Gestational Diabetes:Gestational Diabetes:Addressing the Needs of Addressing the Needs of

Women in ColoradoWomen in ColoradoCityMatCH ConferenceCityMatCH Conference

September 22, 2008September 22, 2008

Overflowing the SystemOverflowing the SystemWhat can we do to change this?What can we do to change this?

New GDM Diagnosis

Postpartum GDM Woman

GDM Tub

Type 2 Diabetes Tub

Public Health System Public Health System ImprovementImprovement

Develop clinical care and nutrition guidelines Develop clinical care and nutrition guidelines for Gestational Diabetes based on the most for Gestational Diabetes based on the most current research availablecurrent research available

Disseminate and offer training on the Disseminate and offer training on the guidelines to all medical and community health guidelines to all medical and community health providers to promote the guidelines as the providers to promote the guidelines as the standard of carestandard of care

Integrate medical prenatal care with Integrate medical prenatal care with community based-systemscommunity based-systems

GDM in Colorado and the USGDM in Colorado and the US ~7.4% of moms in Colorado have diabetic ~7.4% of moms in Colorado have diabetic

pregnanciespregnancies11 (~5,000 women) (~5,000 women) Incidence has doubled in the last 7-8 years from 2-5% of Incidence has doubled in the last 7-8 years from 2-5% of

population to ~4-12%population to ~4-12% Estimate about 200,000 women in the US every year Estimate about 200,000 women in the US every year

(ADA, 2004)(ADA, 2004)

Most likely to develop GDM:Most likely to develop GDM: Older (35+)Older (35+) Lower education (< 12 years)Lower education (< 12 years) Previous birthPrevious birth HispanicHispanic Lower incomeLower income MedicaidMedicaid

Source: Colorado Pregnancy Risk Assessment Monitoring System, 2005

Percent of Women with Diabetes During Pregnancy by Age Group, 2004-2006

4.5 6.28.0

10.6

0

5

10

15

20

15-19 20-24 25-34 35+

Age Group

Per

cen

t (%

)AgeAge

Source: Colorado Pregnancy Risk Assessment Monitoring System, 2004-2006

Percent of Women with Diabetes During Pregnancy by Race/Ethnicity, 2004-2006

6.1

11.3

5.1

9.2

0

5

10

15

20

White/Non-Hispanic

White/Hispanic Black Other

Per

cen

t (%

)Health DisparitiesHealth Disparities

Source: Colorado Pregnancy Risk Assessment Monitoring System, 2004-2006

Why Is This A Problem for Mom?Why Is This A Problem for Mom?

Intensive monitoring of blood Intensive monitoring of blood glucoses, diet restrictions, insulin glucoses, diet restrictions, insulin injections or meds, increased frequency of injections or meds, increased frequency of prenatal visits, financial burdenprenatal visits, financial burden

Higher risk of infectionsHigher risk of infectionsHigher risk of C-sectionHigher risk of C-section~50-80% Maternal risk of developing ~50-80% Maternal risk of developing

Type 2 Diabetes in 5-10 years!!!Type 2 Diabetes in 5-10 years!!!

* Slide adapted from Dr. Linda Barbour, 12.6.06

Why Is This A Problem for Baby?Why Is This A Problem for Baby?

Babies have central obesity and can’t get Babies have central obesity and can’t get through the birth canalthrough the birth canalbirth traumabirth trauma

Babies at Babies at risk of stillbirth because they can risk of stillbirth because they can outgrow their oxygen supplyoutgrow their oxygen supply

Babies have problems regulating their glucose Babies have problems regulating their glucose at birth and may need NICUat birth and may need NICU

Babies develop enlargement of their pancreas, Babies develop enlargement of their pancreas, heart, and liverheart, and liver

Babies at Babies at risk for developing childhood risk for developing childhood obesity and Type 2 “adult onset” diabetes!!obesity and Type 2 “adult onset” diabetes!!

