of diabetes prevention strategies for women with gestational diabetes: design and rationale of the Gestational Diabetes’ Effects on Moms (GEM) study.
      ; perceived risk for T2D—dichotomized as low vs high—using an item from the Risk Perception Survey for Developing Diabetes
      • Walker E.A.
      • Mertz C.K.
      • Kalten M.R.
      • Flynn J.
      Risk perception for developing diabetes: comparative risk judgments of physicians.
      ; the estimated cost of screening (open-ended survey item); and demographic characteristics. We identified the common perceptions, ie, those endorsed by ≥30% of participants. Descriptive analyses were conducted using SAS 9.4 (SAS Institute, Cary, NC, USA). The Kaiser Permanente Northern California institutional review board approved the study (protocol number 1426728).

      Results

      Overall 162 patients participated (67 pregnant, 95 postpartum); the response rate was 26.6% after the single recruitment contact. The Supplemental Table provides the characteristics of the participants. Of the postpartum participants, none of whom had completed their screening, 91% had attended the postpartum visit. Perceptions about screening were organized into 4 themes (Table) . The themes include risk perception, with women endorsing both low perceived risk and the belief that screening rates are low. Competing priorities emerged, including awareness of and a desire to follow clinicians’ advice out of concern for one’s own health. Yet, newborn care presented an obstacle to this. Psychological barriers highlighted fear of results or complications of diabetes. The fourth theme highlighted logistical or practical barriers. Cost also emerged as a barrier. Although 48.0% believed that screening would have no out-of-pocket cost, 27% estimated the cost as up to $50; 19.1% estimated it as >$50. Of the latter, 21.1% estimated it as >$100.
      TablePerceptions of patients with gestational diabetes regarding postpartum diabetes screening in an integrated health system setting (N=162)
      Themen (%)
      Risk perception
      Perceived risk of T2D is low94 (58.0)
      Believe most women do not get screened84 (51.9)
      Competing priorities
      Clinician-recommended screening140 (86.4)
      To take care of myself or my own health (benefit)138 (85.9)
      I would be more focused on my baby’s health (barrier)69 (42.6)
      Psychological barriers or ambivalence
      I would be afraid of getting negative [abnormal] results (barrier)51 (31.5)
      To find out if I have diabetes or prediabetes (benefit)112 (69.1)
      To prevent diabetes or complications from diabetes (benefit)109 (67.3)
      Logistical barriers
      Time constraints84 (51.9)
      It would be hard to find childcare61 (37.7)
      It would be hard to fast55 (34.0)
      GDM, gestational diabetes mellitus; T2D, type 2 diabetes.
      Glaser. Perspectives on postpartum diabetes screening among patients with gestational diabetes in an integrated healthcare system. Am J Obstet Gynecol 2022.

      Conclusion

      Previous studies identified a lack of reminders as a barrier to postpartum screening,
      • Keely E.
      • Clark H.
      • Karovitch A.
      • Graham I.
      Screening for type 2 diabetes following gestational diabetes: family physician and patient perspectives.
      but in a setting where screening is standard care and is promoted, barriers persist. This is despite most of the participants having attended a postpartum visit and recalling advice about screening. Although factors such as cost or practice variabilities are minimized in such a setting, over 50% of the participants assumed a cost for the OGTT. Individual barriers such as low risk perception, fear of negative results, and time constraints remain. Results thus suggest that improvements at the health system level may be insufficient unless patient motivations are also addressed. Previous work indicates the potential impact of a clinician’s personalized messages, so this may be a strategy.
      • Brown S.D.
      • Grijalva C.S.
      • Ferrara A.
      Leveraging EHRs for patient engagement: perspectives on tailored program outreach.
      Other strategies could include emphasizing individual T2D risk, reinforcing the desire to care for oneself, and improving knowledge that screening is a covered healthcare benefit. Future research may investigate patients’ experiences with GDM and screening in previous pregnancies, which was not done here. The patient-level factors identified here, which reinforce recent qualitative findings,
      • Dennison R.A.
      • Fox R.A.
      • Ward R.J.
      • Griffin S.J.
      • Usher-Smith J.A.
      Women’s views on screening for type 2 diabetes after gestational diabetes: a systematic review, qualitative synthesis and recommendations for increasing uptake.
      may inform novel interventions to address risk perception, fear, competing priorities, and logistical barriers.

      Appendix

      Supplemental TableDemographic characteristics of 162 study participants with current or recent gestational diabetes mellitus
      Characteristicsn (%) or mean±standard deviation
      Age (y)33±4.9
      Race or ethnicity
       Black/African American14 (8.6)
       Asian/Pacific Islander51 (31.5)
       Latina31 (19.1)
       Multiracial or multiethnic20 (12.3)
       White45 (27.8)
       Other1 (0.6)
      Education
       High school or less23 (14.2)
       At least some college139 (85.8)
      Reproductive status
       Pregnant67 (41.4)
       Postpartum95 (58.6)
      Parity
       026 (16.0)
       152 (32.1)
       259 (36.4)
       3 or more25 (15.4)
      Glaser. Perspectives on postpartum diabetes screening among patients with gestational diabetes in an integrated healthcare system. Am J Obstet Gynecol 2022.

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