Interdepartmental program to improve outcomes for acute heart failure patients seen in the emergency department.

INTRODUCTION: Acute heart failure patients often have an uncertain or delayed follow-up after discharge from the ED. Our goal was to introduce rapid-access specialty clinics to ensure acute heart failure patients were seen within 7 days, in an effort to reduce admissions and improve follow-up care. METHODS: This prospective cohort study was conducted at two campuses of a large tertiary care hospital. We enrolled acute heart failure patients who presented to the ED with shortness of breath and were later discharged. Following a 12-month before period, we introduced rapid-access acute heart failure clinics staffed by cardiology and internal medicine. We allowed for a 3-month implementation period and then observed outcomes over the subsequent 12-month after period. The primary outcome was hospital admission within 30 days. Secondary outcomes included mortality and actual access to specialty care. RESULTS: Patients in the before (N = 355) and after periods (N = 374) were similar for age and most characteristics. Segmented autoregression analysis demonstrated there was a pre-existing trend to fewer admissions. Attendance at a specialty clinic increased from 17.8 to 42.1% (P < 0.01) and the median days to the clinic decreased from 13 to 6 days (P < 0.01). 30-days mortality did not change. CONCLUSION: Implementation of rapid-access clinics for acute heart failure patients discharged from the ED did not lead to an overall decrease in hospital admissions. It did, however, lead to increased access to specialist care, reduced follow-up times, without an increase in return ED visits or mortality. Widespread use of this rapid-access approach to a specialist can improve care for acute heart failure patients discharged home from the ED.

RéSUMé: INTRODUCTION: Les patients atteints d'insuffisance cardiaque aiguë ont souvent un suivi incertain ou retardé après leur sortie de l'urgence. Notre objectif était de mettre en place des cliniques spécialisées à accès rapide pour veiller à ce que les patients de d'insuffisance cardiaque aiguë soient vus dans les sept jours, afin de réduire les admissions et d'améliorer les soins de suivi. MéTHODES: Cette étude de cohorte prospective a été menée sur deux campus d'un grand hôpital de soins tertiaires. Nous avons recruté des patients atteints de d'insuffisance cardiaque aiguë qui se sont présentés aux urgences avec un essoufflement et qui ont ensuite été renvoyés chez eux. Après une période antérieure de 12 mois, nous avons mis en place des cliniques de d'insuffisance cardiaque aiguë à accès rapide dotées de personnel en cardiologie et en médecine interne. Nous avons prévu une période de mise en œuvre de 3 mois et avons ensuite observé les résultats au cours des 12 mois suivants. Le résultat principal était l'admission à l'hôpital dans les 30 jours. Les résultats secondaires comprenaient la mortalité et l'accès réel aux soins spécialisés. RéSULTATS: Les patients des périodes avant (N = 355) et après (N = 374) étaient similaires pour l'âge et la plupart des caractéristiques. Une analyse d'autorégression segmentée a démontré qu'il y avait une tendance préexistante à moins d'admissions. La fréquentation d'une clinique spécialisée est passée de 17,8 % à 42,1 % (P < 0,01) et les jours médians à la clinique ont diminué de 13 à 6 jours (P < 0,01). La mortalité à 30 jours n'a pas changé. CONCLUSION: La mise en place de cliniques à accès rapide pour les patients d'insuffisance cardiaque aiguë sortant de l'urgence n'a pas entraîné une diminution globale des admissions à l'hôpital Elle a toutefois permis d'améliorer l'accès aux soins spécialisés et de réduire les délais de suivi, sans pour autant augmenter les visites de retour aux urgences ou la mortalité. L'utilisation généralisée de cette approche d'accès rapide à un spécialiste peut améliorer les soins pour les patients atteints de d'insuffisance cardiaque aiguë renvoyés chez eux par les services d'urgence.

The Evolution of General Internal Medicine (GIM)in Canada: International Implications.

General internal medicine (GIM), like other generalist specialties, has struggled to maintain its identity in the face of mounting sub-specialization over the past few decades. In Canada, the path to licensure for general internists has been through the completion of an extra year of training after three core years of internal medicine. Until very recently, the Royal College of Physicians and Surgeons of Canada (RCPSC) did not recognize GIM as a distinct entity. In response to a societal need to train generalist practitioners who could care for complex patients in an increasingly complex health care setting, the majority of universities across Canada voluntarily developed structured GIM training programs independent of RCPSC recognition. However, interest amongst trainees in GIM was declining, and the GIM workforce in Canada, like that in many other countries, was in danger of serious shortfalls. After much deliberation and consultation, in 2010, the RCPSC recognized GIM as a distinct subspecialty of internal medicine. Since this time, despite the challenges in the educational implementation of GIM as a distinct discipline, there has been a resurgence of interest in this field of medicine. This paper outlines the journey of the Canadian GIM to educational implementation as a distinct discipline, the impact on the discipline, and the implications for the international GIM community.

Clinical predictors for diabetes screening in the first year postpartum after gestational diabetes.

BACKGROUND: Postpartum screening for diabetes in women with gestational diabetes (GDM) improves with use of reminder systems. Our primary objective was to identify predictors of diabetes screening in the first year after delivery. METHODS: A retrospective study was performed of 556 women with GDM who received outpatient prenatal care between 2007 and 2009. A mailed reminder system was utilized at two sites. Rates of postpartum glucose testing at 6 and 12 months postpartum were measured. RESULTS: Site of care and non-smoking status were identified as the only predictors of postpartum diabetes screening (p<0.001 and p = 0.02, respectively). Rates of OGTT completion at one year (38% vs. 19% p<0.001) were higher in women who attended clinics with postpartum reminders. CONCLUSIONS: The site of diabetes care in pregnancy is a major predictor of adherence to diabetes screening postpartum. Health care delivery should be considered in the development of strategies to increase screening rates.

