Erin Keely

Original research: Postpartum testing rates among women with a history of gestational diabetes—Systematic review

AIMSnGestational diabetes mellitus (GDM) is increasing and 30% have persistent postpartum dysglycemia. Reported compliance with recommended postpartum testing ranges 9-95% without a clear explanation for this wide variation. Small and conflicting differences in testing rates are associated with some demographics (race, use of insulin), but system factors likely play a larger role. A systematic literature review was performed to identify system based factors that could explain the broad variation in postpartum GDM testing rates.nnnMETHODSnOriginal articles reporting postpartum testing rates among women with GDM were identified within PubMed, OVID, EMBASE, and the Cochrane Database of systematic reviews. Articles that did not report rates for the entire GDM cohort were excluded.nnnRESULTSn54/307 citations met inclusion criteria. The use of proactive patient contact programs increased postpartum testing rates from an average of 33% (range 9-71%) up to 60% (range 14-95%).nnnCONCLUSIONSnProactively contacting patients via phone calls, education programs, or postal reminders was associated with higher postpartum testing rates. Rather than working to identifying individual demographic factors, systems based approaches were associated with a larger potential impact, and appear easily generalizable. Clinicians should think beyond individual habits and consider systematic approaches to improving testing rates.

Pregnancy Outcomes in Diabetes Subtypes: How Do They Compare? A Province-based Study of Ontario, 2005–2006

OBJECTIVEnTo ascertain differences in pregnancy outcomes between women with diabetes subtypes (type 1 [DM1], type 2 [DM2], women with gestational [GDM])] and non-diabetic women within a large Canadian population.nnnMETHODSnWe performed a retrospective multi-cohort analysis of all obstetrical deliveries that occurred in the province of Ontario between April 1, 2005, and March 31, 2006. Data were extracted from the Ontario Niday Perinatal Database.nnnRESULTSnIncreased rates of major negative maternal and perinatal outcomes (i.e. preterm delivery, Caesarean section, pregnancy-induced hypertension/preeclampsia) occurred in women with DM1. Both DM1 and GDM subtypes were associated with the greatest risk of macrosomia, shoulder dystocia, and congenital anomalies. DM2 did not demonstrate an association with an increased risk of congenital malformations and stillbirth.nnnCONCLUSIONnDiabetes in pregnancy, irrespective of subtype, predisposes women to poorer outcomes than those of the general obstetric population. However, this large population analysis is consistent with previous studies in showing that the adversity remains greatest for women with type 1 diabetes.

What are the cost savings associated with providing access to specialist care through the Champlain BASE eConsult service? A costing evaluation

Objective This study estimates the costs and potential savings associated with all eConsult cases completed between 1 April 2014 and 31 March 2015. Design Costing evaluation from the societal perspective estimating the costs and potential savings associated with all eConsults completed during the study period. Setting Champlain health region in Eastern Ontario, Canada. Population Primary care providers and specialists registered to use the eConsult service. Main outcome measures Costs included (1) delivery costs; (2) specialist remuneration; (3) costs associated with traditional (face-to-face) referrals initiated as a result of eConsult. Potential savings included (1) costs of traditional referrals avoided; (2) indirect patient savings through avoided travel and lost wages/productivity. Net potential societal cost savings were estimated by subtracting total costs from total potential savings. Results A total of 3487 eConsults were completed during the study period. In 40% of eConsults, a face-to-face specialist visit was originally contemplated but avoided as result of eConsult. In 3% of eConsults, a face-to-face specialist visit was not originally contemplated but was prompted as a result of the eConsult. From the societal perspective, total costs were estimated at

Risk perception and unrecognized type 2 diabetes in women with previous gestational diabetes mellitus

207u2005787 and total potential savings were

CONCEPTT: Continuous Glucose Monitoring in Women with Type 1 Diabetes in Pregnancy Trial: A multi-center, multi-national, randomized controlled trial - Study protocol

246u2005516. eConsult led to a net societal saving of

A comparison of referral patterns to a multispecialty eConsultation service between nurse practitioners and family physicians: The case for eConsult

38u2005729 or

Thyroid Disease in Pregnancy

11 per eConsult. Conclusions Our findings demonstrate potential cost savings from the societal perspective, as patients avoided the travel costs and lost wages/productivity associated with face-to-face specialist visits. Greater savings are expected once we account for other costs such as avoided tests and visits and potential improved health outcomes associated with shorter wait times. Our findings are valuable for healthcare delivery decision-makers as they seek solutions to improve care in a patient-centred and efficient manner.

