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Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Review
Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies Emer Van Ryswyk a,*, Philippa Middleton a,1, William Hague a,2, Caroline Crowther a,b,3 a
Australian Research Centre for Health of Women and Babies (ARCH), Robinson Research Institute, School of Paediatrics and Reproductive Health, The University of Adelaide, 72 King William Road, North Adelaide, 5006, Adelaide, SA, Australia b Liggins Institute, The University of Auckland, Private Bag 92019 Victoria Street West, Auckland 1142 West Auckland 1142, New Zealand
article info
abstract
Article history:
Aim: To examine clinician views and knowledge regarding postpartum healthcare provi-
Received 14 February 2014
sion for women who have experienced gestational diabetes (GDM).
Received in revised form
Methods: Systematic review that searched PubMed, Web of Science, EMBASE and CINAHL.
9 May 2014
Qualitative studies and surveys, with clinicians as participants, which reported pre-speci-
Accepted 5 September 2014
fied outcomes, including barriers and facilitators to postpartum care for GDM, were includ-
Available online xxx
ed. Two authors independently assessed quality and undertook thematic synthesis. Results: Eleven surveys and two interview studies were included (4435 clinicians). Key
Keywords:
themes included adequacy of knowledge of risk of type 2 diabetes mellitus (T2DM), gaps
Gestational diabetes mellitus
between knowledge and practice relating to postpartum screening, and differing percep-
Postpartum
tions of the value of postpartum screening. Clinicians perceived that women faced obstacles
Healthcare
to accessing healthcare, and a need for improved GDM education. Studies reported shortfalls in systems to ensure postpartum screening occurs, and a need to improve communication and collaboration relating to care of women who have experienced GDM. The surveys were often limited in their depth and ability to identify remedial strategies. Conclusions: Barriers to provision of care for women who have had GDM, such as lack of communication of the diagnosis, need to be addressed, and further interview studies exploring clinician views on screening for T2DM are required. # 2014 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author. Tel.:+61 8 8313 1369; fax: +61 8 8313 1406. E-mail addresses: [email protected], [email protected] (E. Van Ryswyk), [email protected] (P. Middleton), [email protected] (W. Hague), [email protected], [email protected] (C. Crowther). 1 Tel.: + 61 8 8161 7612. 2 Tel.: + 61 8 8161 7619 3 Tel.: + 61 8 8161 7619/+64 9 923 6011. http://dx.doi.org/10.1016/j.diabres.2014.09.001 0168-8227/# 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
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Contents 1. 2.
3.
4.
5.
1.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Selection of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Study selection process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Overview of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.1. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.2. Quality assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.1. Clinician knowledge and views . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.2. Communication and collaboration between clinicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.3. Healthcare systems, training and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.4. Clinicians’ perceptions of the needs and attitudes of women who have experienced GDM Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Summary of the main results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Overall completeness and applicability of evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3. Quality of the evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4. Strengths and limitations of this review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5. Agreements and disagreements with other studies or reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1. Implications for practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2. Implications for research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction
Gestational diabetes mellitus (GDM) is a strong predictor of future risk for Type 2 diabetes mellitus (T2DM) [1,2]. Women who have experienced GDM are advised to be screened for T2DM after giving birth. For these women, the risk of development of T2DM in the first 10 years is almost 20% [2,3], and over their lifetime may be greater than 70% [4]. International and national bodies recommend postpartum screening following GDM [5–9], but rates of such screening are sub-optimal in many health facilities worldwide; a recent systematic review found that over a quarter of women who had experienced GDM did not subsequently complete postpartum screening (27–66% completion rate) [10]. Whilst in some areas, the rate of postpartum screening may be rising [11], in others, rates continue to be low. A recent study examining electronic records from 127 primary care practices across England found that just 18.5% of women who had experienced GDM had blood glucose testing within 6 months after giving birth [12]. It is likely that many healthcare related factors contribute to lower rates of follow-up, such as fragmentation of care between obstetricians and primary care providers [13], lack of communication or documentation of the diagnosis of GDM [14], inconsistent guidance [15], lack of knowledge about the association between GDM and future risk of T2DM and perceived lack of efficacy of preventative measures by caring
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clinicians [13]. It is therefore important to identify and modify these factors where possible, to ensure optimal postpartum care of women with GDM. The objective of this systematic review is to synthesise thematically results from qualitative and survey studies that include clinicians as participants, in order to identify the healthcare-related factors influencing postpartum provision of care for women who have experienced GDM.
2.
Methods
The protocol for this review is registered with the international systematic review register PROSPERO (CRD42013003619).
2.1.
Search strategy
PubMed, EMBASE, Web of Science, and CINAHL were searched from inception to 27th February 2013, with no date or language restrictions. The full search strategy is available in Appendix A. Reference lists of included studies were searched for additional studies. Titles and abstracts were examined for eligibility by one author. The full text of studies that appeared to meet inclusion criteria were assessed independently by two authors, with a final list of included studies resulting from discussion and consensus between two authors.
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
DIAB-6153; No. of Pages 11 diabetes research and clinical practice xxx (2014) xxx–xxx
2.2.
Selection of studies
Studies were selected for inclusion in the review if they met the following criteria: (a) qualitative study, or survey (b) participants were clinicians who provide care to women who have experienced GDM (including any health professional providing such care and not limited to doctors, midwives, nurses) and (c) reported at least one of the following pre-specified outcomes: Primary outcomes (1) Barriers to provision of healthcare for women with GDM after birth. (2) Facilitators of provision of healthcare for women with GDM after birth. Secondary outcomes (1) Knowledge of risk of T2DM (following GDM diagnosis). (2) Knowledge of guidelines regarding follow-up care for women with GDM. (3) Opinions of guidelines regarding follow-up care for women with GDM. (4) Attitudes towards postpartum follow-up of women with GDM. (5) Attitudes towards postpartum blood glucose testing of women with GDM. (6) Attitudes towards reminders for follow-up or blood glucose testing of women with GDM.
full-text articles. After removal of duplicates and exclusion on the basis of title and abstract alone, two authors assessed 19 records for inclusion (full-text of 14 studies plus 3 additional abstract/letter records for the same studies and the abstract only for 2 studies). Four studies were excluded [21–25]. One study was identified from the reference list of included studies [26]. As a result of this process, 13 studies were included (Fig. 1).
3.2.
Overview of studies
3.2.1.
Study characteristics
A summary of the characteristics of the included studies is provided in Table 1. These 13 studies included data from 4435 clinicians (obstetrician–gynaecologists, internal medicine physicians, consultant diabetologists, family physicians, paediatric specialists, family medicine residents, midwives, nurse–practitioners and a dietician). Eleven included studies were surveys (conducted by post, online, over telephone or fax), while the other two studies involved interviews [27,28]. Eight of the studies were conducted in the United States [14,26,29–34]; two of these studies were nationwide [26,34], while the other surveys were conducted in Texas [29], North Carolina [30], Massachusetts [14], Oregon [31] and Ohio [31,33]. The remaining five studies were conducted in various countries: England [35], India [36–38], Canada [39,40], Sweden [28] and Tonga [27].
3.2.2. 2.3.
Data extraction
Two authors (EH and PM) independently extracted data on the characteristics, pre-specified outcomes, and funding sources of the included studies.
2.4.
Quality assessment
Quality assessment was carried out using the Critical Appraisal Skills Programme (CASP) checklist for qualitative studies [16]. Any differences between assessments were resolved through discussion amongst authors.
2.5.
Data synthesis
Qualitative research synthesis is an evolving area, with continuing discussion regarding search methods, quality assessment and synthesis [17]. Thematic synthesis was chosen due to its successful application in previous systematic reviews of qualitative studies [17–19]. The independently extracted outcome data from each included study were compared and finalised by two authors (EH and PM); potential themes and theme categories were then identified, discussed and modified until a final decision regarding each was reached.
3.
Results
3.1.
