Cost-effectiveness of diagnosis and treatment of early gestational diabetes mellitus: economic evaluation of the TOBOGM study, an international multicenter randomized controlled trial.

Background: A recently undertaken multicenter randomized controlled trial (RCT) "Treatment Of BOoking Gestational diabetes Mellitus" (TOBOGM: 2017-2022) found that the diagnosis and treatment of pregnant women with early gestational diabetes mellitus (GDM) improved pregnancy outcomes. Based on data from the trial, this study aimed to assess the cost-effectiveness of diagnosis and treatment of early GDM (from <20 weeks') among women with risk factors for hyperglycemia in pregnancy compared with usual care (no treatment until 24-28 weeks') from a healthcare perspective. Methods: Participants' healthcare resource utilization data were collected from their self-reported questionnaires and hospital records, and valued using the unit costs obtained from standard Australian national sources. Costs were reported in US dollars ($) using the purchasing power parity (PPP) estimates to facilitate comparison of costs across countries. Intention-to-treat (ITT) principle was followed. Missing cost data were replaced using multiple imputations. Bootstrapping method was used to estimate the uncertainty around mean cost difference and cost-effectiveness results. Bootstrapped cost-effect pairs were used to plot the cost-effectiveness (CE) plane and cost-effectiveness acceptability curve (CEAC). Findings: Diagnosis and treatment of early GDM was more effective and tended to be less costly, i.e., dominant (cost-saving) [-5.6% composite adverse pregnancy outcome (95% CI: -10.1%, -1.2%), -$1373 (95% CI: -$3,749, $642)] compared with usual care. Our findings were confirmed by both the CE plane (88% of the bootstrapped cost-effect pairs fall in the south-west quadrant), and CEAC (the probability of the intervention being cost-effective ranged from 84% at a willingness-to-pay (WTP) threshold value of $10,000-99% at a WTP threshold value of $100,000 per composite adverse pregnancy outcome prevented). Sub-group analyses demonstrated that diagnosis and treatment of early GDM among women in the higher glycemic range (fasting blood glucose 95-109 mg/dl [5.3-6.0 mmol/L], 1-h blood glucose ≥191 mg/dl [10.6 mmol/L] and/or 2-h blood glucose 162-199 mg/dl [9.0-11.0 mmol/L]) was more effective and less costly (dominant) [-7.8% composite adverse pregnancy outcome (95% CI: -14.6%, -0.9%), -$2795 (95% CI: -$6,638, -$533)]; the intervention was more effective and tended to be less costly [-8.9% composite adverse pregnancy outcome (95% CI: -15.1%, -2.6%), -$5548 (95% CI: -$16,740, $1547)] among women diagnosed before 14 weeks' gestation as well. Interpretation: Our findings highlight the potential health and economic benefits from the diagnosis and treatment of early GDM among women with risk factors for hyperglycemia in pregnancy and supports its implementation. Long-term follow-up studies are recommended as a key future area of research to assess the potential long-term health benefits and economic consequences of the intervention. Funding: National Health and Medical Research Council (grants 1104231 and 2009326), Region O¨rebro Research Committee (grants Dnr OLL-970566 and OLL-942177), Medical Scientific Fund of the Mayor of Vienna (project 15,205 and project 23,026), South Western Sydney Local Health District Academic Unit (grant 2016), and Western Sydney University Ainsworth Trust Grant (2019).

Regression From Early GDM to Normal Glucose Tolerance and Adverse Pregnancy Outcomes in the Treatment of Booking Gestational Diabetes Mellitus Study.

OBJECTIVE: To compare pregnancy outcomes among women with a normal oral glucose tolerance test (OGTT) before 20 weeks' gestation (early) and at 24-28 weeks' gestation (late) (no gestational diabetes mellitus, or No-GDM), those with early GDM randomized to observation with a subsequent normal OGTT (GDM-Regression), and those with GDM on both occasions (GDM-Maintained). RESEARCH DESIGN AND METHODS: Women at <20 weeks' gestation with GDM risk factors who were recruited for a randomized controlled early GDM treatment trial were included. Women with treated early GDM and late GDM (according to the World Health Organization's 2013 criteria) were excluded from this analysis. Logistic regression compared pregnancy outcomes. RESULTS: GDM-Regression (n = 121) group risk factor profiles and OGTT results generally fell between the No-GDM (n = 2,218) and GDM-Maintained (n = 254) groups, with adjusted incidences of pregnancy complications similar between the GDM-Regression and No-GDM groups. CONCLUSIONS: Women with early GDM but normal OGTT at 24-28 weeks' gestation had pregnancy outcomes that were similar to those of individuals without GDM. Identifying early GDM likely to regress would allow treatment to be avoided.

