Charlotte Niznik

Optimizing postpartum care for the patient with gestational diabetes mellitus

Gestational diabetes mellitus poses well-established risks to both the mother and infant. As >50% of women with gestational diabetes mellitus will develop type 2 diabetes mellitus in their lifetime, performing postpartum oral glucose tolerance testing is paramount to initiation of appropriate lifestyle interventions and pharmacologic therapy. Nonetheless, test completion among women with gestational diabetes mellitus is estimated to be <50%, with particularly low rates in Latina patients, as well as patients with public insurance, low education levels, and low health literacy. Data suggest our current health services infrastructure loses patients in the postpartum gap between pregnancy-focused care and primary care. Previous studies have suggested strategies to promote oral glucose tolerance testing completion to identify type 2 diabetes mellitus. Based on existing evidence, we propose best practices for the postpartum care of women with gestational diabetes mellitus: (1) enhanced patient support for identifying long-term health care providers, (2) patient-centered medical home utilization when possible, (3) patient and provider test reminders, and (4) formalized obstetrician-primary care provider hand offs using the Situation Background Assessment Recommendation (SBAR) mnemonic. These strategies deserve future investigation to solidify a multilevel approach for identifying and preventing the continuum of diabetes.

Factors promoting diabetes self-care among low-income, minority pregnant women

Objective:To prospectively identify factors promoting healthy self-management of gestational and type 2 diabetes mellitus among underserved pregnant women.Study design:Twenty-nine in-depth, semi-structured interviews were performed over the course of pregnancy for 10 women with diabetes. Interviews on factors promoting diabetes self-management used cognitive load theory to frame questions. Qualitative analysis of longitudinal interview data applied grounded theory techniques to generate themes.Result:Half this cohort of minority, low-income, public aid-supported women had type 2 diabetes. Four themes, comprised of both internal self-driven motivators and external sources of support, were identified. These themes were: (1) disease familiarity and diabetes self-efficacy; (2) external motivation (for health of fetus and responsibilities to older children); (3) supportive social and physical environment; and (4) self-regulatory behavior, including goal responsiveness and long-term goal-setting.Conclusion:Low-income women used multiple internal and external resources to promote health during a pregnancy complicated by diabetes. Successful behavior modification and achievement of diabetes care goals require leveraging these resources.

“I was tired of all the sticking and poking”: Identifying barriers to diabetes self- care among low- income pregnant women

Objective. Diabetes in pregnancy is a significant problem for low-income, minority women. We sought to evaluate barriers to diabetes self-care during pregnancy in an underserved population. Methods. Twenty-nine in-depth, semi-structured interviews were performed over 10 women’s pregnancies to identify barriers to successful diabetes management, using cognitive load theory to frame interview questions. Qualitative analysis of interview data used grounded theory techniques. Results. Fifty percent of this cohort of minority, low-income, public aid-supported women had pregestational diabetes. Six barrier domains were identified: diabetes novelty; social and economic chaos; nutrition challenges; psychological stressors; burden of disease management; and outcome expectation inability to promote behavior change. Conclusions. Low-income women face multiple barriers to successful diabetes self-care during pregnancy. Ability to achieve diabetes goals in pregnancy is influenced by several social, cognitive, and knowledge-based factors. Understanding this complex interplay of factors impacting diabetes management may help providers work with patients in achieving healthy pregnancies.

Postpartum glucose tolerance in women with gestational diabetes using levonorgestrel intrauterine contraception.

OBJECTIVE Postpartum contraception is critical in women with gestational diabetes mellitus (GDM). We evaluated the effect of the levonorgestrel intrauterine system (LNG-IUS) on glucose tolerance in postpartum women with GDM. STUDY DESIGN The study is a descriptive analysis of 12-month glucose tolerance in women with recent GDM who used the LNG-IUS, the copper IUD or postpartum sterilization. RESULTS Twelve months postpartum, 3 of 13 LNG-IUS users (23.1%) and 1 of 6 nonhormonal contraceptive users (16.6%) had prediabetes. No woman developed overt diabetes. CONCLUSIONS This study is the first and only to measure the metabolic effects of the LNG-IUS women with GDM. Larger trials are necessary. IMPLICATIONS Use of levonorgestrel intrauterine contraception does not appear to negatively affect glucose tolerance in postpartum women with a history of gestational diabetes. Additional appropriately powered clinical studies are needed to confirm these results.

Social and Environmental Barriers to Nutrition Therapy for Diabetes Management Among Underserved Pregnant Women: A Qualitative Analysis.

