Cherie Whitbread

Complications of diabetes in urban Indigenous Australians: The DRUID study

AIMS To accurately assess the management and complications of type 2 diabetes in urban Indigenous Australians and compare the risk of complications with a general Australian population (AusDiab Study). METHODS The Darwin Region Urban Indigenous Diabetes (DRUID) Study included 1004 volunteers aged >/=15 years; diabetes status was classifiable for 866. The assessment of diabetic complications and metabolic control was performed in participants with known diabetes (KDM) and diabetes newly diagnosed by the study (NDM) using an interviewer-administered questionnaire and clinical examination. RESULTS Among 172 DRUID participants eligible for complications assessment, 135 were assessed, including 99 KDM (mean age 53 years) and 36 NDM (mean age 47 years). Percentages of KDM participants meeting therapeutic targets were: HbA1c<7%, 29%; blood pressure<130/80mmHg, 45%; total cholesterol<5.5mmol/L, 65%. Among KDM, 39% had albuminuria, 21% retinopathy, 12% peripheral vascular disease (PVD), 9% neuropathy. Factors independently associated with diabetic complications were: albuminuria-HbA1c, systolic blood pressure; retinopathy-diabetes duration; PVD-age. Compared to AusDiab participants after adjusting for other risk factors, DRUID participants had 2-3-fold increased risk of albuminuria and PVD and a non-significant increased risk of neuropathy, but no increased risk of retinopathy. CONCLUSIONS Urban Indigenous Australians with diabetes are relatively young and have poor glycaemic control. Compared to the general Australian population with type 2 diabetes, they have greater adjusted risk of albuminuria and PVD but not retinopathy. Urgent action is required to prevent diabetes at a population level and improve diabetes management in this high-risk population.

Implementation of a diabetes in pregnancy clinical register in a complex setting: Findings from a process evaluation

Background Rates of diabetes in pregnancy are disproportionately higher among Aboriginal than non-Aboriginal women in Australia. Additional challenges are posed by the context of Aboriginal health including remoteness and disadvantage. A clinical register was established in 2011 to improve care coordination, and as an epidemiological and quality assurance tool. This paper presents results from a process evaluation identifying what worked well, persisting challenges and opportunities for improvement. Methods Clinical register data were compared to the Northern Territory Midwives Data Collection. A cross-sectional survey of 113 health professionals across the region was also conducted in 2016 to assess use and value of the register; and five focus groups (49 healthcare professionals) documented improvements to models of care. Results From January 2012 to December 2015, 1,410 women were referred to the register, 48% of whom were Aboriginal. In 2014, women on the register represented 75% of those on the Midwives Data Collection for Aboriginal women with gestational diabetes and 100% for Aboriginal women with pre-existing diabetes. Since commencement of the register, an 80% increase in reported prevalence of gestational diabetes among Aboriginal women in the Midwives Data Collection occurred (2011–2013), prior to adoption of new diagnostic criteria (2014). As most women met both diagnostic criteria (81% in 2012 and 74% in 2015) it is unlikely that the changes in criteria contributed to this increase. Over half (57%) of survey respondents reported improvement in knowledge of the epidemiology of diabetes in pregnancy since establishment of the register. However, only 32% of survey respondents thought that the register improved care-coordination. The need for improved integration and awareness to increase use was also highlighted. Conclusion Although the register has not been reported to improve care coordination, it has contributed to increased reported prevalence of gestational diabetes among high risk Aboriginal women, in a routinely collected jurisdiction-wide pregnancy dataset. It has therefore contributed to an improved understanding of epidemiology and disease burden and may in future contribute to improved management and outcomes. Regions with similar challenges in context and high risk populations for diabetes in pregnancy may benefit from this experience of implementing a register.

Improving health service delivery for women with diabetes in pregnancy in remote Australia:: survey of care in the Northern Territory Diabetes in Pregnancy Partnership

In the Northern Territory (NT), 38% of 3500 births each year are to Indigenous women, 80% of whom live in regional and remote areas. Compared with the general Australian population, rates of pre‐existing type 2 diabetes in pregnancy are 10‐fold higher and rates of gestational diabetes are 1.5‐fold higher among Indigenous women. Current practices in screening for diabetes in pregnancy in remote Australia are not known.

Preconception care for women with type 2 diabetes mellitus: a mixed-methods study of provider knowledge and practice

AIMS Preconception care may decrease adverse pregnancy outcomes associated with pre-existing diabetes mellitus. Aboriginal Australians are at high risk of type 2 diabetes mellitus (T2DM), with earlier onset. We explored practitioner views on preconception care delivery for women with T2DM in the Northern Territory, where 31% of births are to Aboriginal women. METHODS Mixed-methods study including cross-sectional survey of 156 health practitioners and 11 semi-structured interviews. RESULTS Practitioners reported low attendance for preconception care however, 51% provided counselling on an opportunistic basis. Rural/remote practitioners were most likely to find counselling feasible. The majority (69%) utilised appropriate guidelines and addressed lifestyle modifications including smoking (81%), weight management (79%), and change medications appropriately such as ceasing ACE inhibitors (69%). Fewer (40%) prescribed the recommended dose of folate (5mg) or felt comfortable recommending delaying pregnancy to achieve optimal preconception glucose control (42%). Themes identified as barriers to care included the complexity of care setting and infrequent preconception consultations. There was a focus on motivation of women to make informed choices about conception, including birth spacing, timing and contraception. Preconception care enablers included cross-cultural communication, a multi-disciplinary care team and strong client-based relationships. CONCLUSIONS Health practitioners are keen to provide preconception counselling and reported knowledge of evidence-based guidelines. Improvements are needed in recommending high dose folate and optimising glucose control. Cross-cultural communication and team-based care were reported as fundamental to successful preconception care in women with T2DM. Continued education and policy changes are required to support practitioners in opportunities to enhance pregnancy planning.

