Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial

Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
American journal of obstetrics and gynecology (Impact Factor: 4.7). 03/2009; 200(6):634.e1-7. DOI: 10.1016/j.ajog.2009.01.003
Source: PubMed


Women with previous gestational diabetes mellitus rarely receive the recommended 2-hour oral glucose tolerance test (OGTT) after delivery. We sought to determine whether postal reminders to be sent after delivery to a patient, her physician, or both would increase screening rates.
Patients were assigned randomly to 4 groups: reminders sent to both physician and patient, to physician but not patient, or to patient but not physician or no reminders were sent. The primary outcome was the proportion of patients who underwent an OGTT within 1 year after delivery. The secondary outcome was the performance of other postpartum screening tests.
OGTT rates were significantly increased in the physician/patient reminder group (49/81 women; 60.5%), in the patient-only reminder group (42/76 women; 55.3%), and in the physician-only reminder group (16/31 women; 51.6%) compared with the no reminder group (5/35 women; 14.3%; P < .05).
Postpartum reminders greatly increased screening rates for women with gestational diabetes mellitus.

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    • "A RCT from New Zealand showed that patient and/or computer reminders resulted in increased screening rates in general practice (Kenealy et al., 2005). Among mothers having gestational diabetes mellitus, a RCT had shown that postal reminder to patient, physician or both was associated with 3 times increase in screening rate (oral glucose tolerance test within a year of delivery) (Clark et al., 2009). Similarly, letter or phone reminder in Canada resulted in 2 times increase in screening rates within 6 months after delivery (Shea et al., 2011) and a retrospective review from Canada also showed 3 fold increase in odds of being screened due to a reminder checklist (Lega et al., 2012). "
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    ABSTRACT: Introduction: We previously showed that there was high loss to follow up for definitive tests, resulting in low screening yield, during opportunistic screening for diabetes with random blood glucose as the initial screening tool. Aims and Objectives: In this study we examined the effect of mobile reminder on follow up for definitive tests and therefore screening yield. Research Design and Methods: This was a facility-based parallel randomized controlled trial during routine outpatient department hours in a primary health care setting. We offered random blood glucose testing to non-pregnant non-diabetic adults (667 total, 390 consented); eligible outpatients (n=268) were offered definitive tests. We randomized eligible outpatients into intervention (n=133) and control arm (n=135): those in intervention arm received a mobile reminder to follow up for definitive tests. We measured blood glucose using a glucometer. Results: Our data showed that eligible outpatients in intervention arm (85.7%) when compared to control arm (53.3%) had 1.6 times more chance of returning for definitive tests [RR = 1.61, (0.95 CI - 1.35,1.91)]. Screening yield in intervention and control arm was 18.6% and 10.2% respectively. Etiologic fraction was 45.2%.and number needed to screen was 11.9. Conclusion: These findings provide objective evidence that mobile reminders result in significant improvement in follow up and therefore improvement in screening yield. Also, considering the wide prevalent use of mobile phones, and real life resource limited settings in which this study was carried out, mobile reminders during opportunistic screening appears feasible for successful replication in the region.
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    • "Possible interventions could concern reduction of fragmented care and facilitation of other efforts to improve participation in follow-up screening. Such efforts could concern reminder systems, which has shown to improve the participation in follow-up screening significantly [8, 11, 35, 36]. Such systems can have a positive impact on the participation in follow-up screening [31]. "
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    ABSTRACT: Background Women whose pregnancy was complicated by gestational diabetes have a 7-fold higher risk of developing diabetes, primarily type 2. Early detection can prevent or delay the onset of late complications, for which follow-up screening is important. This study investigated the extent of participation in follow-up screening and the possible consequences of nonattendance in the Region of North Jutland, Denmark. Method In Danish national registers covering the years 1994–2011 we identified 2171 birthing women whose pregnancy was complicated by first-time gestational diabetes. Control visits to general practitioners and biochemical departments after giving birth were charted. Following national guidelines we defined four intervals for assessment of participation in follow-up screening. Diagnosis of diabetes or treatment with glucose-lowering agents after giving birth were also identified. Participation in follow-up screening and risk of diabetes was calculated. Time to obtaining diagnosis of diabetes or initiating treatment was analysed by Cox regression models. All models were adjusted for age, ethnicity and income. Results High attendance was found during the first control interval, after which attendance decreased with time after giving birth for both controls at general practitioners and biochemical departments. All differences in proportions were statistically significant. Women attending controls at general practitioners had a significantly higher risk of diabetes diagnosis and treatment after gestational diabetes than women not attending. The results for women attending testing at biochemical departments also showed an increased risk of initiation of treatment. Women attending at least one general practitioners control had a significantly higher risk of early diabetes diagnosis or treatment. Time to initiation of treatment was significantly higher for testing at biochemical departments. Women with high incomes had a significantly lower risk of diabetes diagnosis or initiation of treatment compared to low-income women. Conclusion Participation in follow-up screening after gestational diabetes is low in the North Denmark Region. Follow-up screening ensures early detection of diabetes and initiation of treatment. Our results emphasize the importance of development of interventions to improve early detection and prevention of diabetes after gestational diabetes.
    BMC Public Health 08/2014; 14(1):841. DOI:10.1186/1471-2458-14-841 · 2.26 Impact Factor
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    • "Reminders and advice on postpartum screening have been assessed by four studies. Hence, two studies from Canada found that receiving reminders about testing increased the likelihood of testing [55,56]. Similarly, an Australian study by Morrison et al. found that providing postnatal written information or individualised risk reduction advice significantly increased the likelihood for postpartum screening [44], and in the US, Kim et al. found that women who recalled receiving advice on postpartum screening were more likely to report actually being tested [57]. "
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    ABSTRACT: Gestational diabetes mellitus (GDM) - a transitory form of diabetes first recognised during pregnancy complicates between < 1% and 28% of all pregnancies. GDM has important short and long-term health consequences for both the mother and her offspring. To prevent adverse pregnancy outcomes and to prevent or delay, future onset of type 2 diabetes in mother and offspring, timely detection, optimum treatment, and preventive postpartum care and follow-up is necessary. However the area remains grossly under prioritised. To investigate determinants and barriers to GDM care from initial screening and diagnosis, to prenatal treatment and postpartum follow-up, a PubMed database search to identify quantitative and qualitative studies on the subject was done in September 2012. Fifty-eight relevant studies were reviewed. Adherence to prevailing GDM screening guidelines and compliance to screening tests seems sub-optimal at best and arbitrary at worst, with no clear or consistent correlation to health provider, health system or client characteristics. Studies indicate that most women express commitment and motivation for behaviour change to protect the health of their unborn baby, but compliance to recommended treatment and advice is fraught with challenges, and precious little is known about health system or societal factors that hinder compliance and what can be done to improve it. A number of barriers related to health care provider/system and client characteristics have been identified by qualitative studies. Immediately following a GDM pregnancy many women, when properly informed desire and intend to maintain healthy lifestyles to prevent future diabetes, but find the effort challenging. Adherence to recommended postpartum screening and continued lifestyle modifications seems even lower. Here too, health care provider, health system and client related determinants and barriers were identified. Studies reveal that sense of self-efficacy and social support are key determinants. The paper identifies and discusses determinants and barriers for GDM care, fully recognising that these are highly dependent on the context.
    BMC Pregnancy and Childbirth 01/2014; 14(1):41. DOI:10.1186/1471-2393-14-41 · 2.19 Impact Factor
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