Perinatal Outcomes in Early and Late Gestational Diabetes Mellitus After Treatment From 24-28 Weeks' Gestation: A TOBOGM Secondary Analysis.

OBJECTIVE: In most gestational diabetes mellitus (GDM) studies, cohorts have included women combined into study populations without regard to whether hyperglycemia was present earlier in pregnancy. In this study we sought to compare perinatal outcomes between groups: women with early GDM (EGDM group: diagnosis before 20 weeks but no treatment until 24-28 weeks if GDM still present), with late GDM (LGDM group: present only at 24-28 weeks), and with normoglycemia at 24-28 weeks (control subjects). RESEARCH DESIGN AND METHODS: This is a secondary analysis of a randomized controlled treatment trial where we studied, among women with risk factors, early (<20 weeks' gestation) GDM defined according to World Health Organization 2013 criteria. Those receiving early treatment for GDM treatment were excluded. GDM was treated if present at 24-28 weeks. The primary outcome was a composite of birth before 37 weeks' gestation, birth weight ≥4,500 g, birth trauma, neonatal respiratory distress, phototherapy, stillbirth/neonatal death, and shoulder dystocia. Comparisons included adjustment for age, ethnicity, BMI, site, smoking, primigravity, and education. RESULTS: Women with EGDM (n = 254) and LGDM (n = 467) had shorter pregnancy duration than control subjects (n = 2,339). BMI was lowest with LGDM. The composite was increased with EGDM (odds ratio [OR] 1.59, 95% CI 1.18-2.12)) but not LGDM (OR 1.19, 95% CI 0.94-1.50). Induction of labor was higher in both GDM groups. In comparisons with control subjects there were higher birth centile, higher preterm birth rate, and higher rate of neonatal jaundice for the EGDM group (but not the LGDM group). The greatest need for insulin and/or metformin was with EGDM. CONCLUSIONS: Adverse perinatal outcomes were increased with EGDM despite treatment from 24-28 weeks' gestation, suggesting the need to initiate treatment early, and more aggressively, to reduce the effects of exposure to the more severe maternal hyperglycemia from early pregnancy.

Treatment of Gestational Diabetes Mellitus Diagnosed Early in Pregnancy.

BACKGROUND: Whether treatment of gestational diabetes before 20 weeks' gestation improves maternal and infant health is unclear. METHODS: We randomly assigned, in a 1:1 ratio, women between 4 weeks' and 19 weeks 6 days' gestation who had a risk factor for hyperglycemia and a diagnosis of gestational diabetes (World Health Organization 2013 criteria) to receive immediate treatment for gestational diabetes or deferred or no treatment, depending on the results of a repeat oral glucose-tolerance test [OGTT] at 24 to 28 weeks' gestation (control). The trial included three primary outcomes: a composite of adverse neonatal outcomes (birth at <37 weeks' gestation, birth trauma, birth weight of ≥4500 g, respiratory distress, phototherapy, stillbirth or neonatal death, or shoulder dystocia), pregnancy-related hypertension (preeclampsia, eclampsia, or gestational hypertension), and neonatal lean body mass. RESULTS: A total of 802 women underwent randomization; 406 were assigned to the immediate-treatment group and 396 to the control group; follow-up data were available for 793 women (98.9%). An initial OGTT was performed at a mean (±SD) gestation of 15.6±2.5 weeks. An adverse neonatal outcome event occurred in 94 of 378 women (24.9%) in the immediate-treatment group and in 113 of 370 women (30.5%) in the control group (adjusted risk difference, -5.6 percentage points; 95% confidence interval [CI], -10.1 to -1.2). Pregnancy-related hypertension occurred in 40 of 378 women (10.6%) in the immediate-treatment group and in 37 of 372 women (9.9%) in the control group (adjusted risk difference, 0.7 percentage points; 95% CI, -1.6 to 2.9). The mean neonatal lean body mass was 2.86 kg in the immediate-treatment group and 2.91 kg in the control group (adjusted mean difference, -0.04 kg; 95% CI, -0.09 to 0.02). No between-group differences were observed with respect to serious adverse events associated with screening and treatment. CONCLUSIONS: Immediate treatment of gestational diabetes before 20 weeks' gestation led to a modestly lower incidence of a composite of adverse neonatal outcomes than no immediate treatment; no material differences were observed for pregnancy-related hypertension or neonatal lean body mass. (Funded by the National Health and Medical Research Council and others; TOBOGM Australian New Zealand Clinical Trials Registry number, ACTRN12616000924459.).

