Gestational diabetes mellitus (GDM) is defined as hyperglycemia first recognised during pregnancy (World Health Organisation [WHO], 2013). In 2017, it was approximated that 21.3million live births were impacted by various forms of hyperglycaemia. Of these, roughly 18.4 million were attributed to GDM, constituting 86.4% of all instances of hyperglycemia in pregnancy (Cho et al, 2018).
A history of GDM is shown to have significant implications for long term health, those affected face an 8–10 times greater risk of developing T2DM (Adam, 2023) and a two-fold higher risk of future cardiovascular events (Kramer et al, 2019). Incidences of GDM and T2DM are increasing worldwide, resulting in huge healthcare and economic costs (Bellamy et al, 2009).
Due to these associated risks it is advisable to conduct follow-up screening after a pregnancy complicated by GDM. In the United Kingdom, National Institute of Clinical Excellence guidelines (NG3) (2020) recommended that women with GDM should have post-natal screening for T2DM. These guidelines stipulate women should have a Fasting Blood Glucose (FBG) test at 6-13 weeks post-natal, or an HbA1c or FBG test done after 13 weeks post-natal, repeated annually for life. It also provides recommendations for appropriate referrals to the National Diabetes Prevention Programme (NDPP) depending on results.
Post-natal screening rates
Pregnancy often serves as a catalyst for women to make positive health choices, highlighting the significance of targeting this actively engaged demographic (Thayer et al, 2020). Post-natal screening offers a chance to enhance long-term maternal well-being by identifying high-risk women who should be referred to prevention programmes (Walsh et al, 2019). Despite this rates are suboptimal, with only around 20% receiving long-term follow-up (Ferrara et al, 2016). Contributing factors for inadequate screening rates encompass patient concerns; provider misunderstandings; uncertainty surrounding guideline discrepancies; and hindrances to dependable healthcare transitions (Thayer et al, 2020).
Previous studies have shown that only 50% of women undergo initial post-natal screening within a year of giving birth, and less than 25% undergo annual glucose screening (Vounzoulaki et al, 2020). Major risk factors include maternal obesity, advanced maternal age, previous GDM, family history of type 2 diabetes, and ethnicity (Fuller et al, 2022). In the Middle East, North Africa, and South Asia, GDM prevalence can exceed 20% of pregnancies, while in Europe it's typically around 5% (Laurie and McIntyre, 2020).
Barriers to follow-up screening
Communication
Women undergoing treatment for GDM experience a lack of continuity and poor coordination of care across sectors and found general practitioners (GPs) had limited knowledge about risk of diabetes and follow-up screening (Nielsen et al, 2015). The healthcare system contributes to low post-natal screening due to poor bridging of antenatal to post-natal care with inadequate communication from secondary care to primary care compounded by a lack of agreed protocol or procedures (Scavini et al, 2020). GPs do not always receive clear guidance of what is expected with recommendations to facilitate ordering of screening tests not regularly included (Kilgour et al, 2019).
The implementation of patient or provider reminder systems has demonstrated an ability to elevate rates of testing (Jeppesen et al, 2015). The development of patient recall registers to send screening reminders has shown improved rates for up to 5 years in Australia and Belgium (Balaji et al, 2019).
Awareness of guidelines
Lack of clarity regarding the role of primary care in the post-natal period and a lack of awareness can leave women with a sense of abandonment by the healthcare system during the postnatal period (McMillan et al, 2018).
Some HCPs felt that despite familiarity with guidelines, numerous logistical and systemic obstacles impeded their inclination and capacity to request, administer, and convey test results. They argued that implementing electronic solutions to address communication gaps and enhancing provider training to outline roles and responsibilities could lead to improvements in post-GDM screening and follow-up procedures (McCloskey et al, 2019).