Study selection process
This systematic review is reported in accordance with the PRISMA statement [20]. We identified 1249 abstracts and
3
Quality assessment
All included studies were appraised using the 10-item CASP checklist for qualitative studies [16] (Table 2). One study met all of the criteria for quality assessment [27]. In all other studies, it was unclear whether one or more quality assessment criteria were met. The two studies with the lowest quality assessment ratings were not full-text articles, with many aspects of interest not described. All studies unambiguously stated their aims and objectives, and in all cases, a qualitative assessment (i.e., research seeking to interpret or illuminate the actions and/or subjective experiences of research participants) was warranted. Ten studies did not clearly meet criteria for reporting details on ethical considerations, including ethics approval, confidentiality and informed consent, although the two interview studies and one of the surveys fulfilled these criteria [27,28,30]. Similarly, implications of the relationship between the various researchers and the participants were not mentioned in ten studies. Research design, recruitment and data collection methods were adequately described and justified in most of the included studies. Response rates ranged from 39% to 93% in the surveys, with the two interview studies achieving 86% and 100% completion, respectively [27,28]. Seven studies did not clearly meet the quality assessment criteria relating to data analysis, because of either insufficient details of the analysis process being available to allow assessment, incomplete reporting of results or potential author bias. Findings were effectively communicated in the majority of the studies. In four of the studies it was unclear how the findings arose from the results of the study, and more detailed descriptions of the findings would have been useful. Generally, the research value
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
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Records idenfied through database searching (n = 1249 )
Records aer duplicates removed (n = 873)
Records excluded based on tle and abstract (n = 854)
Full-text of studies assessed for eligibility for this review (n = 16) (19 records)
Included studies (n =12) (14 records)
Studies excluded base on full-text (n = 4) (5 records) - Did not meet parcipant inclusion criterion (n = 1) - Did not report any of the outcomes of interest (n = 3)
Addional studies idenfied through reference lists (n = 1)
Final list of Included studies (n =13)
Fig. 1 – Flow chart of study selection, with reasons for exclusion.
was well communicated in the included studies, although five of the included studies had limited coverage of implications of their findings and requirements for further research.
training and guidelines, and (4) clinician perceptions of women’s needs and attitudes (Table 3).
3.3.1. 3.3.
Data synthesis
Synthesis led to the identification of four theme categories: (1) clinician knowledge and views, (2) communication and collaboration between clinicians, (3) healthcare systems,
Clinician knowledge and views
Eleven studies asked clinicians about their knowledge of the risk of T2DM in women with a history of GDM; in ten of those studies, the majority of clinicians were aware of the risk of T2DM for women with a history of GDM [14,26,28,30,31, 33–36,39]. In two studies, clinicians were not specifically asked
Table 1 – Characteristics of included studies. Study Surveys Power [34] Gabbe [26] Weaver [29] Baker [30] Stuebe [14] Hunsberger [31] Oza-Frank [32] Ko [33] Keely [39] Pierce [35] Divakar [36] Interviews Persson [28] Doran [27]
Location
Data collection
Date
Participants
US (nationwide) US (nationwide) Texas, US North Carolina, US Massachusetts, US Oregon, US Ohio, US Ohio, US Ottawa, Canada England India
Post Post Post Postal Online Post Post & online Post & online Fax, or telephone Post Online
Unclear 1996 Unclear 2005–2006 Unclear 2005 2010 2010 2006–2007 2008–2009 Unclear
510 493 347 399 207 285 936 155 173 324 584
Sweden Nuku’alofa, Tonga
Semi-structured Semi-structured
2005–2007 2006
12 NM 10 NM, dietician, physician (NS)
OB/GYN OB/GYN FP FP, OB/GYN, NM OB/GYN, NM, FP, IM, PAED, NS FM, OB/GYN FP, IM, OB/GYN, NM NM FP IM, OB/GYN OB/GYN
Response (%) 55 39 45 40 43 42 46 62 78 93 58 86 100
OB/GYN = obstetrician/gynaecologist, FP = family physician, NM = nurse-midwife, NP = nurse practitioner, IM = internal medical physician, PAED = paediatric or adolescent medical physician, NS = not specified.
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
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Table 2 – Quality assessment of included studies.
about their knowledge of the risk of T2DM, although knowledge was implied. In four of the 10 studies where the knowledge level was found to be moderately good, clinician responses indicated a gap between clinician appreciation of risk of T2DM, and the practice of screening for T2DM; for example, in Baker 2009, 71% of clinicians were aware of increased risk of type 2 DM, although only 21% always screened for type 2 DM postpartum in women with a history of GDM [30]. Six studies recounted the views of clinicians relating specifically to the value or priority placed on postpartum glucose screening, with two studies relaying positive views, but four studies indicated more negative views of the value of postpartum glucose screening amongst some clinicians [30,31,33,34]. For example, screening women with a history of GDM for T2DM was considered to be a ‘‘low priority’’ by 55% of participants (certified nurse–midwives) in Ko [33] and by 58% of family medicine doctors/60% of obstetrician-gynaecologists in Hunsberger [31]. In two of these four latter studies, clinicians said that they were too busy or time poor for adequate provision of postpartum healthcare for GDM [30,34]. The two studies in which clinicians were interviewed [27,28] revealed three additional facilitators of postpartum follow-up, which were all proactive approaches taken by clinicians. These were giving advice to women about their future risk of T2DM, aiming to motivate women to change their lifestyle, and aiming to create empowering relationships with the women.
3.3.2.
Communication and collaboration between clinicians
Themes relating to communication and/or collaboration between clinicians were found in most of the studies. Noncommunication of the diagnosis of GDM was the most common theme. In Oza-Frank [32], fewer than 5% of family practice or internal medicine physicians said they ‘‘always’’
had access to a woman’s GDM status. In Pierce [35], almost 19% (167/900) of primary care physicians said that they had ‘‘difficulties finding out’’ that their patient had GDM. In Keely [39], 5% of family physicians (n = 3) said that they did not screen women for T2DM as they ‘‘Did not know the patient had GDM.’’ This lack of communication between clinicians regarding GDM was explored in more detail in Stuebe [14]. In this study, most primary care physicians (78/127, 62%) indicated that in more than 75% of cases, they did not receive information about the pregnancy outcome or complications for women to whom they were providing care to. Similarly, 40% of prenatal care providers in the study said that they updated their electronic medical record list of diagnoses (‘‘problem list’’) to include GDM ‘‘less than half of the time.’’ Difficulties with collaboration, or arranging referrals to specialists were highlighted but not further explored in two studies. In Baker [30], 13% of health providers stated that their provision of postpartum healthcare was limited by lack of ‘‘collaboration with specialists’’ [30], whilst in Power [34], about half of obstetric doctors agreed or strongly agreed that ‘‘arranging referrals to specialists’’ was a ‘‘barrier to providing appropriate treatment.’’ A need to clarify responsibility for GDM follow-up was also identified [28,35,39]. For example, in the Pierce [35] study, 716 general practitioners (GPs) and 323 specialists (obstetric doctors and diabetologists) were asked who was responsible for ordering glucose tests for type 2 diabetes after pregnancy; about 26% of GPs and 89% of specialists said ‘‘hospital,’’ 47% of GPs and 8% of specialists said ‘‘general practice,’’ 26% of GPs and 7% of specialists said there was ‘‘no clear responsibility,’’ and 3.5% of GPs/1% of specialists said ‘‘don’t know.’’ Finally, one study that included trainee family medicine doctors (in residency programs) found that lack of continuity of care for women with GDM was a barrier to optimal healthcare provision [29].
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
Type of study Location
Clinician knowledge and views Most clinicians aware of risk of T2DM Gap between knowledge and practice of screening for T2DM Value or priority of PP glucose screening: Low/moderate High/Cost-effective Practice too busy Pro-active approaches: Giving advice for prevention of T2DM Aiming to motivate women to change their lifestyle Creating empowering relationships with women Communication and collaboration between clinicians Lack of communication regarding diagnosis of GDM Need to improve collaboration with other clinicians Need to clarify responsibility for follow-up of GDM PP Lack of continuity of care–barrier to follow-up PP
US (nationwide) Power [34]
Gabbe [26]
Interviews
Texas, US
North Carolina, US
Massachusetts, US
Oregon, US
Weaver [29]
Baker [30]
Stuebe [14]
Hunsberger [31]
Ko [33]
Ohio, US Oza-Frank [32]
Canada
England
India
Sweden
Keely [39]
Pierce [35]
Divakar [36]
Persson [28]
Tonga
Doran [27]
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Study ID
Surveys
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Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
Table 3 – Theme categories and themes.