Fulminant type 1 diabetes mellitus in a GDM pregnancy: early recognition is vital for maternal and fetal outcomes.

Summary: Fulminant type 1 diabetes mellitus (FT1DM) is characterised by extremely rapid destruction of pancreatic beta cells. An association between FT1DM and pregnancy has been reported and can lead to unfavourable pregnancy outcomes without timely treatment. We report a case of FT1DM in a pregnancy with gestational diabetes mellitus (GDM), the first of its kind in the English literature to date. A 27-year-old woman with insulin-requiring GDM presented with rapidly deteriorating glycaemic control in her third trimester of pregnancy despite good concordance to treatment. The investigation identified the hallmarks of FT1DM: hyperglycaemia with acute metabolic decompensation and non-immune-mediated beta-cell failure. She received prompt treatment with intravenous insulin therapy and was transitioned to subcutaneous insulin once biochemical improvement had been achieved, albeit with higher insulin requirements than before. She had a good pregnancy outcome and delivered a healthy male infant 5 weeks later through induction of labour. Due to persistent beta-cell dysfunction, she remained on basal-bolus insulin postpartum. This case highlights the importance of early recognition and treatment of FT1DM in pregnancy to prevent adverse maternal and fetal prognoses. Learning points: Fulminant type 1 diabetes mellitus (FT1DM) is a subtype of type 1 diabetes characterised by extremely rapid beta-cell destruction, leading to abrupt-onset hyperglycaemia with ketosis or ketoacidosis. The pathognomonic characteristics of FT1DM include the development of diabetic ketosis or ketoacidosis typically within 7 days after the onset of symptoms of hyperglycaemia, a near-normal level of glycated haemoglobin despite elevated plasma glucose levels and the absence of islet cell autoantibodies. The pathophysiology of FT1DM is unclear but the association with genetic predisposition, viral infection and pregnancy has been reported. Due to its predilection for pregnancy, clinicians should have a high index of suspicion for FT1DM in pregnant women with rapidly progressing hyperglycaemic ketoacidosis. As diabetic ketoacidosis in pregnancy is associated with adverse maternal and fetal outcomes, immediate initiation of treatment in pregnant women with suspected FT1DM is extremely vital to prevent morbidity and mortality, even if investigations are still underway. Patients with FT1DM require lifelong insulin therapy due to the complete loss of beta-cell function.

Medical nutrition therapy for gestational diabetes mellitus in Australia: What has changed in 10 years and how does current practice compare with best practice?

BACKGROUND: The present study aimed to report Australian dietetic practice regarding management of gestational diabetes mellitus (GDM) and to make comparisons with the findings from a 2009 survey of dietitians and with the Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guidelines (NPG). METHODS: Cross-sectional surveys were conducted in 2019 and 2009 of dietitians providing medical nutrition therapy (MNT) to women with GDM in Australia. The present study compares responses on demographics, dietetic assessment and interventions, and guideline use in 2019 vs. 2009. RESULTS: In total, 149 dietitians (2019) and 220 (2009) met survey inclusion criteria. In both surveys >60% of respondents reported dietary interventions aiming for >45% energy from carbohydrate, 15%-25% energy from protein and 15%-30% energy from fat. Many variations in MNT found in 2009 continued to be evident in 2019, including the percentage of energy from carbohydrate aimed for (30%-65% in 2019 vs. 20%-75% in 2009) and the wide range in the recommended minimum daily carbohydrate intake (40-220 and 60-300 g). Few dietitians reported aiming for the NPG minimum of 175 g of carbohydrate daily in both surveys (32% in 2019 vs. 26% in 2009). There were, however, some significant increases in MNT consistent with NPG recommendations in 2019 vs. 2009, including the minimum frequency of visits provided (49%, n = 61 vs. 33%, n = 69; p < 0.001) and provision of gestational weight gain advice (59%, n = 95 vs. 40%, n = 195; p < 0.05). CONCLUSIONS: Although many dietitians continue to provide MNT consistent with existing NPG, there is a need to support greater uptake, especially for recommendations regarding carbohydrate intake.