OBJECTIVE To identify social and environmental barriers to nutrition therapy for diabetes management during pregnancy among a population of low-income, minority pregnant women. DESIGN Prospective, in-depth, semi-structured interviews performed serially during pregnancy and continued until thematic saturation was reached. SETTING Urban academic medical center. PARTICIPANTS Ten pregnant low-income, minority women with gestational diabetes and type 2 diabetes mellitus. PHENOMENON OF INTEREST Social and environmental barriers to nutrition therapy for diabetes management during pregnancy. ANALYSIS Qualitative analysis of interview data using electronic coding software was performed using theme analysis. RESULTS Participants perceived limited ability and self-efficacy to adopt nutrition recommendations. Specific themes identified as barriers included (1) feeling overwhelmed by the unfamiliar; (2) using and decoding nutrition labels; (3) managing nutrition choices and seeking control in the setting of food insecurity; (4) experiencing lack of control and motivation, and limited self-efficacy; (5) balancing recommendations with taste preferences and cultural food norms; (6) maintaining a healthy eating schedule; and (7) accommodating diabetes in family and social life. CONCLUSIONS AND IMPLICATIONS Pregnant women with diabetes encounter a number of knowledge-based, attitudinal, and resource-related barriers that reduce capacity for nutrition therapy adherence. Provision of culturally informed, practical nutrition support that addresses the needs of women in low-resource communities is an important component of comprehensive diabetes care during pregnancy.

Update on gestational diabetes

Boyd E Metzger1†, LaTasha Nelson2, Charlotte Niznik3 & Sharon L Dooley4 †Author for correspondence 1Professor of Medicine, Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Attending Physician, Northwestern Memorial Hospital, Chicago, IL, 60611, USA. Tel.: +1 312 503 7979; Fax: +1 312 503 0037; E-mail: bem@northwestern.edu 2Fellow in Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA 3Advanced Practice Nurse – Clinical Research, Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA 4Professor of Obstetrics and Gynecology, Division of Maternal–Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Attending Physician, Prentice Women’s Hospital, Northwestern Memorial Hospital, Chicago, IL, 60611, USA

POP-PL: a patient-oriented prescription programming language

Medical professionals have long used algorithmic thinking to describe and implement health care processes without the benefit of the conceptual framework provided by a programming language. Instead, medical algorithms are expressed using English, flowcharts, or data tables. This results in prescriptions that are difficult to understand, hard to debug, and awkward to reuse. This paper reports on the design and evaluation of a domain-specific programming language, POP-PL for expressing medical algorithms. The design draws on the experience of researchers in two disciplines, programming languages and medicine. The language is based around the idea that programs and humans have complementary strengths, that when combined can make for safer, more accurate performance of prescriptions. We implemented a prototype of our language and evaluated its design by writing prescriptions in the new language and administering a usability survey to medical professionals. This formative evaluation suggests that medical prescriptions can be conveyed by a programming languages mode of expression and provides useful information for refining the language. Analysis of the survey results suggests that medical professionals can understand and correctly modify programs in POP-PL.

Decentralized Lab Testing: A Collaborative Approach to Point of Care Testing

What is involved in setting up and managing a decentralized laboratory testing program at a hospital? What elements are involved in making such a program a success? Multidepartmental and multidisciplinary cooperation and communication are the keys to implementing a cost-effective, user-friendly system that assures quality patient care and operator competence.

Management of Diabetes in the Intrapartum and Postpartum Patient

Abstract Achieving maternal euglycemia in women with pregestational and gestational diabetes mellitus is critical to decreasing the risk of neonatal hypoglycemia, as maternal blood glucose levels around the time of delivery are directly related to the risk of hypoglycemia in the neonate. Many institutions use continuous insulin and glucose infusions during the intrapartum period, although practices are widely variable. At Northwestern Memorial Hospital, the “Management of the Perinatal Patient with Diabetes” policy and protocol was developed to improve consistency of management while also allowing individualization appropriate for the patients specific diabetic needs. This protocol introduced standardized algorithms based on maternal insulin requirements to drive real‐time maternal glucose control during labor as well as provided guidelines for postpartum glycemic control. This manuscript describes the development and implementation of this protocol to encourage other institutions to adopt a standardized protocol that allows highly individualized intrapartum care to women with diabetes.

POP-PL: A Patient-Oriented Prescription Programming Language

A medical prescription is a set of health care instructions that govern the plan of care for an individual patient, which may include orders for drug therapy, diet, clinical assessment, and laboratory testing. Clinicians have long used algorithmic thinking to describe and implement prescriptions but without the benefit of a formal programming language. Instead, medical algorithms are expressed using a natural language patois, flowcharts, or as structured data in an electronic medical record system. The lack of a prescription programming language inhibits expressiveness; results in prescriptions that are difficult to understand, hard to debug, and awkward to reuse; and increases the risk of fatal medical error. This article reports on the design and evaluation of Patient-Oriented Prescription Programming Language (POP-PL), a domain-specific programming language designed for expressing prescriptions. The language is based around the idea that programs and humans have complementary strengths that, when combined properly, can make for safer, more accurate performance of prescriptions. Use of POP-PL facilitates automation of certain low-level vigilance tasks, freeing up human cognition for abstract thinking, compassion, and human communication. We implemented this language and evaluated its design attempting to write prescriptions in the new language and evaluated its usability by assessing whether clinicians can understand and modify prescriptions written in the language. We found that some medical prescriptions can be expressed in a formal domain-specific programming language, and we determined that medical professionals can understand and correctly modify programs written in POP-PL. We also discuss opportunities for refining and further developing POP-PL.