Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization.

OBJECTIVE: This study was undertaken to compare the use of glyburide with insulin for the treatment of gestational diabetes mellitus (GDM) unresponsive to diet therapy. STUDY DESIGN: A retrospective study was performed among women with singleton pregnancies who had GDM diagnosed, with fasting plasma glucose 140 mg/dL or less on glucose tolerance testing, between 12 and 34 weeks who failed diet therapy from 1999 to 2002. We identified 584 women and compared those treated with insulin between 1999 and 2000 with women treated with glyburide between 2001 and 2002. Maternal and neonatal outcomes and complications were assessed. Statistical methods included univariate analyses and multivariable logistic regression. RESULTS: In 1999 through 2000, 268 women had GDM diagnosed and were treated with insulin; in 2001 through 2002, 316 women had GDM diagnosed of which 236 (75%) received glyburide. The 2 groups were similar with regard to age, nulliparity, and historical GDM risk factors; however, women in the insulin group had a higher mean body mass index (31.9 vs 30.6 kg/m 2 , P=.04), a greater proportion identified themselves as white (43%, 28%, P<.001) and fewer as Asian (24%, 37%, P=.001), and they had a significantly higher mean fasting on glucose tolerance test (105.4 vs 102.4 mg/dL , P=.005) compared with the glyburide group. There were no significant differences in birth weight (3599+/-650 g vs 3661+/-629 g, P=.3), macrosomia (24%, 25%, P=.7), or cesarean delivery (35%, 39 %, P=.4). Women in the glyburide group had a higher incidence of preeclampsia (12%, 6%, P=.02), and neonates in the glyburide group were more likely to receive phototherapy (9%, 5%, P<.05), and less likely to be admitted to the neonatal intensive care unit (NICU) (15%, 24%, P=.008) though they had a longer NICU length of stay (4.3+/-9.6 vs 8.0+/-10.1, P=.002). Posttreatment glycemic control data were available for 122 women treated with insulin and 137 women treated with glyburide. More women in the glyburide group achieved mean fasting and postprandial goals (86%, 63%, P<.001). These findings remained significant in logistic regression analysis. CONCLUSION: In a large managed care organization, glyburide was at least as effective as insulin in achieving glycemic control and similar birth weights in women with GDM who failed diet therapy. The increased risk of preeclampsia and phototherapy in the glyburide group warrant further study.

Effects of a depression education program on residents' knowledge, attitudes, and clinical skills.

OBJECTIVE: To determine whether an interactive educational program would improve obstetrics and gynecology residents' knowledge, attitudes, confidence, and skills in caring for depressed patients. METHODS: We recruited 74 residents from eight residency programs to attend the Depression Education Program, which consists of a 1-hour lecture and two 2-hour workshops combining discussion, diagnosis and treatment tools, critique of a videotape, practice with feedback, and audiotape self-assessment. Before and after the program, participants 1) completed a questionnaire measuring knowledge, attitudes, and reported actions taken with a recent depressed patient; 2) received a standardized patient visit; and 3) kept lists of patients they suspected were depressed. Clinic patients completed a depression screening questionnaire. To assess improvement, we used paired t tests, McNemar chi2 tests, and multivariate models adjusting for training site. RESULTS: The education program led to 3-month improvements in participants' reported use of formal diagnostic criteria (38% before, 66% after; P =.004), clinical actions documented for suspected depression (P =.035), and perceived self-efficacy in depression care (P <.001). Perceived preparedness to diagnose depression, treat with medications, and comanage with a mental health practitioner improved (P <.05 for each). Small improvements in clinical behaviors with standardized patients and clinic-based depression detection rates were not statistically significant. CONCLUSION: The Depression Education Program improved residents' knowledge, confidence, and reported clinical actions with depressed patients, but did not improve most objectively assessed outcomes.