Does weight management after gestational diabetes mellitus diagnosis improve pregnancy outcomes? A multi-ethnic cohort study.

AIMS: To assess the impact of achieving an Institute of Medicine based personalised weight target in addition to conventional glycaemic management after gestational diabetes mellitus diagnosis on maternal and neonatal outcomes. METHODS: A retrospective audit of clinical data (2016-2019) for singleton gestational diabetes pregnancies was conducted in a multi-ethnic cohort. Logistic regression analyses assessed relationships between achieving, exceeding and gaining less than a personalised weight target provided after gestational diabetes diagnosis and rates of large for gestational age, small for gestational age infants, insulin therapy initiation and neonatal outcomes. Adjusted odds ratios (aOR) were adjusted for glucose 2-h post-glucose load value, family history of type 2 diabetes, previous gestational diabetes, macrosomia in a previous pregnancy, and East and South-East Asian ethnicity. RESULTS: Of 1034 women, 44% (n = 449) achieved their personalised weight target. Women who exceeded their personalised weight target had significantly and higher mean insulin doses (28.8 ± 21.5 units vs. 22.7 ± 18.7, p = 0.006) and higher rates of large for gestational age infants (19% vs. 9.8%, p < 0.001), with aOR of 1.99 [95% CI 1.25-3.15] p = 0.004, but no difference in rates of small for gestational age infants (5.3% vs. 8.0%) (aOR 0.77 [0.41-1.44] p = 0.41). Lower rates of large for gestational age infants occurred in those who gained below their personalised weight target (aOR 0.48 [0.25-0.95] p = 0.034), but rates of small for gestational age infants concurrently increased (aOR 1.9 [1.19-3.12] p = 0.008). CONCLUSIONS: Weight management after gestational diabetes diagnosis does not appear to be too late to confer additional benefits to glucose-lowering treatment, resulting in lower mean insulin doses, and lower rates of large for gestational age infants without increasing the risk of small for gestational age infants.

The ADIPS Pilot National Diabetes in Pregnancy Benchmarking Programme.

BACKGROUND: To test the feasibility of benchmarking the care of women with pregnancies complicated by hyperglycaemia. METHODS: A retrospective audit of volunteer diabetes services in Australia and New Zealand involving singleton pregnancies resulting in live births between 2014 and 2020. Ranges are shown and compared across services. RESULTS: The audit included 10,144 pregnancies (gestational diabetes mellitus (GDM) = 8696; type 1 diabetes (T1D) = 435; type 2 diabetes (T2D) = 1013) from 11 diabetes services. Among women with GDM, diet alone was used in 39.4% (ranging among centres from 28.8-57.3%), metformin alone in 18.8% (0.4-43.7%), and metformin and insulin in 10.1% (1.5-23.4%); when compared between sites, all p < 0.001. Birth was by elective caesarean in 12.1% (3.6-23.7%) or emergency caesarean in 9.5% (3.5-21.2%) (all p < 0.001). Preterm births (<37 weeks) ranged from 3.7% to 9.4% (p < 0.05), large for gestational age 10.3-26.7% (p < 0.001), admission to special care nursery 16.7-25.0% (p < 0.001), and neonatal hypoglycaemia (<2.6 mmol/L) 6.0-27.0% (p < 0.001). Many women with T1D and T2D had limited pregnancy planning including first trimester hyperglycaemia (HbA1c > 6.5% (48 mmol/mol)), 78.4% and 54.6%, respectively (p < 0.001). CONCLUSION: Management of maternal hyperglycaemia and pregnancy outcomes varied significantly. The maintenance and extension of this benchmarking service provides opportunities to identify policy and clinical approaches to improve pregnancy outcomes among women with hyperglycaemia in pregnancy.

Oral Health Status, Knowledge, and Behaviours of People with Diabetes in Sydney, Australia.