Study ID Healthcare systems, training and guidelines Need for: Systematic methods of ensuring follow-up after pregnancy Training - GDM postpartum follow-up Definitive, consistent guidelines Health promotion - diabetes prevention Clinician perceptions of women’s needs and attitudes Healthcare opportunity not taken up by women Improved GDM education required Healthcare access barrier Improved self-preventive care required Screening as a foreign idea View of midwives as counsellors not diabetes experts
US (nationwide) Power [34]
Gabbe [26]
Interviews
Texas, US
North Carolina, US
Massachusetts, US
Oregon, US
Weaver [29]
Baker [30]
Stuebe [14]
Hunsberger [31]
Ohio, US
Canada
England
India
Sweden
Divakar [36]
Persson [28]
Ko [33]
Oza-Frank [32]
Keely [39]
Pierce [35]
Tonga
Doran [27]
Abbreviations: Postpartum (PP), gestational diabetes mellitus (GDM), type 2 diabetes mellitus (T2DM).
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Surveys
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Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
Type of study
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3.3.3.
Healthcare systems, training and guidelines
Themes relating to healthcare systems, training and guidelines were described in 10 studies. Six of these studies indicated a requirement for systematic methods of ensuring postpartum follow-up, including reminders, intake forms covering GDM history, and/or defined postpartum follow-up protocols [14,30,32,33,35,39]. Clinicians had very positive views of the potential for reminders to facilitate their provision of postpartum care, with 87% of family physicians in the Keely [39] study indicating that the postal reminder they received was useful, 64% agreeing that the reminder contributed to their decisions to screen, and for those who did not receive reminder letters, 83% thought it would be beneficial to receive one. Similarly, in two other studies, many clinicians indicated that automatic reminders in patient charts or electronic medical records would be beneficial [32,33]. Deficiencies in education and training for clinicians regarding GDM postpartum follow-up were also apparent, especially for issues such as how to respond to abnormal blood glucose results [14,29,30,33,34]. In a small number of cases, clinicians articulated a need for more consistent, definitive guidelines, indicating that conflicting guidelines may be a source of confusion. In addition, one study highlighted the benefits of public health promotion relating to diabetes prevention as a facilitator to healthcare provision.
3.3.4. Clinicians’ perceptions of the needs and attitudes of women who have experienced GDM Clinicians’ perceptions regarding the needs of women who have experienced GDM, and their attitudes were explored in eight studies. In five studies, clinicians perceived that women were not taking up healthcare opportunities [28,30,34,39]. These included not attending appointments, and non-completion of glucose testing. Although, healthcare access barriers were recognised by clinicians in three studies from the United States [30,32,34], particularly with regards to financial cost to women. Facilitation of improved self-preventive care for women was recognised as an important task by some clinicians, with more than two-thirds of obstetrician/gynaecologists and midwives in Oza-Frank [32], and 72% of nurse–midwives in Ko reporting a need for ‘‘increased patient responsibility for self-preventive care’’ [32,33]. Three studies highlighted a need to ensure the availability of appropriate GDM educational materials for women [14,32,34], and almost half (49%) of respondent nurse–midwives in Ko [33] thought that there was a need to improve GDM patient education. [27,28]. A perception that women view midwives as counsellors rather than diabetes experts was seen also as a potential barrier [28].
4.
Discussion
4.1.
Summary of the main results
Most clinicians knew of the substantial risk of T2DM in women who had a history of GDM, but there was a gap between this knowledge level, and their actual practice of postpartum screening. Several barriers prevented clinicians from
providing care to women with GDM after pregnancy. Clinicians providing postnatal care for these women often never found out about the GDM diagnosis, or had some difficulty with doing so. This could be improved by using systematic methods of ensuring postpartum care, such as reminder systems, about which clinicians had positive views. Where the diagnosis of GDM was known, clinicians faced further barriers, such as deficiencies in their knowledge and training regarding follow-up, being unsure who was responsible for postpartum care, and difficulty with collaboration with specialists. Often clinicians observed that healthcare opportunities were not being taken up by women, and some thought women could benefit from taking greater responsibility for their own health in terms of prevention of T2DM. At the same time, clinicians recognised deficiencies in the GDM education and support available, and that the women faced significant barriers, particularly financial barriers, to attendance for care and glucose test completion. Some clinicians thought that facilitators of provision of healthcare to women who had had GDM included creating an empowering relationship, providing advice about future risk of T2DM, and public health promotion relating to T2DM prevention.
4.2.
Overall completeness and applicability of evidence
Most of the included studies were surveys, rather than interviews or focus group studies, and this limited the depth of exploration of the topics of interest. However, use of survey designs resulted in the possibility of assessing knowledge, views and practices of a much larger number of relevant clinicians than interviews alone would allow. While there was variation in locations and settings of the included studies, there were strong themes that were identifiable across studies.
4.3.
Quality of the evidence
The majority of the included studies were of moderate-togood quality, as assessed with the CASP tool. Aims, research design, recruitment and data collection were generally well described. Additionally, findings and implications were adequately communicated. However, more details regarding ethical considerations and data analysis were needed in many of the studies, and the authors neglected to discuss the relationship between themselves and their participants, and how this may have influenced their findings.
4.4.
Strengths and limitations of this review
This systematic review of qualitative and survey studies synthesises the views and knowledge of clinicians who provide care to women who have experienced GDM, relating to provision of healthcare in the postpartum period. The strengths of this review include well defined pre-specified outcomes, as well as not using date or language restrictions in the search process. Furthermore, abstracts, as well as fulltext articles were eligible for inclusion, enhancing the breadth of information. Review author bias in assessment and analysis was minimised by two authors independently assessing the full-text of potentially eligible studies, extracting data, appraising study quality, and analysing data. Quality
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
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assessment was undertaken using an unmodified and respected quality assessment method.
4.5. Agreements and disagreements with other studies or reviews The inadequate communication of the diagnosis of GDM, which was often apparent within the included studies, was previously noted by Keely [13] and in another recent systematic review [41]. Keely wrote about the possibility that a perceived lack of efficacy of preventive measures may play a role in sub-optimal screening, and our results agree with this suggestion. Another possibility put forward by the same author was that healthcare providers may not fully appreciate the risk of T2DM following GDM, but this was not demonstrated to be the case within the studies that we reviewed. An impact of financial cost to women on postpartum healthcare attendance was apparent in three included studies from the United States [30,32,34], which may reflect the relatively high out-of-pocket healthcare costs in this country [42]. However, it should be noted that financial impact is not always correlated with postpartum attendance for glucose screening, as screening in Australia is reportedly higher than in England, despite the lower out-of-pocket cost in England [12,42,43]. A recent systematic review examining system-based factors influencing postpartum GDM testing rates [44], with 54 included studies, found that systematic approaches to improving follow-up were associated with higher postpartum testing rates. Our systematic review found that whilst such systems were being underutilised, clinicians expressed positive views towards them.
5.2.
9
Implications for research
More research is required into developing strategies to improve postpartum care for women with recent GDM, such as ways to improve communication between clinicians regarding GDM diagnosis and care. Studies that focus on improving clinician education relating to postpartum care recommendations are necessary. It is important to investigate methods of education provision for women who have experienced GDM so that they can be optimally informed about their ongoing risk of T2DM. There is also a need to raise awareness of the risks of GDM and subsequent T2DM for women, using public health promotion methods.
Conflict of interest statement The authors of this review are investigators for the DIAMIND study: postpartum SMS reminders to women who have had gestational diabetes mellitus to test for type 2 diabetes: a randomised controlled trial [45]. The authors declare that they have no financial conflict of interest.
Grant support No grant support was received for this systematic review. All authors are currently in receipt of funding from the HCF Health and Medical Research Foundation for the DIAMIND Study: Postpartum text message reminders to test for type 2 diabetes in women who have experienced GDM.
Acknowledgements 5.
Conclusion
5.1.
Implications for practice
Many barriers to provision of healthcare in the postpartum period for women who have experienced GDM exist, and there is a gap between clinician knowledge regarding the risk of T2DM following GDM, and practice of postpartum screening of these women. Lack of communication of the diagnosis of GDM amongst clinicians is a key issue, which could be improved using systematic methods, such as always having documentation of the diagnosis of GDM in diagnostic lists shared between clinicians (in discharge summaries or electronic medical records), having new patient intake forms or checklists for clinicians which ask about past history of GDM, or by utilising reminder systems for clinicians and/or women. There is a need to clarify responsibility for follow up of women with GDM, to improve referral pathways between GDM-related care providers, and to ensure that clinician training covers important details regarding postpartum screening (e.g. how to respond to abnormal test results). For women who are diagnosed with GDM, it is important that they are provided with appropriate and timely verbal and written education on their condition and associated short-term and long-term risks. It is equally important to ensure that obstacles to women accessing healthcare, such as cost, are minimised.
