Abstract
Background/Aims Postpartum diabetes screening is recommended for women with gestational diabetes (GDM); up to 36.0% of them will have glucose abnormalities after delivery. To improve the <60% rate of postpartum diabetes screening in Kaiser Permanente Northwest, we conducted a multi- faceted process improvement project.
Methods The intervention included revision of protocols used to guide outpatient care provided to pregnant patients with types 1, 2, and gestational diabetes, and revision of electronic order entry tools; development of an electronic reminder system to trigger phone calls to patients who had not completed postpartum glucose testing within 3 months after delivery; and a series of 60 minute educational sessions for clinicians, nurses, and medical assistants conducted between January and April 2009. The pre-implementation population was GDM-affected deliveries July 1, 2007—June 30, 2008 (n=200) and the post-implementation population was GDM-affected deliveries July 1, 2009— June 30, 2010 (n=179). Two main outcomes were evaluated:
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clinician orders for either a fasting blood glucose (FBG) test or 2-hr oral glucose tolerance test (OGTT) placed between one month before to 3 months after delivery, and
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a completed FBG or 2-hour OGTT performed between 14 days after delivery and December 31, 2008 (pre-implementation) or December 31, 2010 (post-implementation). Because patient characteristics did not differ significantly between the pre-and post-implementation populations, an unadjusted Cox Proportional Hazards model was used to evaluate test completion.
Results The prevalence of GDM was 3.8% in pre-(200/5250) and post- populations (179/4765). The proportion of women who received an order for a postpartum glucose test within 3 months of delivery increased from 77.5% (155/200) to 88.8% (159/179) (p=.004); the proportion completing the test Within 3 months of delivery increased from 53.5% (107/200) to 60.3% (108/179) (p=.18). When including tests completed beyond the first 3 months postpartum (through December 2008 pre-and December 2010 post-implementation), women in the post-implementation group had a significantly higher rate of test completion (59.5% [119/200] vs. 71.5% [128/179], p=0.01, Hazards Ratio 1.37, 95% CI 1.07 to 1.7.
Discussion Rates of postpartum diabetes testing among women with recent GDM can be improved with system changes and reminders to women.