This study assessed self-reported oral health status, knowledge, and behaviours of people living with diabetes along with barriers and facilitators in accessing dental care. A cross sectional survey of 260 patients from four public diabetes clinics in Sydney, Australia was undertaken using a 35-item questionnaire. Data were analysed using SPSS software with descriptive and logistic regression analyses. More than half (53.1%) of respondents reported having dental problems which negatively impacted their related quality of life. Less than half (45%) had adequate oral health knowledge. Only 10.8% reported receiving any oral health information in diabetes care settings, which had higher odds of demonstrating adequate oral health knowledge (AOR, 2.60; 95% CI, 1.06-6.34). Similarly, 62.7% reported seeing a dentist in the last 12 months. Having private health insurance (AOR, 3.70; 95% CI, 1.85-7.40) had higher odds of seeing a dentist in the past 12 months. Dental costs were a major contributor to avoiding or delaying dental visit. Patients living with diabetes have unmet oral health needs particularly around the awareness of its importance and access to affordable dental services. Diabetes care providers can play a crucial role in this area by promoting oral health to their patients.

The diagnosis and management of diabetes in Australia: Does the "Rule of Halves" apply?

The Rule of Halves (ROH) is a theoretical framework which states that roughly half of all people with a condition are diagnosed; half of those diagnosed receive care; half of those who receive care achieve their treatment targets; and half of those who reach their targets achieve the desired treatment outcomes. This review examined the applicability of the ROH to diabetes in Australia. Five databases were searched for articles and government reports published between January 2000 and August 2019. Data was extracted for each level of the framework, and pooled sample proportions calculated for the total population and sub-group analysis by ethnicity and type of diabetes. The results showed that 72% of people with diabetes are diagnosed. Approximately 50% are receiving standard care, and 40-60% are meeting treatment targets for HbA1c, blood pressure and lipid levels. Overall, Australia is doing better than the ROH when it comes to achieving treatment outcomes; prevalence of microvascular complications was 20-30% and cardiovascular disease 62%. Indigenous people were less likely to meet treatment targets and more likely to experience adverse complications of diabetes. This review indicates the ROH does generally apply for diabetes care and management in Australia, highlighting the need for further improvement.

Options for screening for gestational diabetes mellitus during the SARS-CoV-2 pandemic.

The balance between avoiding severe acute respiratory syndrome coronavirus-2 contagion and reducing wider clinical risk is unclear for gestational diabetes mellitus (GDM) testing. Recent recommendations promote diagnostic approaches that limit collection but increase undiagnosed GDM, which potentially increases adverse pregnancy outcome risks. The most sensitive approach to detecting GDM at 24-28 weeks beyond the two-hour oral glucose tolerance test (OGTT) is a one-hour OGTT (88% sensitivity). Less sensitive approaches use fasting glucose alone (≥5.1 mmol/L: misses 44-54% GDM) or asking ~20% of women for a second visit (fasting glucose 4.7-5.0 mmol/L (62-72% sensitive)). Choices should emphasise local and patient decision-making.

Antenatal models of care for women with gestational diabetes mellitus: Vignettes from an international meeting.

BACKGROUND: Gestational diabetes (GDM) is one of the commonest pregnancy complications and is placing an increasing burden on diabetes and obstetric resources. AIMS: To describe different antenatal models of care that have developed to address the increasing proportion of pregnancies complicated by GDM. MATERIALS AND METHODS: Narrative review with thematic analysis from 15 volunteer antenatal diabetes in pregnancy services from Australia and New Zealand identified through a national diabetes organisation. Main outcomes were approaches to patient education, medical nutrition therapy (MNT), ongoing management and escalation of therapy for women with GDM. RESULTS: All clinics provided at least one group education and one MNT session within 1-2 weeks of GDM diagnosis. Women from culturally and linguistically diverse communities usually required 1:1 education. Ongoing management of women with GDM was through either all women being seen in the GDM clinic, a step-up approach (ongoing management by the primary antenatal team with diabetes team referral if self-blood glucose monitoring (SBGM) or insulin therapy dosage criteria are reached) or step-down approach (ongoing management by the diabetes team with step-down to the primary antenatal team if SBGM criteria are reached). Telehealth was used to reduce the burden of clinic attendance, particularly in rural areas. CONCLUSIONS: Increasing numbers, earlier diagnoses, the need to provide care to women in rural, remote areas, and cultural/language differences, have generated a range of different antenatal models of care, allowed better workload accommodation and probably reduced costs. Randomised controlled trials of different models of care, with associated health economic analyses, are urgently needed.

