Onset of T2DM after gestational diabetes: What the prevention paradox tells us about risk.

This study investigates the effect of severity of gestational diabetes (GDM) on likelihood of post-delivery glucose testing and early onset Type 2 diabetes (T2DM). We asked if clinical focus on relative risk (RR), i.e. greater probability of T2DM onset in a higher-severity group, contributes to missed opportunities for prevention among women with lower-severity GDM. A sample of 12,622 continuously-insured women with GDM (2006-2015) was drawn from a large national dataset (OptumLabs® Data Warehouse) and followed for 3-years post-delivery. Higher-severity GDM was defined as addition of hypoglycemic therapy to standard of care for GDM. We found that women with higher-severity (n = 2627) were twice as likely as lower-severity women (n = 9995) to obtain glucose testing post-delivery. Moreover, 357 (13.6%) of the higher-severity women developed T2DM by year-3 vs. 600 (6.0%) lower-severity women. In an analysis of the population attributable fraction (PAF), defined as the contribution of excess risk to population prevalence, lower-severity women contributed more cases to diabetes rates than higher-risk women (PAF 79% vs. 21%), despite an increased RR in the higher-severity group (13.6% vs. 6.0%, RR 2.26, 95%CI 2.00, 2.56). Projecting out to the 327,950 U.S. deliveries in 2014, we estimate that 9277 higher-severity women (13.6%) and 15,584 lower-severity women (6.0%), will have developed T2DM by 2018. These data demonstrate that lower-severity GDM contributes substantially to the diabetes epidemic. Greater awareness of clinical and cost implications of gaps in follow-up for lower-severity GDM may strengthen the likelihood of post-delivery testing and primary care referral, and thus reinforce the path to prevention.

Interrupting the Pathway from Gestational Diabetes Mellitus to Type 2 Diabetes: The Role of Primary Care.

OBJECTIVE: Our objective was to describe patient-, provider-, and health systems-level factors associated with likelihood of obtaining guideline-recommended follow-up to prevent or mitigate early-onset type 2 diabetes after a birth complicated by gestational diabetes mellitus (GDM). METHODS: This study presents a retrospective cohort analysis of de-identified demographic and health care system characteristics, and clinical claims data for 12,622 women with GDM who were continuously enrolled in a large, national U.S. health plan from January 31, 2006, to September 30, 2012. Data were obtained from the OptumLabs Data Warehouse. We extracted 1) known predictors of follow-up (age, race, education, comorbidities, GDM severity); 2) novel factors that had potential as predictors (prepregnancy use of preventive measures and primary care, delivery hospital size); and 3) outcome variables (glucose testing within 1 and 3 years and primary care visit within 3 years after delivery). RESULTS: Asian ethnicity, higher education, GDM severity, and delivery in a larger hospital predicted greater likelihood of post-GDM follow-up. Women with a prepregnancy primary care visit of any type were two to three times more likely to receive postpartum glucose testing and primary care at 1 year, and 3.5 times more likely to have obtained testing and primary care at 3 years after delivery. CONCLUSIONS: A history of use of primary care services before a pregnancy complicated by GDM seems to enhance the likelihood of postdelivery surveillance and preventive care, and thus reduce the risk of undetected early-onset type 2 diabetes. An emphasis on promoting early primary care connections for women in their early reproductive years, in addition to its overall value, is a promising strategy for ensuring follow-up testing and care for women after complicated pregnancies that forewarn risk for later chronic illness. Health systems should focus on models of care that connect primary and reproductive/maternity care before, during, and long after pregnancies occur.

After Gestational Diabetes: Impact of Pregnancy Interval on Recurrence and Type 2 Diabetes.

The contribution of pregnancy interval after gestational diabetes (GDM) to type 2 diabetes (T2DM) onset is a poorly understood but potentially modifiable factor for T2DM prevention. The purpose of this study was to assess the impact of GDM recurrence and/or delivery interval on follow-up care and T2DM onset in a sample of continuously insured women with a term livebirth within 3 years of a GDM-affected delivery. This is a secondary analysis of a cohort of 12,622 women with GDM, 2006-2012, drawn from a national administrative data system (OptumLabs Data Warehouse). We followed 1091 women with GDM who had a subsequent delivery within 3 years of their index delivery. GDM recurred in 49.3% of subsequent pregnancies regardless of the interval to the next conception. Recurrence tripled the odds of early T2DM onset within 3 years of the second delivery. Women with GDM recurrence had greater likelihood of glucose testing in that 3-year interval, but not transition to primary care for continued monitoring, as required by both American Congress of Obstetricians and Gynecologists (ACOG) and the American Diabetes Association (ADA) guidelines. In multivariable analysis, we found a trend toward increased likelihood of T2DM onset for short interpregnancy intervals (≤1 year vs. 3 year, 0.08). Pregnancy interval may play a previously unrecognized role in progression to T2DM. T2DM onset after GDM can be prevented or mitigated, but many women in even this insured sample did not receive recommended follow-up monitoring and preventive care, even after a GDM recurrence. The postpartum visit may be an ideal time to inform patients about T2DM prevention opportunities, and discuss potential benefits of optimal spacing of future pregnancies.

Follow-up after gestational diabetes: a fixable gap in women's preventive healthcare.

OBJECTIVE: Gestational diabetes mellitus (GDM) is a known harbinger of future type 2 diabetes mellitus (T2DM), hypertension, and cardiac disease. This population-based study was designed to identify gaps in follow-up care relevant to prevention of T2DM in a continuously insured sample of women diagnosed with GDM. RESEARCH DESIGN AND METHODS: We analyzed data spanning 2005-2015 from OptumLabs Data Warehouse, a comprehensive, longitudinal, real-world data asset with deidentified lives across claims and clinical information, to describe patterns of preventive care after GDM. Women with GDM were followed, from 1 year preconception through 3 years postdelivery to identify individual and healthcare systems characteristics, and report on GDM-related outcomes: postpartum glucose testing, transition to primary care for monitoring, GDM recurrence, and T2DM onset. RESULTS: Among 12 622 women with GDM, we found low rates of glucose monitoring in the recommended postpartum period (5.8%), at 1 year (21.8%), and at 3 years (51%). A minority had contact with primary care postdelivery (5.7% at 6 months, 13.2% at 1 year, 40.5% at 3 years). Despite increased population risk (GDM recurrence in 52.2% of repeat pregnancies, T2DM onset within 3 years in 7.6% of the sample), 70.1% of GDM-diagnosed women had neither glucose testing nor a primary care visit at 1 year and 32.7% had neither at 3 years. CONCLUSIONS: We found low rates of glucose testing and transition to primary care in this group of continuously insured women with GDM. Despite continuous insurance coverage, many women with a pregnancy complication that portends risk for future chronic illness fail to obtain follow-up testing and may have difficulty navigating between clinician specialties. Results point to a need for action to close the gap between obstetrics and primary care to ensure receipt of preventive monitoring as recommended by both the American Diabetes Association and the American Congress of Obstetricians and Gynecologists.