Thank you to Michael Draper, who provided guidance and assistance with development of the search strategy for this review.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.diabres.2014.09.001.
references
[1] Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet 2009;373:1773–9. [2] Feig DS, Zinman B, Wang X, Hux JE. Risk of development of diabetes mellitus after diagnosis of gestational diabetes. CMAJ 2008;179:229–34. [3] Lee AJ, Hiscock RJ, Wein P, Walker SP, Permezel M. Gestational diabetes mellitus: clinical predictors and longterm risk of developing type 2 diabetes: a retrospective cohort study using survival analysis. Diabetes Care 2007;30:878–83.
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
DIAB-6153; No. of Pages 11
10
diabetes research and clinical practice xxx (2014) xxx–xxx
[4] Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002;25:1862–8. [5] Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, 37. Canadian Diabetes Association 2013; 2013. p. S1–2. Suppl 1. [6] American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care 2013;36(Suppl 1):S11–66. [7] National Institute for Health and Care Excellence. Diabetes in Pregnancy: Management of Diabetes and Its Complications [CG63]. London: National Institute for Health and Care Excellence; 2008. [8] IADPSG Consensus Panel. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676–82. [9] Nankervis A, McIntyre HD, Moses R, Ross GP, Callaway L, Porter C, et al. ADIPS Consensus Guidelines for the Testing and Diagnosis of Gestational Diabetes Mellitus in Australia. Available from http://www.adips.org/downloads/ ADIPSConsensusGuidelinesGDM03.05.13VersionACCEPTEDFINAL.pdf. 2013. [10] Tovar A, Chasan-Taber L, Eggleston E, Oken E. Postpartum screening for diabetes among women with a history of gestational diabetes mellitus. Prev Chronic Dis 2011; 8:A124. [11] Dietz PM, Vesco KK, Callaghan WM, Bachman DJ, Bruce FC, Berg CJ, et al. Postpartum screening for diabetes after a gestational diabetes mellitus-affected pregnancy. Obstet Gynecol 2008;112:868–74. [12] McGovern A, Butler L, Jones S, van Vlymen J, Sadek K, Munro N, et al. Diabetes screening after gestational diabetes in England: a quantitative retrospective cohort study. Br J Gen Pract 2014;64:317–23. [13] Keely E. An opportunity not to be missed—how do we improve postpartum screening rates for women with gestational diabetes. Diabetes Metab Res Rev 2012;28:312–6. [14] Stuebe A, Ecker J, Bates DW, Zera C, Bentley-Lewis R, Seely E. Barriers to follow-up for women with a history of gestational diabetes. Am J Perinatol 2010;27:705–10. [15] Bentley-Lewis R, Levkoff S, Stuebe A, Seely EW. Gestational diabetes mellitus: postpartum opportunities for the diagnosis and prevention of type 2 diabetes mellitus. Nat Clin Pract Endocrinol Metab 2008;4:552–8. [16] Critical Appraisal Skills Programme (CASP). Qualitative Research Checklist. Oxford. Available from hhttp:// www.casp-uk.neti [accessed 18/12/2013]. [17] Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008;8:45. [18] Tong A, Morton R, Howard K, Craig JC. Adolescent experiences following organ transplantation: a systematic review of qualitative studies. J Pediatr 2009;155:542–9. [19] Schumann I, Schneider A, Kantert C, Lowe B, Linde K. Physicians’ attitudes, diagnostic process and barriers regarding depression diagnosis in primary care: a systematic review of qualitative studies. Fam Pract 2012;29:255–63. [20] Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. BMJ 2009;339:b2535. [21] Hanna FWF, Peters JR, Harlow J, Jones PW. Discrepancy between postnatal and antenatal management of gestational diabetes in the U.K. Diabetes Care 2007;30:e64–70. [22] Hanna FWF, Peters JR, Harlow J, Jones PW. Gestational diabetes screening and glycaemic management; national survey on behalf of the Association of British Clinical
[23]
[24]
[25]
[26]
[27]
[28]
[29] [30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
Diabetologists. QJM 2008;101:777–84 (an International Journal of Medicine). Persson M, Hornsten A, Winkvist A, Mogren I. ‘Dealing with ambiguity’—the role of obstetricians in gestational diabetes mellitus. Acta Obstet Gynecol Scand 2012;91:439–46. Risa CF, Lide´n E, Friberg F. Communication patterns in antenatal diabetes care: an explorative and descriptive study of midwife-led consultations. J Clin Nurs 2011;20:2053–63. Shera AS, Jawad F, Basit A. Diabetes related knowledge, attitude and practices of family physicians in Pakistan. J Pak Med Assoc 2002;52:465–70. Gabbe S, Hill L, Schmidt L, Schulkin J. Management of diabetes by obstetrician–gynecologists. Obstet Gynecol 1998;91:643–7. Doran F, Davis K. Gestational diabetes mellitus in Tonga: insights from healthcare professionals and women who experienced gestational diabetes mellitus. N Z Med J 2010;123:59–67. Persson M, Hornsten A, Winkvist A, Mogren I. Mission Impossible? Midwives’ experiences counseling pregnant women with gestational diabetes mellitus. Patient Educ Couns 2011;84:78–83. Weaver SP. New research gestational diabetes indicates risk later in life. Fam Med 2004;36:159–60. Baker AM, Brody SC, Salisbury K, Schectman R, Hartmann KE. Postpartum glucose tolerance screening in women with gestational diabetes in the state of North Carolina. N C Med J 2009;70:14–9. Hunsberger ML, Donatelle RJ, Lindsay K, Rosenberg KD. Physician care patterns and adherence to postpartum glucose testing after gestational diabetes mellitus in Oregon. PLoS One 2012;2012. Oza-Frank R. Resources to improve care among women with a history of gestational diabetes: a provider perspective. Diabetes 2012;61:A642. Ko JY, Dietz PM, Conrey EJ, Rodgers L, Shellhaas C, Farr SL, et al. Gestational diabetes mellitus and postpartum care practices of nurse–midwives. J Midwifery Womens Health 2013;58:33–40. Power ML, Wilson EK, Hogan SO, Loft JD, Williams JL, Mersereau PW, et al. Patterns of preconception, prenatal and postnatal care for diabetic women by obstetrician– gynecologists. J Reprod Med 2013;58:7–14. Pierce M, Modder J, Mortagy I, Springett A, Hughes H, Baldeweg S. Missed opportunities for diabetes prevention: post-pregnancy follow-up of women with gestational diabetes mellitus in England. Br J Gen Pract 2011;61:e611–9. Divakar H, Manyonda IT. Battling the rising prevalence of gestational diabetes in India: are clinicians on the right track. J Neonatal Perinat Med 2012;5:261–7. Divakar H, Manyonda I. Battling with rising prevalence of gestational diabetes mellitus: screening and diagnosis. IJIFM 2011;2:96–100. Divakar H, Manyonda IT. Battling with rising prevalence of gestational diabetes mellitus—are clinicians in India on the right track. Perinatology 2012;12:133–9. Keely E, Clark H, Karovitch A, Graham I. Screening for type 2 diabetes following gestational diabetes: family physician and patient perspectives. Can Fam Physician 2010;56:558–63. Clark HD, Graham ID, Karovitch A, Keely EJ. Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial. Am J Obstet Gynecol 2009;200:634 e1–e6347. Nielsen KK, Kapur A, Damm P, de Courten M, Bygbjerg IC. From screening to postpartum follow-up—the determinants and barriers for gestational diabetes mellitus
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
DIAB-6153; No. of Pages 11 diabetes research and clinical practice xxx (2014) xxx–xxx
(GDM) services, a systematic review. BMC Pregnancy Childbirth 2014;14:41. [42] Schoen C, Osborn R, Squires D, Doty MM. Access, affordability, and insurance complexity are often worse in the United States compared to ten other countries. Health Affairs 2013;32:2205–15. [43] Morrison MK, Collins CE, Lowe JM. Postnatal testing for diabetes in Australian women following gestational diabetes mellitus. Aust N Z J Obstet Gynaecol 2009;49:494–8.
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[44] Carson MP, Frank MI, Keely E. Original research: postpartum testing rates among women with a history of gestational diabetes—systematic review. Prim Care Diabetes 2013;7:177–86. [45] Heatley E, Middleton P, Hague W, Crowther C. The DIAMIND study: postpartum SMS reminders to women who have had gestational diabetes mellitus to test for type 2 diabetes: a randomised controlled trial—study protocol. BMC Pregnancy Childbirth 2013;13:92.