Perceptions and practices of general practitioners on providing oral health care to people with diabetes - a qualitative study.

BACKGROUND: Poorly controlled diabetes leads to multiple complications including oral health problems. General practitioners (GPs) are at the forefront of management of chronic diseases in primary health care. Diabetes guidelines encourage a proactive role for GPs in oral health complications management in people with diabetes, yet little is known about this area of care. This study aimed to explore current practices, perceptions and barriers of GPs towards oral health care for people with diabetes. METHODS: We employed a qualitative research method utilising telephone interviews. Purposive and snowball sampling were used to recruit 12 GPs from Greater Sydney region. A thematic analysis involving an inductive approach was used to identify and analyse contextual patterns and themes. RESULTS: A majority of participants were males (n = 10), working in group practices (n = 11) with a mean ± SD age of 55 ± 11.4 years and 25 ± 13.6 years work experience. Three major themes emerged: oral health care practices in general practice settings; barriers and enablers to oral health care; and role of diabetes care providers in promoting oral health. Most GPs acknowledged the importance of oral health care for people with diabetes, identifying their compromised immune capacity and greater risks of infections as risk factors. GPs reported 20-30% of their patients having oral health problems, however their current oral health care practices relating to education, risk assessment and referrals were reported as very limited. GPs identified several barriers including time constraints, absence of referral pathways, and limited knowledge and training in promoting oral health care. They also reported patient barriers including oral health care costs and lower oral health awareness. GPs perceived that resources such as education/training, a standardised assessment tool and patient education materials could support them in promoting oral health care. GPs also perceived that other diabetes care providers such as diabetes educators could play an important role in promoting oral health. CONCLUSIONS: Despite current recommendations, GPs' current oral health care practices among people with diabetes are limited. Further strategies including capacity building GPs by developing appropriate oral health training programs and simple risk assessment tools along with accessible referral pathways are needed to address the current barriers.

Excessive Weight Gain Before and During Gestational Diabetes Mellitus Management: What Is the Impact?

OBJECTIVE: Conventional gestational diabetes mellitus (GDM) management focuses on managing blood glucose in order to prevent adverse outcomes. We hypothesized that excessive weight gain at first presentation with GDM (excessive gestational weight gain [EGWG]) and continued EGWG (cEGWG) after commencing GDM management would increase the risk of adverse outcomes, despite treatment to optimize glycemia. RESEARCH DESIGN AND METHODS: Data collected prospectively from pregnant women with GDM at a single institution were analyzed. GDM was diagnosed on the basis of Australasian Diabetes in Pregnancy Society 1998 guidelines (1992-2015). EGWG means having exceeded the upper limit of the Institute of Medicine-recommended target ranges for the entire pregnancy, by GDM presentation. The relationship between EGWG and antenatal 75-g oral glucose tolerance test (oGTT) values and adverse outcomes was evaluated. Relationships were examined between cEGWG, insulin requirements, and large-for-gestational-age (LGA) infants. RESULTS: Of 3,281 pregnant women, 776 (23.6%) had EGWG. Women with EGWG had higher mean fasting plasma glucose (FPG) on oGTT (5.2 mmol/L [95% CI 5.1-5.3] vs. 5.0 mmol/L [95% CI 4.9-5.0]; P < 0.01), after adjusting for confounders, and more often received insulin therapy (47.0% vs. 33.6%; P < 0.0001), with an adjusted odds ratio (aOR) of 1.4 (95% CI 1.1-1.7; P < 0.01). aORs for each 2-kg increment of cEGWG were a 1.3-fold higher use of insulin therapy (95% CI 1.1-1.5; P < 0.001), an 8-unit increase in final daily insulin dose (95% CI 5.4-11.0; P < 0.0001), and a 1.4-fold increase in the rate of delivery of LGA infants (95% CI 1.2-1.7; P < 0.0001). CONCLUSIONS: The absence of EGWG and restricting cEGWG in GDM have a mitigating effect on oGTT-based FPG, the risk of having an LGA infant, and insulin requirements.