Perceived risk
A fear of a T2DM diagnosis and its potential consequences can be a both a motivating factor and a hurdle (Neven et al, 2022). Those that understand the rationale for screening and that a diagnosis of diabetes places them at higher risk of complications were more likely to take up healthy behaviours. Whilst for some these same realisations caused reluctance to confront such a diagnosis (Sunny et al, 2020). A substantial proportion of women perceived the risks associated with GDM as being minimal, particularly beyond the immediate post-natal period, viewing GDM as a condition confined to pregnancy (Gunn et al, 2020).
Competing demands
The process of adapting to motherhood has been identified as a hindrance to attending screening, as women face competing demands. For instance, some women expressed the challenge of fasting for post-natal screening, particularly when they are breastfeeding. (Balaji et al, 2019). The inability to combine postnatal check-ups and blood glucose testing into a single appointment poses a significant inconvenience (Roberts et al, 2021).
Post-childbirth, the infant remains the predominant source of motivation and influence on women's behaviours as lifestyle choices no longer have a direct impact on the child, focus shifts toward care of the baby, rather than prioritising self-care (Svensson et al, 2018). The risk of diabetes had low priority, affecting participation in follow-up screenings (Nielsen et al, 2015).
A need for change
A recent data audit for the local area identified multiple breakdowns in post-natal follow up care of women with GDM in primary care services. The data highlighted that many women with GDM were not routinely being offered or attending a post-natal 6-13 week FBG check with even fewer women being referred to the NDPP. Between January 2019 and November 2022, 271 women were diagnosed with GDM and discharged back to the care of their GP. Of these, only 243 women had this recorded in their primary care notes. No women received a FBG check within 6-13 weeks; 194 received an HbA1c but the time frame was not specified. Only 17 of these women were referred to the NDPP of which only 8 women attended.
A service improvement project (SIP) was conducted exploring potential barriers preventing women receiving screening and education required following a history of GDM as set out in NICE Guidelines NG3 (2020) and identifying how these may be overcome.
Project goals and objectives
The primary objective of this SIP is to enhance awareness of post-natal screening and promote uptake among women with a history of GDM, aligning with NICE guidelines (NICE NG3, 2020) thereby improving health outcomes for women and their children. Additionally, the SIP aims to increase awareness among GPs and practice nurses (PNs) regarding the importance of post-natal follow-up care for these women, facilitating better education provision on the subject.
Making changes
It was recognised that some changes were relatively simple and could be instigated in a timely manner such as addressing how to improve communication. Primary care stakeholders agreed that the initial change needed was to improve the clarity and conciseness of documentation from the diabetes team. Other required changes were more complex such as creating a standardised electronic pathway as well as designing, and rolling out an education package for staff.
Improving Communication
Discussions with primary care stakeholders revealed that they were not all aware of the recommendations laid out in NICE NG3 (2020). GPs expressed there was limited information provided from secondary care during the antenatal period and discharge information lacked any further plan of care. This was enlightening for the diabetes team as we were aware that a discharge summary is provided from the obstetric team and had wrongly assumed this contained information regarding their GDM diagnosis and that GPs would know post-natal follow up was a responsibility of primary care.
The only direct documentation currently sent from the diabetes team to GPs was a letter on completion of women's first education session with the diabetes team. This letter informed a diagnosis of GDM and requested glucose monitoring equipment is added to repeat prescriptions.
A key issue leading to lack of follow up was that not all women had their diagnosis of GDM recorded within their GP records meaning a requirement for post-natal follow up was not flagged to primary care staff. Kilgour et al (2019) recommended that secondary care documentation should be clear, concise, and easily accessible within the summary. To combat this, the letter sent from the diabetes team following the initial education session with the diabetes team was amended. Changes made it clearer that action was required by using bolder fonts and directly requesting a diagnosis of GDM and the accompanying SNOMED code is added to medical records.
To address the communication gaps, it was decided that a discharge letter should also come directly from the diabetes team providing relevant information regarding women's GDM care and provide a clear plan for post-natal follow up. Key feedback from primary care was that this should not exceed one page so that information is not lost and it is made obvious action is required. Implementation of this small but effective change meant improvements could be seen in a short time frame thus enhancing stakeholder motivation.