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Review
Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies Emer Van Ryswyk a,*, Philippa Middleton a,1, William Hague a,2, Caroline Crowther a,b,3 a
Australian Research Centre for Health of Women and Babies (ARCH), Robinson Research Institute, School of Paediatrics and Reproductive Health, The University of Adelaide, 72 King William Road, North Adelaide, 5006, Adelaide, SA, Australia b Liggins Institute, The University of Auckland, Private Bag 92019 Victoria Street West, Auckland 1142 West Auckland 1142, New Zealand
article info
abstract
Article history:
Aim: To examine clinician views and knowledge regarding postpartum healthcare provi-
Received 14 February 2014
sion for women who have experienced gestational diabetes (GDM).
Received in revised form
Methods: Systematic review that searched PubMed, Web of Science, EMBASE and CINAHL.
9 May 2014
Qualitative studies and surveys, with clinicians as participants, which reported pre-speci-
Accepted 5 September 2014
fied outcomes, including barriers and facilitators to postpartum care for GDM, were includ-
Available online xxx
ed. Two authors independently assessed quality and undertook thematic synthesis. Results: Eleven surveys and two interview studies were included (4435 clinicians). Key
Keywords:
themes included adequacy of knowledge of risk of type 2 diabetes mellitus (T2DM), gaps
Gestational diabetes mellitus
between knowledge and practice relating to postpartum screening, and differing percep-
Postpartum
tions of the value of postpartum screening. Clinicians perceived that women faced obstacles
Healthcare
to accessing healthcare, and a need for improved GDM education. Studies reported shortfalls in systems to ensure postpartum screening occurs, and a need to improve communication and collaboration relating to care of women who have experienced GDM. The surveys were often limited in their depth and ability to identify remedial strategies. Conclusions: Barriers to provision of care for women who have had GDM, such as lack of communication of the diagnosis, need to be addressed, and further interview studies exploring clinician views on screening for T2DM are required. # 2014 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author. Tel.:+61 8 8313 1369; fax: +61 8 8313 1406. E-mail addresses: [email protected], [email protected] (E. Van Ryswyk), [email protected] (P. Middleton), [email protected] (W. Hague), [email protected], [email protected] (C. Crowther). 1 Tel.: + 61 8 8161 7612. 2 Tel.: + 61 8 8161 7619 3 Tel.: + 61 8 8161 7619/+64 9 923 6011. http://dx.doi.org/10.1016/j.diabres.2014.09.001 0168-8227/# 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
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Contents 1. 2.
3.
4.
5.
1.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Selection of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Study selection process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Overview of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.1. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.2. Quality assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.1. Clinician knowledge and views . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.2. Communication and collaboration between clinicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.3. Healthcare systems, training and guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.4. Clinicians’ perceptions of the needs and attitudes of women who have experienced GDM Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Summary of the main results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Overall completeness and applicability of evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3. Quality of the evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4. Strengths and limitations of this review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5. Agreements and disagreements with other studies or reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1. Implications for practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2. Implications for research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction
Gestational diabetes mellitus (GDM) is a strong predictor of future risk for Type 2 diabetes mellitus (T2DM) [1,2]. Women who have experienced GDM are advised to be screened for T2DM after giving birth. For these women, the risk of development of T2DM in the first 10 years is almost 20% [2,3], and over their lifetime may be greater than 70% [4]. International and national bodies recommend postpartum screening following GDM [5–9], but rates of such screening are sub-optimal in many health facilities worldwide; a recent systematic review found that over a quarter of women who had experienced GDM did not subsequently complete postpartum screening (27–66% completion rate) [10]. Whilst in some areas, the rate of postpartum screening may be rising [11], in others, rates continue to be low. A recent study examining electronic records from 127 primary care practices across England found that just 18.5% of women who had experienced GDM had blood glucose testing within 6 months after giving birth [12]. It is likely that many healthcare related factors contribute to lower rates of follow-up, such as fragmentation of care between obstetricians and primary care providers [13], lack of communication or documentation of the diagnosis of GDM [14], inconsistent guidance [15], lack of knowledge about the association between GDM and future risk of T2DM and perceived lack of efficacy of preventative measures by caring
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clinicians [13]. It is therefore important to identify and modify these factors where possible, to ensure optimal postpartum care of women with GDM. The objective of this systematic review is to synthesise thematically results from qualitative and survey studies that include clinicians as participants, in order to identify the healthcare-related factors influencing postpartum provision of care for women who have experienced GDM.
2.
Methods
The protocol for this review is registered with the international systematic review register PROSPERO (CRD42013003619).
2.1.
Search strategy
PubMed, EMBASE, Web of Science, and CINAHL were searched from inception to 27th February 2013, with no date or language restrictions. The full search strategy is available in Appendix A. Reference lists of included studies were searched for additional studies. Titles and abstracts were examined for eligibility by one author. The full text of studies that appeared to meet inclusion criteria were assessed independently by two authors, with a final list of included studies resulting from discussion and consensus between two authors.
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
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2.2.
Selection of studies
Studies were selected for inclusion in the review if they met the following criteria: (a) qualitative study, or survey (b) participants were clinicians who provide care to women who have experienced GDM (including any health professional providing such care and not limited to doctors, midwives, nurses) and (c) reported at least one of the following pre-specified outcomes: Primary outcomes (1) Barriers to provision of healthcare for women with GDM after birth. (2) Facilitators of provision of healthcare for women with GDM after birth. Secondary outcomes (1) Knowledge of risk of T2DM (following GDM diagnosis). (2) Knowledge of guidelines regarding follow-up care for women with GDM. (3) Opinions of guidelines regarding follow-up care for women with GDM. (4) Attitudes towards postpartum follow-up of women with GDM. (5) Attitudes towards postpartum blood glucose testing of women with GDM. (6) Attitudes towards reminders for follow-up or blood glucose testing of women with GDM.
full-text articles. After removal of duplicates and exclusion on the basis of title and abstract alone, two authors assessed 19 records for inclusion (full-text of 14 studies plus 3 additional abstract/letter records for the same studies and the abstract only for 2 studies). Four studies were excluded [21–25]. One study was identified from the reference list of included studies [26]. As a result of this process, 13 studies were included (Fig. 1).
3.2.
Overview of studies
3.2.1.
Study characteristics
A summary of the characteristics of the included studies is provided in Table 1. These 13 studies included data from 4435 clinicians (obstetrician–gynaecologists, internal medicine physicians, consultant diabetologists, family physicians, paediatric specialists, family medicine residents, midwives, nurse–practitioners and a dietician). Eleven included studies were surveys (conducted by post, online, over telephone or fax), while the other two studies involved interviews [27,28]. Eight of the studies were conducted in the United States [14,26,29–34]; two of these studies were nationwide [26,34], while the other surveys were conducted in Texas [29], North Carolina [30], Massachusetts [14], Oregon [31] and Ohio [31,33]. The remaining five studies were conducted in various countries: England [35], India [36–38], Canada [39,40], Sweden [28] and Tonga [27].
3.2.2. 2.3.
Data extraction
Two authors (EH and PM) independently extracted data on the characteristics, pre-specified outcomes, and funding sources of the included studies.
2.4.
Quality assessment
Quality assessment was carried out using the Critical Appraisal Skills Programme (CASP) checklist for qualitative studies [16]. Any differences between assessments were resolved through discussion amongst authors.
2.5.
Data synthesis
Qualitative research synthesis is an evolving area, with continuing discussion regarding search methods, quality assessment and synthesis [17]. Thematic synthesis was chosen due to its successful application in previous systematic reviews of qualitative studies [17–19]. The independently extracted outcome data from each included study were compared and finalised by two authors (EH and PM); potential themes and theme categories were then identified, discussed and modified until a final decision regarding each was reached.
3.
Results
3.1.
