Angela O'Dea

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

OBJECTIVE 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), NPV of 96% (95% CI 92, 98) and PPV of 100% (95% CI 91, 100). Combining HbA1c ≥39 mmol/mol with FPG ≥5.6 mmol/l yielded sensitivity of 90% (95% CI 78, 96), specificity of 84% (95% CI 78, 88), NPV of 97% (95% CI 94, 99) and PPV of 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 for women 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.

A meta-analysis of the effectiveness of crew resource management training in acute care domains

The healthcare industry has seen an increase in the adoption of team training, such as crew resource management (CRM), to improve teamwork and coordination within acute care medical teams. A meta-analysis was carried out in order to quantify the effects of CRM training on reactions, learning, behaviour and clinical care outcomes. Biases in the research evidence are identified and recommendations for training development and evaluation are presented. PUBMED, EMBASE and PsychInfo were systematically searched for all relevant papers. Peer reviewed papers published in English between January 1985 and September 2013, which present empirically based studies focusing on interventions to improve team effectiveness in acute health care domains, were included. A total of 20 CRM-type team training evaluation studies were found to fulfil the a priori criteria for inclusion in the meta-analysis. Overall, CRM trained participants responded positively to CRM (mean score 4.25 out of a maximum of 5), the training had large effects on participants’ knowledge (d=1.05), a small effect on attitudes (d=0.22) and a large effect on behaviours (d=1.25). There was insufficient evidence to support an effect on clinical care outcomes or long term impacts. The findings support the premise that CRM training can positively impact teamwork in healthcare and provide estimates of the expected effects of training. However, there is a need for greater precision in outcome assessment, improved standardisation of methods and measures, and more robust research design. Stronger evidence of effectiveness will require multi-level, multicentre, multispecialty and longitudinal studies.

A methodology for identifying human error in U.S. Navy diving accidents.

Objective: To better understand how human error contributes to U.S. Navy diving accidents. Background: An analysis of 263 U.S. Navy diving accident and mishap reports revealed that the human factors classifications were not informative for further analysis, and 70% of mishaps were attributed to unknown causes; only 23% were attributed to human factors. Method: Five diving fatality reports were examined using the consensual qualitative research (CQR) method to develop a taxonomy of six categories and 21 subcategories for classifying human errors in diving. In addition, 15 critical incident technique (CIT) interviews were conducted with U.S. Navy divers who had been involved in a diving accident or near miss and analyzed using the dive team error taxonomy. Results: Overall, failures in situation awareness and leadership were the most common human errors made by the dive team. Conclusion: The dive team human error taxonomy could aid in accident investigation and in the training and evaluation of U.S. Navy divers. Application: The development of the dive team human error taxonomy has generated a number of considerations that researchers should take into account when developing, or adapting, an error taxonomy from one industry to another.

Identifying and addressing the limitations of safety climate surveys

INTRODUCTION There are a variety of qualitative and quantitative tools for measuring safety climate. However, questionnaires are by far the most commonly used methodology. METHOD This paper reports the descriptive analysis of a large sample of safety climate survey data (n=110,014) collected over 10 years from U.S. Naval aircrew using the Command Safety Assessment Survey (CSAS). RESULTS The analysis demonstrated that there was substantial non-random response bias associated with the data (the reverse worded items had a unique pattern of responses, there was a increasing tendency over time to only provide a modal response, the responses to the same item towards the beginning and end of the questionnaire did not correlate as highly as might be expected, and the faster the questionnaire was completed the higher the frequency of modal responses). It is suggested that the non-random responses bias was due to the negative effect on participant motivation of a number of factors (questionnaire design, lack of a belief in the importance of the response, participant fatigue, and questionnaire administration). CONCLUSIONS Researchers must consider the factors that increase the likelihood of non-random measurement error in safety climate survey data and cease to rely on data that are solely collected using a long and complex questionnaire. IMPACT ON INDUSTRY In the absence of valid and reliable data it will not be possible for organizations to take the measures required to improve safety climate.

Short‐ and long‐term effects of gestational diabetes mellitus on healthcare cost: a cross‐sectional comparative study in the ATLANTIC DIP cohort

This paper examines the association between gestational diabetes mellitus and costs of care during pregnancy and 2–5 years post pregnancy.

Abnormal glucose tolerance post-gestational diabetes mellitus as defined by the International Association of Diabetes and Pregnancy Study Groups criteria

OBJECTIVE An increase in gestational diabetes mellitus (GDM) prevalence has been demonstrated across many countries with adoption of the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria. Here, we determine the cumulative incidence of abnormal glucose tolerance among women with previous GDM, and identify clinical risk factors predicting this. DESIGN Two hundred and seventy women with previous IADPSG-defined GDM were prospectively followed up for 5years (mean 2.6) post-index pregnancy, and compared with 388 women with normal glucose tolerance (NGT) in pregnancy. METHODS Cumulative incidence of abnormal glucose tolerance (using American Diabetes Association criteria for impaired fasting glucose, impaired glucose tolerance and diabetes) was determined using the Kaplan-Meier method of survival analysis. Cox regression models were constructed to test for factors predicting abnormal glucose tolerance. RESULTS Twenty-six percent of women with previous GDM had abnormal glucose tolerance vs 4% with NGT, with the log-rank test demonstrating significantly different survival curves (P<0.001). Women meeting IADPSG, but not the World Health Organization (WHO) 1999 criteria, had a lower cumulative incidence than women meeting both sets of criteria, both in the early post-partum period (4.2% vs 21.7%, P<0.001) and at longer-term follow-up (13.7% vs 32.6%, P<0.001). Predictive factors were glucose levels on the pregnancy oral glucose tolerance test, family history of diabetes, gestational week at testing, and BMI at follow-up. CONCLUSIONS The proportion of women developing abnormal glucose tolerance remains high among those with IADPSG-defined GDM. This demonstrates the need for continued close follow-up, although the optimal frequency and method needs further study.

Can the Onset of Type 2 Diabetes Be Delayed by a Group-Based Lifestyle Intervention in Women with Prediabetes following Gestational Diabetes Mellitus (GDM)? Findings from a Randomized Control Mixed Methods Trial

Objective. To evaluate a 12-week group-based lifestyle intervention programme for women with prediabetes following gestational diabetes (GDM). Design. A two-group, mixed methods randomized controlled trial in which 50 women with a history of GDM and abnormal glucose tolerance postpartum were randomly assigned to intervention (n = 24) or wait control (n = 26) and postintervention qualitative interviews with participants. Main Outcome Measures. Modifiable biochemical, anthropometric, behavioural, and psychosocial risk factors associated with the development of type 2 diabetes. The primary outcome variable was the change in fasting plasma glucose (FPG) from study entry to one-year follow-up. Results. At one-year follow-up, the intervention group showed significant improvements over the wait control group on stress, diet self-efficacy, and quality of life. There was no evidence of an effect of the intervention on measures of biochemistry or anthropometry; the effect on one health behaviour, diet adherence, was close to significance. Conclusions. Prevention programmes must tackle the barriers to participation faced by this population; home-based interventions should be investigated. Strategies for promoting long-term health self-management need to be developed and tested.

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 patients 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. Trial registration number ISRCTN41202110.

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 womens knowledge of their increased long-term 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.