Routine glucose assessment in the emergency department for detecting unrecognised diabetes: a cluster randomised trial.

OBJECTIVE: To determine whether routine blood glucose assessment of patients admitted to hospital from emergency departments (EDs) results in higher rates of new diagnoses of diabetes and documentation of follow-up plans. DESIGN, SETTING: Cluster randomised trial in 18 New South Wales public district and tertiary hospitals, 31 May 2011 - 31 December 2012; outcomes follow-up to 31 March 2016. PARTICIPANTS: Patients aged 18 years or more admitted to hospital from EDs. INTERVENTION: Routine blood glucose assessment at control and intervention hospitals; automatic requests for glycated haemoglobin (HbA1c ) assessment and notification of diabetes services about patients at intervention hospitals with blood glucose levels of 14 mmol/L or more. MAIN OUTCOME MEASURE: New diagnoses of diabetes and documented follow-up plans for patients with admission blood glucose levels of 14 mmol/L or more. RESULTS: Blood glucose was measured in 133 837 patients admitted to hospital from an ED. The numbers of new diabetes diagnoses with documented follow-up plans for patients with blood glucose levels of 14 mmol/L or more were similar in intervention (83/506 patients, 16%) and control hospitals (73/278, 26%; adjusted odds ratio [aOR], 0.83; 95% CI 0.42-1.7; P = 0.61), as were new diabetes diagnoses with or without plans (intervention, 157/506, 31%; control, 86/278, 31%; aOR, 1.51; 95% CI, 0.83-2.80; P = 0.18). 30-day re-admission (31% v 22%; aOR, 1.34; 95% CI, 0.86-2.09; P = 0.21) and post-hospital mortality rates (24% v 22%; aOR, 1.07; 95% CI, 0.74-1.55; P = 0.72) were also similar for patients in intervention and control hospitals. CONCLUSION: Glucose and HbA1c screening of patients admitted to hospital from EDs does not alone increase detection of previously unidentified diabetes. Adequate resourcing and effective management pathways for patients with newly detected hyperglycaemia and diabetes are needed. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12611001007921.

Perceptions and Practices of Diabetes Educators in Providing Oral Health Care: A Qualitative Study.

Purpose The purpose of this study was to explore the current perceptions and practices of diabetes educators (DEs) in providing oral health care to people with diabetes. Methods A qualitative study design involving focus groups was used to gather data. Purposive sampling was used to recruit DEs working across 3 metropolitan hospitals in South Western Sydney, Australia. Results Fourteen DEs participated in 3 focus groups. Participants had a mean ± SD age of 44.4 ± 9.2 years and 5.2 ± 5.3 years of work experience in diabetes care. Four main themes were identified: perceptions about oral health care and diabetes current oral health care practices, perceptions on incorporating oral health, and suggested model of care. DEs agreed that promoting oral health in diabetes clinics is important, and they reported seeing patients frequently with oral health problems. However, the majority do not include oral health care in consultations, primarily because they have limited knowledge in this area and have not received any formal oral health education or training. Additional barriers were the lack of referral pathways and resources for patient education. DEs were receptive to incorporating oral health provided that the current barriers were addressed. DEs also suggested a multidisciplinary team care approach to promote oral health. Conclusions Current practices of DEs in oral health care are limited, but they are willing to address oral health. A suggested model of oral health care should include capacity building of diabetes care providers, appropriate dental referral pathways, and a team approach within multidisciplinary diabetes care.

Hyperglycaemia in early pregnancy: the Treatment of Booking Gestational diabetes Mellitus (TOBOGM) study. A randomised controlled trial.