Study selection process
This systematic review is reported in accordance with the PRISMA statement [20]. We identified 1249 abstracts and
3
Quality assessment
All included studies were appraised using the 10-item CASP checklist for qualitative studies [16] (Table 2). One study met all of the criteria for quality assessment [27]. In all other studies, it was unclear whether one or more quality assessment criteria were met. The two studies with the lowest quality assessment ratings were not full-text articles, with many aspects of interest not described. All studies unambiguously stated their aims and objectives, and in all cases, a qualitative assessment (i.e., research seeking to interpret or illuminate the actions and/or subjective experiences of research participants) was warranted. Ten studies did not clearly meet criteria for reporting details on ethical considerations, including ethics approval, confidentiality and informed consent, although the two interview studies and one of the surveys fulfilled these criteria [27,28,30]. Similarly, implications of the relationship between the various researchers and the participants were not mentioned in ten studies. Research design, recruitment and data collection methods were adequately described and justified in most of the included studies. Response rates ranged from 39% to 93% in the surveys, with the two interview studies achieving 86% and 100% completion, respectively [27,28]. Seven studies did not clearly meet the quality assessment criteria relating to data analysis, because of either insufficient details of the analysis process being available to allow assessment, incomplete reporting of results or potential author bias. Findings were effectively communicated in the majority of the studies. In four of the studies it was unclear how the findings arose from the results of the study, and more detailed descriptions of the findings would have been useful. Generally, the research value
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
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Records idenfied through database searching (n = 1249 )
Records aer duplicates removed (n = 873)
Records excluded based on tle and abstract (n = 854)
Full-text of studies assessed for eligibility for this review (n = 16) (19 records)
Included studies (n =12) (14 records)
Studies excluded base on full-text (n = 4) (5 records) - Did not meet parcipant inclusion criterion (n = 1) - Did not report any of the outcomes of interest (n = 3)
Addional studies idenfied through reference lists (n = 1)
Final list of Included studies (n =13)
Fig. 1 – Flow chart of study selection, with reasons for exclusion.
was well communicated in the included studies, although five of the included studies had limited coverage of implications of their findings and requirements for further research.
training and guidelines, and (4) clinician perceptions of women’s needs and attitudes (Table 3).
3.3.1. 3.3.
Data synthesis
Synthesis led to the identification of four theme categories: (1) clinician knowledge and views, (2) communication and collaboration between clinicians, (3) healthcare systems,
Clinician knowledge and views
Eleven studies asked clinicians about their knowledge of the risk of T2DM in women with a history of GDM; in ten of those studies, the majority of clinicians were aware of the risk of T2DM for women with a history of GDM [14,26,28,30,31, 33–36,39]. In two studies, clinicians were not specifically asked
Table 1 – Characteristics of included studies. Study Surveys Power [34] Gabbe [26] Weaver [29] Baker [30] Stuebe [14] Hunsberger [31] Oza-Frank [32] Ko [33] Keely [39] Pierce [35] Divakar [36] Interviews Persson [28] Doran [27]
Location
Data collection
Date
Participants
US (nationwide) US (nationwide) Texas, US North Carolina, US Massachusetts, US Oregon, US Ohio, US Ohio, US Ottawa, Canada England India
Post Post Post Postal Online Post Post & online Post & online Fax, or telephone Post Online
Unclear 1996 Unclear 2005–2006 Unclear 2005 2010 2010 2006–2007 2008–2009 Unclear
510 493 347 399 207 285 936 155 173 324 584
Sweden Nuku’alofa, Tonga
Semi-structured Semi-structured
2005–2007 2006
12 NM 10 NM, dietician, physician (NS)
OB/GYN OB/GYN FP FP, OB/GYN, NM OB/GYN, NM, FP, IM, PAED, NS FM, OB/GYN FP, IM, OB/GYN, NM NM FP IM, OB/GYN OB/GYN
Response (%) 55 39 45 40 43 42 46 62 78 93 58 86 100
OB/GYN = obstetrician/gynaecologist, FP = family physician, NM = nurse-midwife, NP = nurse practitioner, IM = internal medical physician, PAED = paediatric or adolescent medical physician, NS = not specified.
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Table 2 – Quality assessment of included studies.
about their knowledge of the risk of T2DM, although knowledge was implied. In four of the 10 studies where the knowledge level was found to be moderately good, clinician responses indicated a gap between clinician appreciation of risk of T2DM, and the practice of screening for T2DM; for example, in Baker 2009, 71% of clinicians were aware of increased risk of type 2 DM, although only 21% always screened for type 2 DM postpartum in women with a history of GDM [30]. Six studies recounted the views of clinicians relating specifically to the value or priority placed on postpartum glucose screening, with two studies relaying positive views, but four studies indicated more negative views of the value of postpartum glucose screening amongst some clinicians [30,31,33,34]. For example, screening women with a history of GDM for T2DM was considered to be a ‘‘low priority’’ by 55% of participants (certified nurse–midwives) in Ko [33] and by 58% of family medicine doctors/60% of obstetrician-gynaecologists in Hunsberger [31]. In two of these four latter studies, clinicians said that they were too busy or time poor for adequate provision of postpartum healthcare for GDM [30,34]. The two studies in which clinicians were interviewed [27,28] revealed three additional facilitators of postpartum follow-up, which were all proactive approaches taken by clinicians. These were giving advice to women about their future risk of T2DM, aiming to motivate women to change their lifestyle, and aiming to create empowering relationships with the women.
3.3.2.
Communication and collaboration between clinicians
Themes relating to communication and/or collaboration between clinicians were found in most of the studies. Noncommunication of the diagnosis of GDM was the most common theme. In Oza-Frank [32], fewer than 5% of family practice or internal medicine physicians said they ‘‘always’’
had access to a woman’s GDM status. In Pierce [35], almost 19% (167/900) of primary care physicians said that they had ‘‘difficulties finding out’’ that their patient had GDM. In Keely [39], 5% of family physicians (n = 3) said that they did not screen women for T2DM as they ‘‘Did not know the patient had GDM.’’ This lack of communication between clinicians regarding GDM was explored in more detail in Stuebe [14]. In this study, most primary care physicians (78/127, 62%) indicated that in more than 75% of cases, they did not receive information about the pregnancy outcome or complications for women to whom they were providing care to. Similarly, 40% of prenatal care providers in the study said that they updated their electronic medical record list of diagnoses (‘‘problem list’’) to include GDM ‘‘less than half of the time.’’ Difficulties with collaboration, or arranging referrals to specialists were highlighted but not further explored in two studies. In Baker [30], 13% of health providers stated that their provision of postpartum healthcare was limited by lack of ‘‘collaboration with specialists’’ [30], whilst in Power [34], about half of obstetric doctors agreed or strongly agreed that ‘‘arranging referrals to specialists’’ was a ‘‘barrier to providing appropriate treatment.’’ A need to clarify responsibility for GDM follow-up was also identified [28,35,39]. For example, in the Pierce [35] study, 716 general practitioners (GPs) and 323 specialists (obstetric doctors and diabetologists) were asked who was responsible for ordering glucose tests for type 2 diabetes after pregnancy; about 26% of GPs and 89% of specialists said ‘‘hospital,’’ 47% of GPs and 8% of specialists said ‘‘general practice,’’ 26% of GPs and 7% of specialists said there was ‘‘no clear responsibility,’’ and 3.5% of GPs/1% of specialists said ‘‘don’t know.’’ Finally, one study that included trainee family medicine doctors (in residency programs) found that lack of continuity of care for women with GDM was a barrier to optimal healthcare provision [29].
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
Type of study Location
Clinician knowledge and views Most clinicians aware of risk of T2DM Gap between knowledge and practice of screening for T2DM Value or priority of PP glucose screening: Low/moderate High/Cost-effective Practice too busy Pro-active approaches: Giving advice for prevention of T2DM Aiming to motivate women to change their lifestyle Creating empowering relationships with women Communication and collaboration between clinicians Lack of communication regarding diagnosis of GDM Need to improve collaboration with other clinicians Need to clarify responsibility for follow-up of GDM PP Lack of continuity of care–barrier to follow-up PP
US (nationwide) Power [34]
Gabbe [26]
Interviews
Texas, US
North Carolina, US
Massachusetts, US
Oregon, US
Weaver [29]
Baker [30]
Stuebe [14]
Hunsberger [31]
Ko [33]
Ohio, US Oza-Frank [32]
Canada
England
India
Sweden
Keely [39]
Pierce [35]
Divakar [36]
Persson [28]
Tonga
Doran [27]
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Study ID
Surveys
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Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
Table 3 – Theme categories and themes.
Study ID Healthcare systems, training and guidelines Need for: Systematic methods of ensuring follow-up after pregnancy Training - GDM postpartum follow-up Definitive, consistent guidelines Health promotion - diabetes prevention Clinician perceptions of women’s needs and attitudes Healthcare opportunity not taken up by women Improved GDM education required Healthcare access barrier Improved self-preventive care required Screening as a foreign idea View of midwives as counsellors not diabetes experts
US (nationwide) Power [34]
Gabbe [26]
Interviews
Texas, US
North Carolina, US
Massachusetts, US
Oregon, US
Weaver [29]
Baker [30]
Stuebe [14]
Hunsberger [31]
Ohio, US
Canada
England
India
Sweden
Divakar [36]
Persson [28]
Ko [33]
Oza-Frank [32]
Keely [39]
Pierce [35]
Tonga
Doran [27]
Abbreviations: Postpartum (PP), gestational diabetes mellitus (GDM), type 2 diabetes mellitus (T2DM).