Ask a neurologist: What primary care providers ask, and reducing referrals through eConsults

Women with a history of gestational diabetes mellitus (GDM) have a high chance of developing type 2 diabetes mellitus (T2DM) following the index pregnancy, however, little is known of womens perception of this risk. The objectives were to (1) determine womens perception of risk of future development of T2DM following a GDM pregnancy and (2) describe the prevalence of undetected dysglycaemia in a Canadian population. The study was designed as a 9–11 year follow-up study of women previously enrolled in a randomized controlled trial of tight versus minimal intervention for GDM. Womens perception of future risk of diabetes was determined by questionnaire. Fasting lipid profile, height and weight were performed on all participants. Oral glucose tolerance tests were performed on all women without prior history of diabetes mellitus type 2 (DM2). The study was conducted at Ottawa Hospital General Campus and Childrens Hospital of Eastern Ontario, in Ottawa, Canada. Eighty-nine of 299 (30%) of the original cohort were recruited. Eighty-eight women completed the questionnaire and 77 women without known diabetes underwent two hour glucose tolerance testing. Twenty-three (30%) felt their risk was no different than other women or did not know, 27 (35%) felt risk was increased a little and 27 (35%) felt risk was increased a lot. Only 52% (40/77) had normal glucose tolerance. Of all, 25/88 (28%) patients had diabetes (11 previously diagnosed and 14 diagnosed within the study). Of those newly diagnosed with DM2, four (29%) were diagnosed by fasting glucose, six (42%) by two hour glucose tolerance test (GTT) alone and four (29%) by both. Twenty-four of the women (27%) had impaired glucose tolerance (IGT). Of those with IGT, 12 (57%) had a fasting food glucose < 5.6 mmol/L. In the high-risk perception group with newly diagnosed diabetes, two were overweight, seven were obese, four had a family history of DM2, and all had a waist circumference >88 cm. In conclusion the perception of being at high risk for T2DM did not prevent women from having undetected T2DM. Many factors are likely to contribute to this, including the reliance on screening tests (i.e. fasting glucose) rather than a two hour GTT to detect diabetes. Further studies on effective public and health-care provider education and intervention are needed to identify this high-risk population.

Choosing a Model for eConsult Specialist Remuneration: Factors to Consider

BackgroundWomen with type 1 diabetes strive for optimal glycemic control before and during pregnancy to avoid adverse obstetric and perinatal outcomes. For most women, optimal glycemic control is challenging to achieve and maintain. The aim of this study is to determine whether the use of real-time continuous glucose monitoring (RT-CGM) will improve glycemic control in women with type 1 diabetes who are pregnant or planning pregnancy.Methods/designA multi-center, open label, randomized, controlled trial of women with type 1 diabetes who are either planning pregnancy with an HbA1c of 7.0xa0% to ≤10.0xa0% (53 to ≤u200986xa0mmol/mol) or arexa0in early pregnancy (<13xa0weeks 6xa0days) with an HbA1c of 6.5xa0% to ≤10.0xa0% (48 to ≤u200986xa0mmol/mol). Participants will be randomized to either RT-CGM alongside conventional intermittent home glucose monitoring (HGM), or HGM alone. Eligible women will wear a CGM which does not display the glucose result for 6xa0days during the run-in phase. To be eligible for randomization, a minimum of 4 HGM measurements per day and a minimum of 96xa0hours total with 24xa0hours overnight (11xa0pm-7xa0am) of CGM glucose values are required. Those meeting these criteria are randomized to RT- CGM or HGM. A total of 324 women will be recruited (110 planning pregnancy, 214 pregnant). This takes into account 15 and 20xa0% attrition rates for the planning pregnancy and pregnant cohorts and will detect a clinically relevant 0.5xa0% difference between groups at 90xa0% power with 5xa0% significance. Randomization will stratify for type of insulin treatment (pump or multiple daily injections) and baseline HbA1c. Analyses will be performed according to intention to treat. The primary outcome is the change in glycemic control as measured by HbA1c from baseline to 24xa0weeks or conception in women planning pregnancy, and from baseline to 34xa0weeks gestation during pregnancy. Secondary outcomes include maternal hypoglycemia, CGM time in, above and below target (3.5–7.8xa0mmol/l), glucose variability measures, maternal and neonatal outcomes.DiscussionThis will be the first international multicenter randomized controlled trial to evaluate the impact of RT- CGM before and during pregnancy in women with type 1 diabetes.Trial registrationClinicalTrials.gov Identifier: NCT01788527 Registration Date: December 19, 2012.

A randomized controlled trial of strict glycemic control and tertiary level obstetric care versus routine obstetric care in the management of gestational diabetes: A pilot study

Purpose:To explore referral patterns of nurse practitioners (NPs) and family physicians (FPs) using an electronic consultation (eConsult) service, and assess their perspectives on the services value to their patients and themselves. Data sources:A mixed methods study including a cross‐sectional analysis of utilization data drawn from all eConsults completed from April 15, 2011 to September 30, 2014, and a content analysis of NP survey responses completed from January 1 to September 30, 2014. Conclusions:A total of 4260 eConsults were included in the cross‐sectional analysis (3686 from FPs and 574 from NPs). In our sample, NPs directed more cases to dermatology and fewer cases to cardiology and neurology (p < .0001) than did FPs, and were more likely to report that an eConsult led to new advice for a new or additional course of action (62.8% vs. 57.5%) and less likely to report it resulted in an avoided referral (35.5% vs. 41.8%, p = .005). NPs reported slightly higher levels of perceived value of eConsults for their patients and themselves. Implications for practice:Differences in use and impact of eConsult exist between NPs and FPs. NPs value the service highly for their patients and themselves. The service reduces potential inequities related to outdated payment and scope of practice policies.