* Slide adapted from Dr. Linda Barbour, 12.6.06

Systems ApproachSystems Approach

Professional Webcasts with Physician Professional Webcasts with Physician ChampionChampion

Guideline DevelopmentGuideline Development GDM Toolkit DevelopmentGDM Toolkit Development On-Site TrainingOn-Site Training Provision of Educational MaterialsProvision of Educational Materials

Physician ChampionPhysician Champion

Presented webcast on current recommendationsPresented webcast on current recommendations Advisor to guideline developmentAdvisor to guideline development Consultant for trainings, responded to technical Consultant for trainings, responded to technical

questionsquestions Continues to present to professional Continues to present to professional

organizations throughout Colorado and organizations throughout Colorado and nationallynationally

Linda Barbour, MD, MSPH – Associate Linda Barbour, MD, MSPH – Associate Professor in Endocrinology and Maternal-Fetal Professor in Endocrinology and Maternal-Fetal Medicine at the University of Colorado Health Medicine at the University of Colorado Health Sciences Center Sciences Center

WebcastsWebcasts

Gestational Diabetes:Gestational Diabetes: New New Concepts, New GuidelinesConcepts, New Guidelines

Provided 2 free webcasts in February & March Provided 2 free webcasts in February & March 2007 – 101 active participants, 20 online archive 2007 – 101 active participants, 20 online archive participantsparticipants

Presented findings from the recent landmark trials Presented findings from the recent landmark trials which shaped the recommendations from the 5th which shaped the recommendations from the 5th International Workshop on Gestational DiabetesInternational Workshop on Gestational Diabetes

Offered 1.5 CME (through 3/08) - $15Offered 1.5 CME (through 3/08) - $15 Disk archive still available through DPCPDisk archive still available through DPCP

Clinical and Nutrition Clinical and Nutrition Guidelines for GDMGuidelines for GDM

•Partnered with Colorado Partnered with Colorado Clinical Guidelines Clinical Guidelines CollaborativeCollaborative

•More than 6,000 printed and More than 6,000 printed and distributed to date distributed to date

•Distribution to physicians, Distribution to physicians, midwives, community health midwives, community health workers through variety of workers through variety of avenuesavenues

Increase knowledge of standard of care for GDM

GDM Guideline GDM Guideline RecommendationsRecommendations

Early screening & education for high-risk Early screening & education for high-risk womenwomen

Universal screening between 24-28 weeks Universal screening between 24-28 weeks of pregnancy of pregnancy

Follow-up glucose test at the 6-week Follow-up glucose test at the 6-week postpartum appointment to determine if postpartum appointment to determine if the woman has developed type 2 the woman has developed type 2 diabetes, pre-diabetes or has a normal diabetes, pre-diabetes or has a normal blood sugar. blood sugar.

GDM Tool Kit DevelopmentGDM Tool Kit Development

1-hour and 3-hour Instruction Sheet1-hour and 3-hour Instruction SheetMy Diabetes RecordMy Diabetes RecordGDM FlowsheetGDM FlowsheetWeight Gain GridWeight Gain GridPostpartum Flyer & Reminder CardPostpartum Flyer & Reminder CardEducational MaterialsEducational MaterialsBASIC MaterialsBASIC MaterialsWeb ResourcesWeb Resources

Regional On-Site TrainingsRegional On-Site Trainings Recognize Risk Factors for GDMRecognize Risk Factors for GDM Learn to relate all Guidelines to Learn to relate all Guidelines to

GDM practiceGDM practice Recognize client challenges and Recognize client challenges and

barriers to adequate carebarriers to adequate care Be aware of educational resources Be aware of educational resources

and tools for GDMand tools for GDM Understand long term risk of GDM in Understand long term risk of GDM in

the development of type 2 diabetes the development of type 2 diabetes in mother/childin mother/child

Discuss GDM network and current Discuss GDM network and current systems within each community and systems within each community and ways to expand these systemsways to expand these systems

Training SuccessTraining Success

8 regional trainings were completed with 254 8 regional trainings were completed with 254 individuals attending the 6 hour workshopindividuals attending the 6 hour workshop

66% of the workshop participants completed a 66% of the workshop participants completed a personal action planpersonal action plan

Of those who completed a personal action plan, Of those who completed a personal action plan, 85% took actions in their work as a result of 85% took actions in their work as a result of attending the training. attending the training.

Differences from pre Differences from pre post knowledge in the post knowledge in the areas addressed in the objectives was areas addressed in the objectives was statistically significant based on self assessmentstatistically significant based on self assessment

Training Success (cont.)Training Success (cont.)