BACKGROUND: Gestational diabetes mellitus (GDM) causes adverse pregnancy outcomes that can be averted by treatment from 24-28 weeks' gestation. Assessing and treating women for overt diabetes in pregnancy (ODIP) at the first antenatal clinic booking is now recommended in international guidelines. As a consequence, women with milder hyperglycaemia are being diagnosed and treated for early GDM, but randomised controlled trial (RCTs) assessing the benefits and harms of such treatment have not been undertaken. The Treatment Of Booking Gestational diabetes Mellitus (TOBOGM) study is a multi-centre RCT examining whether diagnosing and treating GDM diagnosed at booking improves pregnancy outcomes. Methods and analysis: 4000 adult pregnant women (< 20 weeks' gestation) at risk of ODIP will be recruited from 12 hospital antenatal booking clinics and referred for an oral glucose tolerance test (OGTT). 800 women with hyperglycaemia (ie, booking GDM) according to the 2014 Australasian Diabetes-in-Pregnancy Society criteria for pregnant women at 24-28 weeks' gestation will be randomised to immediate treatment for GDM (intervention) or to no treatment (control), pending the results of a second OGTT at 24-28 weeks' gestation. Antenatal and GDM care will otherwise follow local guidelines. Randomisation will be stratified by site and OGTT glycaemic risk strata. The primary pregnancy outcome is a composite of respiratory distress, phototherapy, birth trauma, birth before 37 weeks' gestation, stillbirth or death, shoulder dystocia, and birthweight ≥ 4.5 kg. The primary neonatal outcome is neonatal lean body mass. The primary maternal outcome is pre-eclampsia. Ethics approval: South Western Sydney Local Health District Research and Ethics Office (reference, 15/LPOOL/551). Dissemination of results: Peer-reviewed publications, scientific meetings, collaboration with research groups undertaking comparable studies, discussions with guideline groups and policy makers. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12616000924459.

Oral health knowledge, attitudes and care practices of people with diabetes: a systematic review.

BACKGROUND: People with uncontrolled diabetes are at greater risk for several oral health problems, particularly periodontal (gum) disease. Periodontal disease also impacts diabetes control. Good oral hygiene and regular dental visits are recommended to prevent and manage oral health problems. Several studies have been conducted to assess the oral health knowledge, attitudes, and practices of people with diabetes yet a review of these findings has not yet been undertaken. The aim of this systematic review was to synthesize current evidence on the knowledge, attitudes and practices of people with diabetes in relation to their oral health care. METHODS: A systematic search of all literature was carried out in five databases using key search terms. The inclusion criteria were: 1) published in the English language; 2) from 2000 to November, 2017; 3) conducted on persons with any type of diabetes and of all ages; 4) explored at least one study outcome (knowledge or attitude or practices toward oral health care); and 5) used quantitative methods of data collection. No restrictions were placed on the quality and setting of the study. RESULTS: A total of 28 studies met the inclusion criteria. The studies included a total of 27,894 people with diabetes and were conducted in 14 countries. The review found that people with diabetes have inadequate oral health knowledge, poor oral health attitudes, and fewer dental visits. They rarely receive oral health education and dental referrals from their care providers. Provision of oral health education by diabetes care providers and referral to dentists when required, was associated with improved oral health behaviours among patients. CONCLUSIONS: Overall, people with diabetes have limited oral health knowledge and poor oral health behaviours. It is therefore essential to educate patients about their increased risk for oral health problems, motivate them for good oral health behaviours and facilitate access to dental care.

Initial group dietary education compared to individual education in gestational diabetes mellitus management: Do outcomes differ?

AIMS: To assess the effectiveness of Initial Group versus Initial Individual GDM dietary education in terms of insulin requirements and pregnancy outcomes. METHODS: A retrospective audit of clinical data was conducted where English speaking women who received initial education in a group setting (01-2-2012 to 01-2-2014) (Group), were compared to women who received initial individual education with a dietitian (1-2-2010 to 31-1-2012) (Individual), all followed by one individual dietitian appointment. The same dietary information was provided in both settings. Data collected included: attendance rates, insulin requirements, maternal weight gain, and rates of adverse birth outcomes. Data were compared by t-test or Chi-squared test. Multivariable logistic regression analysis was conducted to determine independent predictors of insulin therapy. RESULTS: Of 743 women; (362 Group and 381 Individual), Group women had a lower HbA1c at GDM diagnosis 5.3 ±â€¯0.6% versus 5.5 ±â€¯0.5% (34 ±â€¯6.6 mmol/mol versus 37 ±â€¯5.5 mmol/mol p < 0.0001). There were no other differences in baseline characteristics. More Group women required insulin (42.0% versus 34.6%, p = 0.048). Group education was found to be an independent predictor of insulin therapy (OR = 1.9 [1.29, 2.75] p < 0.001). CONCLUSIONS: Despite adjusting for all known potential confounders, unlike Individual education, Group education remained a significant predictor of insulin therapy (but resulted in similar therapeutic and pregnancy outcomes to Individual education).