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Surveys
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Type of study
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3.3.3.
Healthcare systems, training and guidelines
Themes relating to healthcare systems, training and guidelines were described in 10 studies. Six of these studies indicated a requirement for systematic methods of ensuring postpartum follow-up, including reminders, intake forms covering GDM history, and/or defined postpartum follow-up protocols [14,30,32,33,35,39]. Clinicians had very positive views of the potential for reminders to facilitate their provision of postpartum care, with 87% of family physicians in the Keely [39] study indicating that the postal reminder they received was useful, 64% agreeing that the reminder contributed to their decisions to screen, and for those who did not receive reminder letters, 83% thought it would be beneficial to receive one. Similarly, in two other studies, many clinicians indicated that automatic reminders in patient charts or electronic medical records would be beneficial [32,33]. Deficiencies in education and training for clinicians regarding GDM postpartum follow-up were also apparent, especially for issues such as how to respond to abnormal blood glucose results [14,29,30,33,34]. In a small number of cases, clinicians articulated a need for more consistent, definitive guidelines, indicating that conflicting guidelines may be a source of confusion. In addition, one study highlighted the benefits of public health promotion relating to diabetes prevention as a facilitator to healthcare provision.
3.3.4. Clinicians’ perceptions of the needs and attitudes of women who have experienced GDM Clinicians’ perceptions regarding the needs of women who have experienced GDM, and their attitudes were explored in eight studies. In five studies, clinicians perceived that women were not taking up healthcare opportunities [28,30,34,39]. These included not attending appointments, and non-completion of glucose testing. Although, healthcare access barriers were recognised by clinicians in three studies from the United States [30,32,34], particularly with regards to financial cost to women. Facilitation of improved self-preventive care for women was recognised as an important task by some clinicians, with more than two-thirds of obstetrician/gynaecologists and midwives in Oza-Frank [32], and 72% of nurse–midwives in Ko reporting a need for ‘‘increased patient responsibility for self-preventive care’’ [32,33]. Three studies highlighted a need to ensure the availability of appropriate GDM educational materials for women [14,32,34], and almost half (49%) of respondent nurse–midwives in Ko [33] thought that there was a need to improve GDM patient education. [27,28]. A perception that women view midwives as counsellors rather than diabetes experts was seen also as a potential barrier [28].
4.
Discussion
4.1.
Summary of the main results
Most clinicians knew of the substantial risk of T2DM in women who had a history of GDM, but there was a gap between this knowledge level, and their actual practice of postpartum screening. Several barriers prevented clinicians from
providing care to women with GDM after pregnancy. Clinicians providing postnatal care for these women often never found out about the GDM diagnosis, or had some difficulty with doing so. This could be improved by using systematic methods of ensuring postpartum care, such as reminder systems, about which clinicians had positive views. Where the diagnosis of GDM was known, clinicians faced further barriers, such as deficiencies in their knowledge and training regarding follow-up, being unsure who was responsible for postpartum care, and difficulty with collaboration with specialists. Often clinicians observed that healthcare opportunities were not being taken up by women, and some thought women could benefit from taking greater responsibility for their own health in terms of prevention of T2DM. At the same time, clinicians recognised deficiencies in the GDM education and support available, and that the women faced significant barriers, particularly financial barriers, to attendance for care and glucose test completion. Some clinicians thought that facilitators of provision of healthcare to women who had had GDM included creating an empowering relationship, providing advice about future risk of T2DM, and public health promotion relating to T2DM prevention.
4.2.
Overall completeness and applicability of evidence
Most of the included studies were surveys, rather than interviews or focus group studies, and this limited the depth of exploration of the topics of interest. However, use of survey designs resulted in the possibility of assessing knowledge, views and practices of a much larger number of relevant clinicians than interviews alone would allow. While there was variation in locations and settings of the included studies, there were strong themes that were identifiable across studies.
4.3.
Quality of the evidence
The majority of the included studies were of moderate-togood quality, as assessed with the CASP tool. Aims, research design, recruitment and data collection were generally well described. Additionally, findings and implications were adequately communicated. However, more details regarding ethical considerations and data analysis were needed in many of the studies, and the authors neglected to discuss the relationship between themselves and their participants, and how this may have influenced their findings.
4.4.
Strengths and limitations of this review
This systematic review of qualitative and survey studies synthesises the views and knowledge of clinicians who provide care to women who have experienced GDM, relating to provision of healthcare in the postpartum period. The strengths of this review include well defined pre-specified outcomes, as well as not using date or language restrictions in the search process. Furthermore, abstracts, as well as fulltext articles were eligible for inclusion, enhancing the breadth of information. Review author bias in assessment and analysis was minimised by two authors independently assessing the full-text of potentially eligible studies, extracting data, appraising study quality, and analysing data. Quality
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
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assessment was undertaken using an unmodified and respected quality assessment method.
4.5. Agreements and disagreements with other studies or reviews The inadequate communication of the diagnosis of GDM, which was often apparent within the included studies, was previously noted by Keely [13] and in another recent systematic review [41]. Keely wrote about the possibility that a perceived lack of efficacy of preventive measures may play a role in sub-optimal screening, and our results agree with this suggestion. Another possibility put forward by the same author was that healthcare providers may not fully appreciate the risk of T2DM following GDM, but this was not demonstrated to be the case within the studies that we reviewed. An impact of financial cost to women on postpartum healthcare attendance was apparent in three included studies from the United States [30,32,34], which may reflect the relatively high out-of-pocket healthcare costs in this country [42]. However, it should be noted that financial impact is not always correlated with postpartum attendance for glucose screening, as screening in Australia is reportedly higher than in England, despite the lower out-of-pocket cost in England [12,42,43]. A recent systematic review examining system-based factors influencing postpartum GDM testing rates [44], with 54 included studies, found that systematic approaches to improving follow-up were associated with higher postpartum testing rates. Our systematic review found that whilst such systems were being underutilised, clinicians expressed positive views towards them.
5.2.
9
Implications for research
More research is required into developing strategies to improve postpartum care for women with recent GDM, such as ways to improve communication between clinicians regarding GDM diagnosis and care. Studies that focus on improving clinician education relating to postpartum care recommendations are necessary. It is important to investigate methods of education provision for women who have experienced GDM so that they can be optimally informed about their ongoing risk of T2DM. There is also a need to raise awareness of the risks of GDM and subsequent T2DM for women, using public health promotion methods.
Conflict of interest statement The authors of this review are investigators for the DIAMIND study: postpartum SMS reminders to women who have had gestational diabetes mellitus to test for type 2 diabetes: a randomised controlled trial [45]. The authors declare that they have no financial conflict of interest.
Grant support No grant support was received for this systematic review. All authors are currently in receipt of funding from the HCF Health and Medical Research Foundation for the DIAMIND Study: Postpartum text message reminders to test for type 2 diabetes in women who have experienced GDM.
Acknowledgements 5.
Conclusion
5.1.
Implications for practice
Many barriers to provision of healthcare in the postpartum period for women who have experienced GDM exist, and there is a gap between clinician knowledge regarding the risk of T2DM following GDM, and practice of postpartum screening of these women. Lack of communication of the diagnosis of GDM amongst clinicians is a key issue, which could be improved using systematic methods, such as always having documentation of the diagnosis of GDM in diagnostic lists shared between clinicians (in discharge summaries or electronic medical records), having new patient intake forms or checklists for clinicians which ask about past history of GDM, or by utilising reminder systems for clinicians and/or women. There is a need to clarify responsibility for follow up of women with GDM, to improve referral pathways between GDM-related care providers, and to ensure that clinician training covers important details regarding postpartum screening (e.g. how to respond to abnormal test results). For women who are diagnosed with GDM, it is important that they are provided with appropriate and timely verbal and written education on their condition and associated short-term and long-term risks. It is equally important to ensure that obstacles to women accessing healthcare, such as cost, are minimised.
Thank you to Michael Draper, who provided guidance and assistance with development of the search strategy for this review.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.diabres.2014.09.001.
references
[1] Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet 2009;373:1773–9. [2] Feig DS, Zinman B, Wang X, Hux JE. Risk of development of diabetes mellitus after diagnosis of gestational diabetes. CMAJ 2008;179:229–34. [3] Lee AJ, Hiscock RJ, Wein P, Walker SP, Permezel M. Gestational diabetes mellitus: clinical predictors and longterm risk of developing type 2 diabetes: a retrospective cohort study using survival analysis. Diabetes Care 2007;30:878–83.