3-6 months after the training, participants 3-6 months after the training, participants working in a clinical setting, related that they working in a clinical setting, related that they were following the recommendations in the were following the recommendations in the clinical guidelines regarding: clinical guidelines regarding: Early Risk Assessment at Initial Visit - 78%Early Risk Assessment at Initial Visit - 78% Universal Screening at 24-28 weeks - 68%Universal Screening at 24-28 weeks - 68% Postpartum Follow-up with 2-hour OGTT - 56%Postpartum Follow-up with 2-hour OGTT - 56%

25% of individuals from the training contacted 25% of individuals from the training contacted another participant who could be a resourceanother participant who could be a resource

23% of workshop participants reordered 23% of workshop participants reordered educational materialseducational materials

Educational MaterialsEducational Materials

Free to training participantsFree to training participants International Diabetes CenterInternational Diabetes CenterNational Diabetes Education ProgramNational Diabetes Education Program

ChallengesChallenges

Changing medical practice is difficult to Changing medical practice is difficult to achieveachieve

Specialty medical care for GDM can be Specialty medical care for GDM can be difficult to obtain in rural areasdifficult to obtain in rural areas

Lessons LearnedLessons Learned

Having a physician champion was an Having a physician champion was an integral component of our successintegral component of our success

Developing a standard of care brought Developing a standard of care brought together a network of providers offering together a network of providers offering the same messagethe same message

Using multiple methods of distribution Using multiple methods of distribution helped us to reach as many providers as helped us to reach as many providers as possiblepossible

Future Data on GDM in Future Data on GDM in ColoradoColorado

Starting in 2009: New PRAMS Questions Starting in 2009: New PRAMS Questions added to monitor universal screening rates, added to monitor universal screening rates, postpartum follow-up and adequacy of GDM postpartum follow-up and adequacy of GDM educationeducationDuring this pregnancy, did you have a blood test During this pregnancy, did you have a blood test

that required you to drink a very sweet liquid at that required you to drink a very sweet liquid at 6-7 months of pregnancy? 6-7 months of pregnancy?

Since you new baby was born, have you been Since you new baby was born, have you been tested for diabetes or high blood sugar?tested for diabetes or high blood sugar?

Future Data on GDM in Future Data on GDM in Colorado (cont.)Colorado (cont.)

During this pregnancy, when you were told During this pregnancy, when you were told that you had GDM, did a doctor, nurse or that you had GDM, did a doctor, nurse or other health care worker do any of the things other health care worker do any of the things listed below:listed below:Refer you to a nutritionist/dietitianRefer you to a nutritionist/dietitianTalk to you about the importance of exercise/being Talk to you about the importance of exercise/being

physically activephysically activeTalk to you about getting to and staying at a Talk to you about getting to and staying at a

healthy weight after deliveryhealthy weight after deliverySuggest that you breastfeed your new babySuggest that you breastfeed your new babyTalk to you about your risk for developing type 2 Talk to you about your risk for developing type 2

diabetesdiabetes

Continued GDM WorkContinued GDM Work

Update to the Guidelines based on review Update to the Guidelines based on review of recently released studiesof recently released studies

Hyperglycemia and Adverse Pregnancy Outcome Hyperglycemia and Adverse Pregnancy Outcome Study (HAPO)Study (HAPO)

National Institute of Child Health and Human National Institute of Child Health and Human Development (NICHD)Development (NICHD)

MiG TrialMiG Trial

Additional webcasts addressing GDM Additional webcasts addressing GDM Clinical Guidelines and Nutrition GuidelinesClinical Guidelines and Nutrition Guidelines

Potential online learning module for clientsPotential online learning module for clients

ConclusionConclusion Create a standard of care for women at risk Create a standard of care for women at risk

for, and diagnosed with, GDM to improve the for, and diagnosed with, GDM to improve the health status of women during pregnancy and health status of women during pregnancy and their birth outcomes.their birth outcomes.

Use a systems approach to establish a Use a systems approach to establish a powerful network of healthcare professionals powerful network of healthcare professionals and community workers that speak uniformly and community workers that speak uniformly to women with GDM for improved access and to women with GDM for improved access and quality care in Colorado.quality care in Colorado.

THANK YOU!THANK YOU!Mandy McCulloch, RDMandy McCulloch, RD

303-692-2495303-692-2495mandy.mcculloch@state.co.us mandy.mcculloch@state.co.us

http://www.cdphe.state.co.us/pp/diabetes/index.html