Health service changes to address diabetes in pregnancy in a complex setting: perspectives of health professionals

BackgroundAustralian Aboriginal and Torres Strait Islander women have high rates of gestational and pre-existing type 2 diabetes in pregnancy. The Northern Territory (NT) Diabetes in Pregnancy Partnership was established to enhance systems and services to improve health outcomes. It has three arms: a clinical register, developing models of care and a longitudinal birth cohort. This study used a process evaluation to report on health professional’s perceptions of models of care and related quality improvement activities since the implementation of the Partnership.MethodsChanges to models of care were documented according to goals and aims of the Partnership and reviewed annually by the Partnership Steering group. A ‘systems assessment tool’ was used to guide six focus groups (49 healthcare professionals). Transcripts were coded and analysed according to pre-identified themes of orientation and guidelines, education, communication, logistics and access, and information technology.ResultsKey improvements since implementation of the Partnership include: health professional relationships, communication and education; and integration of quality improvement activities. Focus groups with 49 health professionals provided in depth information about how these activities have impacted their practice and models of care for diabetes in pregnancy. Co-ordination of care was reported to have improved, however it was also identified as an opportunity for further development. Recommendations included a central care coordinator, better integration of information technology systems and ongoing comprehensive quality improvement processes.ConclusionsThe Partnership has facilitated quality improvement through supporting the development of improved systems that enhance models of care. Persisting challenges exist for delivering care to a high risk population however improvements in formal processes and structures, as demonstrated in this work thus far, play an important role in work towards improving health outcomes.

Cohort profile: The Pregnancy and Neonatal Diabetes Outcomes in Remote Australia (PANDORA) Study

I-Lynn Lee, Brydie Purbrick, Federica Barzi, Alex Brown, Christine Connors, Cherie Whitbread ... et al.

Improving postpartum screening after diabetes in pregnancy: Results of a pilot study in remote Australia

BACKGROUND The postpartum period is a critical time to improve health outcomes for Aboriginal women, particularly for those who have chronic conditions. AIMS To assess enhanced support methods (for women following diabetes in pregnancy (DIP)) to improve completion rates of recommended postpartum health checks. MATERIALS AND METHODS Fifty-three Aboriginal women in the Northern Territory (NT) were contacted in the postpartum period to encourage medical check-ups. Messages were delivered through phone (call or text messages) or other methods (Facebook or email). The primary outcome was postpartum blood glucose testing (oral glucose tolerance testing (OGTT), random or fasting glucose and HbA1c). RESULTS Establishing contact with women was difficult. Of 137 messages sent to 52 women, 22 responded (42%). Phone was the most common contact method with successful contact made from 16 of 119 (13%) attempts. Rates of postpartum OGTT completion were higher in the group successfully contacted (32% vs 7%). However, for any postpartum glucose testing (including OGTT and HbA1c) rates were 25 of 42 (60%) and neither success in making contact nor the contact method was associated with higher rates. CONCLUSIONS The small sample size limits our conclusions; however, results highlight that engaging remote women postpartum is difficult. While rates of postpartum OGTT completion differed according to successful contacts, rates of any postpartum blood glucose testing did not. Further research is needed to explore feasible intervention methods to improve postpartum screening after a pregnancy complicated by diabetes.

Anthropometrics of neonates born to mothers with diabetes in pregnancy in the Northern Territory

Type 2 diabetes (T2DM) is increasing in prevalence in Indigenous Australian children and adolescents. High rates of diabetes in pregnancy (DIP) in Indigenous Australians increases the risk of diabetes for the next generation. DIP is associated with neonatal adiposity, which correlates with long-term risk of obesity and diabetes. Indigenous Australians have high rates of low birth weight and increasingly, large for gestational age associated with DIP. The aims are: 1. To evaluate adiposity in babies born to Indigenous mothers and those of European background with DIP in the Northern Territory; 2. To evaluate the relationship between maternal factors and neonatal birth weight and body composition. Thus far 266 mothers and neonates from the PANDORA cohort (Pregnancy and Neonatal Outcomes in Remote Australia) have been assessed. Neonatal anthropometrics were performed on all neonates, including skin fold measures. Calculations of fat mass were made using a validated equation (fat mass=0.39055(birth weight)+0.0453(flank skinfold)-0.03237(length)+0.54657). Significant differences were found in maternal characteristics between Indigenous and European background participants, including diabetes type (T2DM 14.7% vs 1.1%, p<0.001), smoking in pregnancy (26.5% vs 9.1%, p<0.001) and location of residence (regional/remote 41.4%vs 9.8% p<0.001). Gestational age at birth was significantly different (38.2 vs 39 weeks p<0.001), however birth weight was not significantly different (3380 vs 3428g). Indigenous neonates had greater subscapular (4.69 vs 4.20mm, p=0.003) triceps (4.75 vs 4.22mm, p=0.004) and flank skin folds (4.08 vs 3.60mm, p=0.006). This difference remained significant for the flank skin fold only, after adjustment for diabetes type and maternal body mass index (BMI). There was no significant difference in calculated fat mass. On regression analysis, maternal BMI, smoking, nulliparity and T2DM were each independently associated with birth-weight z-score. Recruitment to PANDORA is ongoing. Preliminary data reveals higher skin fold measures, indicative of adiposity, in Indigenous neonates. There was no significant difference in fat mass. Smoking, BMI, nulliparity and T2DM were independently associated with birth-weight z-score, ethnicity was not independently associated.