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
DIAB-6153; No. of Pages 11
10
diabetes research and clinical practice xxx (2014) xxx–xxx
[4] Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002;25:1862–8. [5] Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada, 37. Canadian Diabetes Association 2013; 2013. p. S1–2. Suppl 1. [6] American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care 2013;36(Suppl 1):S11–66. [7] National Institute for Health and Care Excellence. Diabetes in Pregnancy: Management of Diabetes and Its Complications [CG63]. London: National Institute for Health and Care Excellence; 2008. [8] IADPSG Consensus Panel. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676–82. [9] Nankervis A, McIntyre HD, Moses R, Ross GP, Callaway L, Porter C, et al. ADIPS Consensus Guidelines for the Testing and Diagnosis of Gestational Diabetes Mellitus in Australia. Available from http://www.adips.org/downloads/ ADIPSConsensusGuidelinesGDM03.05.13VersionACCEPTEDFINAL.pdf. 2013. [10] Tovar A, Chasan-Taber L, Eggleston E, Oken E. Postpartum screening for diabetes among women with a history of gestational diabetes mellitus. Prev Chronic Dis 2011; 8:A124. [11] Dietz PM, Vesco KK, Callaghan WM, Bachman DJ, Bruce FC, Berg CJ, et al. Postpartum screening for diabetes after a gestational diabetes mellitus-affected pregnancy. Obstet Gynecol 2008;112:868–74. [12] McGovern A, Butler L, Jones S, van Vlymen J, Sadek K, Munro N, et al. Diabetes screening after gestational diabetes in England: a quantitative retrospective cohort study. Br J Gen Pract 2014;64:317–23. [13] Keely E. An opportunity not to be missed—how do we improve postpartum screening rates for women with gestational diabetes. Diabetes Metab Res Rev 2012;28:312–6. [14] Stuebe A, Ecker J, Bates DW, Zera C, Bentley-Lewis R, Seely E. Barriers to follow-up for women with a history of gestational diabetes. Am J Perinatol 2010;27:705–10. [15] Bentley-Lewis R, Levkoff S, Stuebe A, Seely EW. Gestational diabetes mellitus: postpartum opportunities for the diagnosis and prevention of type 2 diabetes mellitus. Nat Clin Pract Endocrinol Metab 2008;4:552–8. [16] Critical Appraisal Skills Programme (CASP). Qualitative Research Checklist. Oxford. Available from hhttp:// www.casp-uk.neti [accessed 18/12/2013]. [17] Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008;8:45. [18] Tong A, Morton R, Howard K, Craig JC. Adolescent experiences following organ transplantation: a systematic review of qualitative studies. J Pediatr 2009;155:542–9. [19] Schumann I, Schneider A, Kantert C, Lowe B, Linde K. Physicians’ attitudes, diagnostic process and barriers regarding depression diagnosis in primary care: a systematic review of qualitative studies. Fam Pract 2012;29:255–63. [20] Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. BMJ 2009;339:b2535. [21] Hanna FWF, Peters JR, Harlow J, Jones PW. Discrepancy between postnatal and antenatal management of gestational diabetes in the U.K. Diabetes Care 2007;30:e64–70. [22] Hanna FWF, Peters JR, Harlow J, Jones PW. Gestational diabetes screening and glycaemic management; national survey on behalf of the Association of British Clinical
[23]
[24]
[25]
[26]
[27]
[28]
[29] [30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
Diabetologists. QJM 2008;101:777–84 (an International Journal of Medicine). Persson M, Hornsten A, Winkvist A, Mogren I. ‘Dealing with ambiguity’—the role of obstetricians in gestational diabetes mellitus. Acta Obstet Gynecol Scand 2012;91:439–46. Risa CF, Lide´n E, Friberg F. Communication patterns in antenatal diabetes care: an explorative and descriptive study of midwife-led consultations. J Clin Nurs 2011;20:2053–63. Shera AS, Jawad F, Basit A. Diabetes related knowledge, attitude and practices of family physicians in Pakistan. J Pak Med Assoc 2002;52:465–70. Gabbe S, Hill L, Schmidt L, Schulkin J. Management of diabetes by obstetrician–gynecologists. Obstet Gynecol 1998;91:643–7. Doran F, Davis K. Gestational diabetes mellitus in Tonga: insights from healthcare professionals and women who experienced gestational diabetes mellitus. N Z Med J 2010;123:59–67. Persson M, Hornsten A, Winkvist A, Mogren I. Mission Impossible? Midwives’ experiences counseling pregnant women with gestational diabetes mellitus. Patient Educ Couns 2011;84:78–83. Weaver SP. New research gestational diabetes indicates risk later in life. Fam Med 2004;36:159–60. Baker AM, Brody SC, Salisbury K, Schectman R, Hartmann KE. Postpartum glucose tolerance screening in women with gestational diabetes in the state of North Carolina. N C Med J 2009;70:14–9. Hunsberger ML, Donatelle RJ, Lindsay K, Rosenberg KD. Physician care patterns and adherence to postpartum glucose testing after gestational diabetes mellitus in Oregon. PLoS One 2012;2012. Oza-Frank R. Resources to improve care among women with a history of gestational diabetes: a provider perspective. Diabetes 2012;61:A642. Ko JY, Dietz PM, Conrey EJ, Rodgers L, Shellhaas C, Farr SL, et al. Gestational diabetes mellitus and postpartum care practices of nurse–midwives. J Midwifery Womens Health 2013;58:33–40. Power ML, Wilson EK, Hogan SO, Loft JD, Williams JL, Mersereau PW, et al. Patterns of preconception, prenatal and postnatal care for diabetic women by obstetrician– gynecologists. J Reprod Med 2013;58:7–14. Pierce M, Modder J, Mortagy I, Springett A, Hughes H, Baldeweg S. Missed opportunities for diabetes prevention: post-pregnancy follow-up of women with gestational diabetes mellitus in England. Br J Gen Pract 2011;61:e611–9. Divakar H, Manyonda IT. Battling the rising prevalence of gestational diabetes in India: are clinicians on the right track. J Neonatal Perinat Med 2012;5:261–7. Divakar H, Manyonda I. Battling with rising prevalence of gestational diabetes mellitus: screening and diagnosis. IJIFM 2011;2:96–100. Divakar H, Manyonda IT. Battling with rising prevalence of gestational diabetes mellitus—are clinicians in India on the right track. Perinatology 2012;12:133–9. Keely E, Clark H, Karovitch A, Graham I. Screening for type 2 diabetes following gestational diabetes: family physician and patient perspectives. Can Fam Physician 2010;56:558–63. Clark HD, Graham ID, Karovitch A, Keely EJ. Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial. Am J Obstet Gynecol 2009;200:634 e1–e6347. Nielsen KK, Kapur A, Damm P, de Courten M, Bygbjerg IC. From screening to postpartum follow-up—the determinants and barriers for gestational diabetes mellitus
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001
DIAB-6153; No. of Pages 11 diabetes research and clinical practice xxx (2014) xxx–xxx
(GDM) services, a systematic review. BMC Pregnancy Childbirth 2014;14:41. [42] Schoen C, Osborn R, Squires D, Doty MM. Access, affordability, and insurance complexity are often worse in the United States compared to ten other countries. Health Affairs 2013;32:2205–15. [43] Morrison MK, Collins CE, Lowe JM. Postnatal testing for diabetes in Australian women following gestational diabetes mellitus. Aust N Z J Obstet Gynaecol 2009;49:494–8.
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[44] Carson MP, Frank MI, Keely E. Original research: postpartum testing rates among women with a history of gestational diabetes—systematic review. Prim Care Diabetes 2013;7:177–86. [45] Heatley E, Middleton P, Hague W, Crowther C. The DIAMIND study: postpartum SMS reminders to women who have had gestational diabetes mellitus to test for type 2 diabetes: a randomised controlled trial—study protocol. BMC Pregnancy Childbirth 2013;13:92.
Please cite this article in press as: Heatley E, et al. Clinician views and knowledge regarding healthcare provision in the postpartum period for women with recent gestational diabetes: A systematic review of qualitative/survey studies. Diabetes Res Clin Pract (2014), http://dx.doi.org/ 10.1016/j.diabres.2014.09.001