CHR research informs OB/GYN clinical care

Translational research improves postpartum screening rates for women with gestational diabetes

(PORTLAND, Ore.)—In the community, it may take a decade or more to translate research findings into clinical practice. But with the unique relationship between TCHR and KPNW, we’re often able to put research directly to work to help our patients, because research is woven right into our integrated health care delivery system.

Nowhere is this efficiency better demonstrated than in the work of Dr. Kimberly Vesco, TCHR investigator and Northwest Permanente obstetrician. Among a select few to have a joint appointment as a physician researcher, Dr. Vesco is ideally set up to do her own bench-to-bedside, translational research—which has motivated her to make immediate improvements in care delivery at KPNW’s Ob/Gyn clinics.

Specifically Dr. Vesco wants to improve postpartum screening rates for women who develop diabetes while they are pregnant (gestational diabetes or GDM). Today about 3.6% of American women develop GDM—roughly 140,000 pregnancies each year (of those resulting in live births). Without intervention, up to half of these women will develop type 2 diabetes within 5 years—so postpartum screening is critical in prevention and treatment.

Research findings: Nearly 1 in 2 GDM patients fail to complete postpartum screening

Dr. Vesco is a team member of the CDC-funded Maternal Morbidity in a Managed-Care Setting, which is led by THCR’s Dr. Mark Hornbrook. This group recently completed a seven-year retrospective study of postpartum diabetes screening rates for women with GDM in the KPNW region.

In a paper published last fall in Obstetrics & Gynecology, Dr. Vesco—along with coauthor Dr. Patricia Dietz, an epidemiologist at the CDC, and others—reported that 42% of women with GDM failed to have a postpartum fasting plasma glucose test (FPG). The FPG is a screening test for diabetes mellitus that is recommended for all women with GDM by both the American College of Obstetrics and Gynecologists and the American Diabetes Association.

What’s more, in half of these cases (that’s a full 21% of the total number of women with GDM), the tests had not even been ordered by clinicians.

How many patients are we talking about in this study? Not an insignificant amount—especially given the health care costs of diabetes, which run an average of $10,000 per year per patient. Among 36,251 live births followed at KPNW from 1999 to 2006, the study found 1,127 confirmed cases of GDM. If 42% of these new mothers either hadn’t received a clinician’s order for screening or hadn’t followed through with their appointment, that’s around 473 women who missed their critical postpartum FPG test. If up to half of them develop type 2 diabetes within 5 years, that’s 236 people (at $10,000 per year per patient in health care costs) whose diabetes may have been delayed or prevented.

From bench to bedside: Improving screening rates

So, Dr. Vesco wondered, why wasn’t FPG screening ordered consistently? Looking more closely, she discovered wide variation among the 8 clinics providing prenatal care, with lab order rates for women with GDM ranging from 28.6% to 93.6%. Dr. Vesco set out to remedy this matter as soon as data collection concluded in 2006.

Today she is:

  • making presentations to every clinic to explain postpartum screening methods and the long-term risks for type 2 diabetes among women with GDM
  • helping update nursing protocols for entering postpartum fasting glucose orders and working with GDM patient care managers to improve postpartum followup
  • collaborating with Dr. Melanie Plaut to revise charting and order entry tools used by medical assistants and clinicians
  • teaming with Drs. Rob Unitan and Tom Hickey to develop a flag in the Panel Support Tool for primary care providers to indicate women with GDM who are due for screening
  • working with Don Bachman, TCHR senior research analyst, to develop a patient tracking system for the Ob/Gyn GDM nurse care managers to pick up patients who did not get screening
  • reminding clinicians and nurses to add “Hx of gestational diabetes” to each patient’s problem list in the EMR, so every practitioner will be alerted about the patient’s history at future clinic visits.

Then beginning this June, Dr. Vesco will once again begin tracking postpartum screening orders, with the intent to publish the results of this clinic-level intervention. This is classic quality improvement: plan, do, study, act.

GDM is a problem that’s worsening. In KPNW, the prevalence of GDM increased from 2.9 to 3.6% between 1999 and 2006. But thanks to clinicians like Dr. Vesco, our capabilities are broadening. By disseminating the results of her research findings and developing new ways to enhance clinic practice, Dr. Vesco is improving care for KPNW patients.

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