Patient education
Failure to meet women's information needs during pregnancy can heighten worries and anxiety. It's crucial for pregnant women to receive tailored, timely, and appropriate information (Vogels-Broeke et al, 2022). Current practice within the diabetes antenatal appointments included informing women of the importance of continuing a healthy lifestyle to reduce risks of developing T2DM and encouraging attendance for post-natal screening. However this tended to happen in their final diabetes review prior to delivery.
It was recognised that appointment time was limited, not always allowing time for further discussions or questions women may have regarding how to implement such lifestyle changes similar to experiences voiced by women in previous studies (Nielsen et al, 2015). Women were also more focussed on plans for delivery and how their diabetes may be managed during labour in these appointments meaning their priority was not focussed on care after pregnancy and delivery.
Several short slides were added to the education session provided to women at their initial appointment following their GDM diagnosis. Future risks of developing T2DM after GDM and recommended post-natal screening process alongside potential referrals required is highlighted as well as discussion regarding the importance of continuing a healthy lifestyle after pregnancy providing guidance and examples of how this may be achieved. Providing a consistent message from the start of diagnosis means women are aware of long-term risks and that there is a requirement for continued health care after pregnancy thereby managing women's expectations from the start.
While verbal communication is essential for education, it is insufficient on its own. To enhance information being provided verbally, a post-natal information leaflet was also produced. Patient information leaflets (PILs) serve as valuable tools for patients to recall essential information from their consultations (Protheroe et al, 2015). Combining printed educational materials with healthcare provider counselling can effectively complement patient educationm – empowering them with the necessary information for informed decisions and greater participation in their healthcare improving quality of life, complication prevention, and reduced healthcare costs (Staynova and Yanachkova, 2022; Sustersic et al, 2017).
Electronic care pathway creation
During stakeholder feedback sessions it became apparent that the lack of recall systems could be contributing to some women being lost to follow up. Recurrent themes from primary care stakeholders were that there was no standardised pathway or role responsibility assigned to the stages of follow up required.
A recent local project to improve leg ulcer management in primary care highlighted how implementing a standardised electronic care pathway could assist. Such Integrated Care Pathways are useful in co-ordinating care between HCPs and patients incorporating clinical guidelines making it difficult for HCPs to disregard, it also permitts the auditing of their effectiveness and efficiency (Dent and Tutt, 2014).
The pathway offers the option to book a FBG test, or HbA1c if after 12 weeks, and prompts HCPs to offer referral to the NDPP regardless of results – something GPs had voiced being unaware of. One GP had admitted in initial meetings they assumed if results came back normal there was no requirement for further input. The pathway then initiates a recall for a yearly HbA1c. Whilst the pathway creates standardised care from the point of booking an FBG it remains the responsibility of women to arrange this.
Staff education
Implementation of staff education combined with patient reminders has been shown to increase post-natal screening rates significantly (Vesco et al, 2012). Local GP surgeries have monthly Primary Care Network training afternoons providing an ideal opportunity to reach key staff involved in the follow up care of women with GDM. As well as offering face to face training a short video podcast was created highlighting recent suboptimal local statistics alongside a patient case scenario demonstrating the importance of providing follow up in line with NICE recommendations.
The steps taken so far to help improve our statistics were discussed and a further short video demonstrating how the new Electronic Care Pathway works in practice was shown. This video has been uploaded to the online training Moodle, allowing an opportunity for anyone that was unable to make face-to-face sessions or staff wishing to revisit the information.
Conclusion
A review of data approx 12 months following the implementations made has shown promising results. Thanks to improved documentation from secondary to primary care all women had their diagnosis of GDM correctly coded; 91 women booked and received their FBG, an improvement of 62%; and 54% of women received their yearly HbA1c. Unfortunately, however referral rates to the NDPP remain suboptimal with only 6 referrals made and no women attending. Due to the timeframe to design and implement the ECP this has only just been implemented, it is hoped once the ECP has been in use referrals to NDPP will also improve.
Another significant success of the SIP is the improved communication and working relationships between primary and secondary care achieved by embracing a teamwork approach.