Exploring the psychological wellbeing of women with gestational diabetes mellitus (GDM): increased risk of anxiety in women requiring insulin. A Prospective Longitudinal Observational Pilot Study.

Introduction: Gestational diabetes mellitus (GDM) complicates ∼16% of pregnancies in Australia and has significant implications for health of both mother and baby. Antenatal anxiety and depression are also associated with adverse pregnancy outcomes. The interaction between GDM and mental health in pregnancy is poorly understood. With the aim of exploring the nuanced interaction between GDM and mental health further, we investigated whether GDM treatment modality (diet versus insulin) influenced psychological wellbeing in women with GDM. Methods: Psychological wellbeing was assessed in women with GDM treated with diet (GDM-Diet, n = 20) or insulin (GDM-Insulin, n = 15) and pregnant women without GDM (non-GDM, n = 20) using questionnaires [Edinburgh Depression Scale (EDS), State-Trait Anxiety Inventory (STAI-6), and in women with GDM, Problem Areas in Diabetes (PAID)] at 24-34 weeks gestation and again at ∼36 weeks gestation. Results: Women in the GDM-insulin group had significantly higher levels of anxiety than the non-GDM group at both time points. Women in the GDM-Diet group had higher levels of anxiety at 24-34 weeks gestation than the non-GDM group but did not differ at ∼36 weeks gestation. Although depression scores tended to be higher in GDM-Insulin and GDM-Diet groups than in the non-GDM group at both time points, this was not statistically significant. Diabetes-related distress was similar in the GDM-Diet and GDM-Insulin groups at both time points and did not change during pregnancy. A high proportion of the GDM-Insulin group had past/current mental illness (60%). Conclusions: In this pilot study GDM was associated with differences in psychological wellbeing, specifically increased anxiety in women treated with insulin. Specialised interventions to support women with GDM should be considered, especially those requiring insulin.Trial registration: Not applicable as this was a purely observational study.

Glycosylated haemoglobin for screening and diagnosis of gestational diabetes mellitus.

OBJECTIVES: The oral glucose tolerance test (OGTT) is a cumbersome test that is time consuming, labour intensive and often poorly tolerated by pregnant women. To date, glycosylated haemoglobin (HbA1c) is the most accepted measure of chronic glycaemia outside of pregnancy. HbA1c is an uncomplicated test, less time consuming, does not require any specific patient preparation and is considered straightforward compared with the OGTT. Therefore, we prospectively tested the utility of the HbA1c when used as a screening tool in pregnancy for gestational diabetes mellitus (GDM). SETTINGS: Primary health care. Single tertiary referral centre, Tasmania, Australia. PARTICIPANTS: A direct comparison between HbA1c levels and the OGTT results in pregnant women, tested concurrently at the 24-28 gestational week, was undertaken. A full profile of 480 pregnant women during the period from September 2012 to July 2014 was completed. Median and mean age of participants was 29 years (range 18-47 years). INTERVENTIONS: A simultaneous prospective assessment of HbA1c versus standard OGTT in a cohort of consecutive pregnant women presenting to our institute was performed. RESULTS: The number of women who had GDM according to OGTT criteria was 57, representing 11.9% of the evaluated 480 pregnant women. Using a cut-off value for HbA1c at 5.1% (32 mmol/mol) for detecting GDM showed sensitivity of 61% and specificity of 68% with negative predictive value (NPV) of 93%, versus sensitivity of 27% and specificity of 95% with NPV of 91% when using HbA1c cut-off value of 5.4% (36 mmol/mol). CONCLUSIONS: Our results suggest that pregnant women with an HbA1c of≥5.4% (36 mmol/mol) should proceed with an OGTT. This may result in a significant reduction in the burden of testing on both patients and testing facility staff and resources. Further investigations are required to integrate and optimise the HbA1c as a single, non-fasting, screening tool for GDM. TRIAL REGISTRATION NUMBER: ACTRN12611000739910.

Achieving "a better state of health": Healthy North Carolina 2020 and the Center for Healthy North Carolina.

Healthy North Carolina 2020 is the state's health improvement plan, which has 40 objectives focused on making North Carolina a healthier state. Communities in the state have identified health priorities aligned with those objectives, and the Center for Healthy North Carolina is helping these communities implement evidence-based strategies to address their goals.

Fasting blood glucose predicts response to extended-release metformin in gestational diabetes mellitus.

