A comparison of follow-up rates of women with gestational diabetes before and after the updated National Institute for Health and Care Excellence guidance advocating routine follow-up, and the association with neighbourhood deprivation
Keywords:diabetes, gestational, cohort studies, health services research, follow-up studies, health equity
Background: Gestational diabetes mellitus (GDM) occurs in one in every 23 UK pregnancies. GDM identifies the mother as high-risk for development of type 2 diabetes. The National Institute for Health and Care Excellence (NICE) published updated guidance in February 2015 recommending routine follow-up of women with GDM.
Aims: This cohort study compared follow-up rates of women with GDM before and after the updated guidance. We also investigated for an association between follow-up rates and deprivation.
Methods: Participants were identified from the database of the GDM service of two English hospitals and were organised into two cohorts: ‘pre-guidance’ (2012–2015) and ‘post-guidance’ (2015–2016). Using the recommendations of the NICE guidance as the follow-up standard, we used the hospitals’ computer system to compare follow-up rates of the two cohorts. The English Indices of Deprivation split the country into 32,844 small areas and rank them in order of deprivation such that 1 is the most deprived area and 32,844 is the least deprived. We compared the patients’ postcodes against the English Indices of Deprivation to investigate the relative levels of neighbourhood deprivation of those followed up compared with those not followed up. The Z statistic was used to test for statistical significance.
Results: 535 participants were included (pre-guidance n=306, post-guidance n=229). Baseline average age (pre-guidance 32.2 years, post-guidance 32.5 years), body mass index (30.7 kg/m2, 30.9 kg/m2) and fasting glucose (4.9 mmol/L, 4.8 mmol/L) were all comparable between cohorts. The follow-up rate improved from 60.5% in the pre-guidance group to 69.9% in the post-guidance group. The median deprivation rank of those followed up was 14,565 compared with 13,393 in those not followed up. This difference was not found to be significant.
Conclusion: A higher proportion of women with GDM were followed up with screening for type 2 diabetes after the updated NICE guidance in 2015 recommended routine follow-up. Across the study, over a third of women were not followed up. There was no statistically significant difference in the deprivation levels of those women followed up compared with those not followed up.
National Institute for Health and Care Excellence (NICE). Diabetes in pregnancy: management from preconception to the postnatal period. NG3. February 2015. www.nice.org.uk
Getahun D, Fassett M, Jacobsen S. Gestational diabetes: risk of recurrence in subsequent pregnancies. Am J Obstet Gynecol 2010;203:467. https://doi.org/10.1016/j.ajog.2010.05.032
Noctor E, Dunne F. Type 2 diabetes after gestational diabetes: the influence of changing diagnostic criteria. World J Diabetes 2015;6:234–44. https://doi.org/10.4239/wjd.v6.i2.234
Crowther C, Hiller J, Moss J, McPhee A. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005;352:2477–86. https://doi.org/10.1056/NEJMoa042973
Gonzalez-Quintero V, Istwan N, Rhea D, et al. The impact of glycemic control on neonatal outcome in singleton pregnancies complicated by gestational diabetes. Diabetes Care 2007;30:467–70. https://doi.org/10.2337/dc06-1875
Shrewsbury and Telford NHS Hospital Trust (SaTH). https://www.sath.nhs.uk/about-us/
Office for National Statistics. 2011 Census. https://www.ons.gov.uk/census/2011census
Nielsen K, Kapur A, Damm P, de Courten M, Bygbjerg C. From screening to postpartum follow-up – the determinants and barriers for gestational diabetes mellitus (GDM) services, a systematic review. BMC Pregnancy Childbirth 2014;14:41. https://doi.org/10.1186/1471-2393-14-41.
Kjos S, Peters R, Xiang A, Henry O, Montoro M, Buchanan T. Predicting future diabetes in Latino women with gestational diabetes: utility of early postpartum glucose tolerance testing. Diabetes 1995;44:586–91. https://doi.org/10.2337/diab.44.5.586
Ministry of Housing, Communities and Local Government. English indices of deprivation 2015. https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015
Smirnakis K, Chasan-Taber L, Wolf M, Markenson G, Ecker J, Thadhani R. Postpartum diabetes screening in women with a history of gestational diabetes. Obstet Gynecol 2005;106:1297–303. https://doi.org/10.1097/01.AOG.0000189081.46925.90
Stasenko M, Cheng Y, McLean T, Jelin A, Rand L, Caughey A. Postpartum follow-up for women with gestational diabetes mellitus. Am J Perinatol 2010;27:737–42. https://doi.org/10.1055/s-0030-1253557
Stasenko M, Liddell J, Cheng Y, Sparks T, Killion M, Caughey A. Patient counseling increases postpartum follow-up in women with gestational diabetes mellitus. Am J Obstet Gynecol 2011;204:522.e1–522.e6. https://doi.org/10.1016/j.ajog.2011.01.057
Ward R, Hanna F, Shelley-Hitchen A, et al. Gestational diabetes mellitus: are mothers being followed-up? A retrospective study. Br J Gen Pract 2018;68(Suppl 1). https://doi.org/10.3399/bjgp18X697469
Rosenbloom JI, Blanchard MH. Compliance with postpartum diabetes screening recommendations for patients with gestational diabetes. J Womens Health 2018;27:498–502. https://doi.org/10.1089/jwh.2017.6477
Publish & Transfer of Copyright Agreement
For the mutual benefit and protection of the Author and the Journal Owner/Publisher it is necessary that the Author provides formal written Consent to Publish and Transfer of Copyright before publication of the Work.