BACKGROUND: Metformin is increasingly accepted as an alternative to insulin therapy in gestational diabetes mellitus (GDM). The Metformin in Gestational Diabetes (MiG) trial reported similar pregnancy outcomes for metformin versus insulin; however, supplemental insulin was required in 46% of women on metformin. AIMS: We aimed to identify predictors of response to metformin monotherapy in women with GDM attending a general hospital antenatal clinic. METHODS: We offered extended-release metformin to women diagnosed with GDM (ADIPS 1998 criteria) at ≥24 weeks of gestation. If glucose targets were not achieved (≤5.0 mmol/L fasting, ≤6.7 mmol/L two-h post-meal), women were changed to insulin. We carried out an audit to determine characteristics of metformin responders versus nonresponders. RESULTS: Twenty-five women chose initial metformin therapy; 16 (64%) achieved satisfactory glycaemic control (responders). Nine women (36%) were changed to insulin: seven due to inadequate control (nonresponders) and two had metformin intolerance. Fasting glucose at oral glucose tolerance test (OGTT) was significantly lower in metformin responders versus nonresponders; two-h glucose and BMI did not differ. Ninety-three percent of women with fasting glucose ≤5.2 mmol/L responded to metformin: conversely, at fasting glucose >5.2 mmol/L, 33% responded (P = 0.005). Neonatal outcomes were similar in metformin responders and nonresponders, women who chose initial insulin therapy (n = 25), or were diet-controlled (n = 21). CONCLUSIONS: In women with GDM, fasting glucose on OGTT predicted response to metformin: at fasting glucose ≤5.2 mmol/L, the probability of response was 93%. Antenatal clinics should determine locally relevant predictors of response to metformin in women with GDM.

The relationship between the financial status of sole community independent pharmacies and their broader involvement with other rural providers.

PURPOSE: To document sole community pharmacists' involvement with other local health care organizations, these pharmacies' current financial status, and to determine whether financial position was associated with the provision of pharmacy services to other local health care providers. METHODS: We conducted semistructured interviews with pharmacist-owners of 401 sole community pharmacies randomly selected using data from the National Council for Prescription Drug Programs, Inc. Bivariate and multivariate analyses of responses were conducted to examine associations between pharmacy characteristics, financial position, and involvement with other local health care providers. FINDINGS: About 4 in 5 pharmacies provided services to at least 1 local health care organization. Most respondents (70%) described their store's overall financial position as good or very good, but about one-third reported that their financial conditions had deteriorated since the previous year. Providing services to other organizations was associated with higher prescription sales volume. After controlling for prescription volume, there was no association between providing services to other organizations and pharmacist-owners' self-assessed financial position. CONCLUSION: Sole community pharmacists provide important pharmaceutical support services to other health care organizations. Other than increased volume of business, this support often does not translate directly to an improved financial position for the pharmacy. The survival of sole community pharmacies not only ensures retail access to pharmaceuticals and patient counseling, but it also, in many cases, plays a key role in supporting other local health care providers, helping to preserve access to important services that are particularly needed in communities with limited health care options.

Trends in behavioral health care service provision by community health centers, 1998-2007.

OBJECTIVE: The federal government boosted support for community health centers in medically underserved areas in 2002-2007. This investigation compared trends in behavioral health services provided by community health centers nationwide during the first several years of that initiative with immediately prior trends. METHODS: Data were extracted from the Health Resources and Services Administration's Uniform Data System on community health centers for 1998-2007 (2007, N=1,067). Regression analyses revealed trends in individual community health centers' likelihood of providing on-site specialty mental health care, crisis services, and substance abuse treatment. Aggregate data were used to show national trends in numbers of behavioral health encounters, patients, and encounters per patient. RESULTS: The number of federally funded community health centers increased 43% between 2001 and 2007, from 748 to 1,067, over twice the annual growth rate between 1998 and 2001. However, trends in individual community health centers' likelihood of providing different types of behavioral health care were generally consistent across the two time periods. In 2007, 77% of community health centers offered specialty mental health services, 20% offered 24-hour crisis intervention services, and 51% offered substance abuse treatment. The mean number of mental health encounters per mental health patient at community health centers in 2007 was 2.9. CONCLUSIONS: The behavioral health care safety net has widened through rapid recent growth in the number of community health centers as well as a continuing increase in the proportion offering specialty mental health services.

Continuing effects of Medicare Part D on rural independent pharmacies who are the sole retail provider in their community.

BACKGROUND: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established funding to allow Medicare beneficiaries to enroll in plans providing outpatient prescription drug coverage beginning in January 2006. The Medicare Part D program has changed the means by which beneficiaries purchase prescription drugs, impacting the business operations of pharmacies. OBJECTIVES: To describe the experiences of rural independently owned pharmacies that are the sole retail pharmacy in their community 1 year after implementation of Medicare Part D, in order to learn if the initial financial and administrative problems associated with the implementation of the program in 2006 resolved over time. METHODS: A semistructured interview protocol was used in telephone interviews with 51 pharmacist owners of rural sole community pharmacies in 27 states who were identified through a random sampling process. RESULTS: The sole community pharmacists interviewed continue to face challenges directly related to Medicare Part D. Dealing with Part D plans and working with patients during enrollment periods remains administratively burdensome. Reimbursement amounts, complexity of dealing with multiple plans, and timeliness of payments continue to be cited as problems which could threaten the viability of independently owned pharmacies who are the sole retail providers in their communities. CONCLUSIONS: Actions should be considered to help sole community pharmacies deal with the ongoing administrative and financial challenges of Part D. To ensure full choice for rural Medicare beneficiaries and full access to pharmaceuticals through the ongoing presence of a local pharmacy, the development of a mechanism to structure prescription reimbursement so that drug acquisition costs and related overhead are covered and a reasonable profit margin provided should be considered. Further study is needed to determine how existing policies and regulations can be modified to ensure reasonable access to pharmacy services for rural Medicare and Medicaid beneficiaries.

Rural hospitals: are you missing out on drug savings?

The 340B Drug Pricing Program requires drug manufacturers to offer outpatient drugs at a reduced price to certain safety net organizations that provide healthcare services to vulnerable populations. In a survey, participants reported pharmacy savings ranging from $600 to $158,000 per month, with a mean savings of $19,700 and a median savings of $10,000. The biggest challenge in administering the program is maintaining separate records for inpatient and outpatient drugs, according to participants.

The experience of rural independent pharmacies with medicare part D: reports from the field.

CONTEXT: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) created prescription drug coverage for Medicare beneficiaries through a new Part D program, the single largest addition to Medicare since its creation in 1965. Prior to program implementation in January 2006, concerns had been voiced as to how independent pharmacies, which represent a higher proportion of all retail pharmacies in rural areas, would fare under the new program. PURPOSE: This article describes first-hand reports from rural pharmacist-owners about their experiences with Medicare Part D plans in the first 7 months of 2006 in order to gain a more thorough understanding of the challenges faced by rural independent pharmacies as a result of program implementation. METHODS: A semi-structured interview protocol was utilized in telephone interviews with 22 pharmacist-owners of rural independent pharmacies in 10 states. FINDINGS: The rural independent pharmacists interviewed are experiencing major changes in payment, administrative burden, and interaction with patients as a result of the shift of patients into Medicare Part D plans. While administrative burden has greatly increased, payment and clinical interaction have decreased. CONCLUSION: Actions should be considered that would help rural independent pharmacists adjust to the new circumstances of having Medicare patients mirror, for administrative and payment purposes, commercially insured patients. Long-term modification of existing policies and regulations may be necessary to assure reasonable access to pharmaceuticals for rural populations. Further study is needed to determine how best to target these modifications to essential pharmacies.

A comparative performance scorecard for federally funded community health centers in North Carolina.

To make informed management decisions, healthcare executives must have timely and useful information about the performance of their organizations. A review of the methods used by the Health Resources and Services Administration's Bureau of Primary Health Care to evaluate the performance of community health centers (CHCs) revealed a lack of such information. This information gap motivated the development of a comparative performance scorecard for the federally funded CHCs in North Carolina. The scorecard includes 19 indicators in four performance dimensions (access to care, financial performance, human resources, and utilization and productivity). A survey of participating CHC executive directors showed that the comparative performance scorecard is a useful tool for managing and evaluating the performance of CHCs.

Contracting with Medicare Advantage plans: a brief for critical access hospital administrators.

This document summarizes the experience of CAH administrators with contracts offered by Medicare Advantage (MA) plans. Telephone surveys were conducted with CAH administrators across the country to learn about their experiences with MA plans. This brief includes information about the contract terms administrators have been offered, their experiences negotiating with MA plans, and their advice for others dealing with this issue.