Blood pressure after recent stroke: baseline findings from the secondary prevention of small subcortical strokes trial.

BACKGROUND: Hypertension is the most powerful risk factor for stroke. The aim of this study was to characterize baseline blood pressure in participants in the Secondary Prevention of Small Subcortical Strokes trial. METHODS: For this cross-sectional analysis, participants were categorized by baseline systolic blood pressure (SBP) < 120, 120-139, 140-159, 160-179, and ≥ 180 mm Hg and compared on demographic and clinical characteristics. Predictors of SBP < 140 mm Hg were examined. RESULTS: Mean SBP was 143±19 mm Hg while receiving an average of 1.7 antihypertensive medications; SBP ≥ 140 mm Hg for 53% and ≥ 160 mm Hg for 18% of the 3,020 participants. Higher SBP was associated with a history of hypertension and hypertension for longer duration (both P < 0.0001). Higher SBPs were associated with more extensive white matter disease on magnetic resonance imaging (P < 0.0001). There were significant differences in entry-level SBP when participants were categorized by race and region (both P < 0.0001). Black participants were more likely to have SBP ≥ 140 mm Hg. Multivariable logistic regression showed an independent effect for region with those from Canada more likely (odds ratio = 1.7; 95% confidence interval, 1.29, 2.32) to have SBP < 140 mm Hg compared with participants from United States. CONCLUSIONS: In this cohort with symptomatic lacunar stroke, more than half had uncontrolled hypertension at approximately 2.5 months after stroke. Regional, racial, and clinical differences should be considered to improve control and prevent recurrent stroke.

Do postal reminders increase postpartum screening of diabetes mellitus in women with gestational diabetes mellitus? A randomized controlled trial.

OBJECTIVE: Women with previous gestational diabetes mellitus rarely receive the recommended 2-hour oral glucose tolerance test (OGTT) after delivery. We sought to determine whether postal reminders to be sent after delivery to a patient, her physician, or both would increase screening rates. STUDY DESIGN: Patients were assigned randomly to 4 groups: reminders sent to both physician and patient, to physician but not patient, or to patient but not physician or no reminders were sent. The primary outcome was the proportion of patients who underwent an OGTT within 1 year after delivery. The secondary outcome was the performance of other postpartum screening tests. RESULTS: OGTT rates were significantly increased in the physician/patient reminder group (49/81 women; 60.5%), in the patient-only reminder group (42/76 women; 55.3%), and in the physician-only reminder group (16/31 women; 51.6%) compared with the no reminder group (5/35 women; 14.3%; P < .05). CONCLUSION: Postpartum reminders greatly increased screening rates for women with gestational diabetes mellitus.

Why do family physicians fail to detect renal impairment?

OBJECTIVE: To investigate why many patients with renal impairment (30.7%) were not recognized by their family physicians despite an earlier educational intervention on detecting renal impairment; and to determine whether certain factors related to physicians, patients, or the intervention itself were associated with whether renal impairment was detected. DESIGN: Qualitative approach using grounded theory. SETTING: A Health Service Organization in Ottawa, Ont. PARTICIPANTS: A purposeful sample of six family physicians. METHODS: In semistructured interviews, participants were asked to describe the workup ordered and their decision-making processes for patients in whom they had recently detected renal impairment. They were also asked to evaluate the six components of an educational intervention designed to help them to detect renal impairment. Finally, one patient's chart was reviewed (a chart containing a laboratory report noting an abnormal result for kidney function and having no indication that renal impairment had been recognized) to identify reasons for lack of detection. RESULTS: Most physicians did not investigate every patient with renal impairment (glomerular filtration rate of < 78 mL/min) in the same way because they took individual patient factors into consideration. Reasons for not detecting renal impairment were "managed differently" or "missed," with the former being the most common. The educational intervention physicians remembered most often was chart rounds, and these were viewed as helpful. "Missed" cases were more often deliberately managed differently than unintentionally not detected. CONCLUSION: Physicians used various approaches to detect and manage renal impairment despite interventions that recommended a consistent procedure.

Combination therapy with an angiotensin receptor blocker and an ACE inhibitor in proteinuric renal disease: a systematic review of the efficacy and safety data.

Blockade of the renin-angiotensin system with either an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) was shown to decrease urinary protein excretion and slow the progression of both diabetic and nondiabetic proteinuric renal disease. The safety and efficacy of combined ACE-inhibitor and ARB therapy is not well established. We conducted a systematic review and meta-analysis of randomized trials evaluating the combination of an ACE inhibitor and an ARB in patients with chronic proteinuric renal disease. Twenty-one randomized controlled studies (n = 654 patients) were identified using MEDLINE, EMBASE, and Cochrane Central databases. Five trials had a parallel-group design and 16 trials used a crossover design. Combination therapy with an ACE inhibitor and an ARB resulted in a small, but significant, increase in serum potassium levels (weighted mean difference, 0.11 mEq/L [0.11 mmol/L]; 95% confidence interval [CI], 0.05 to 0.17) and a nonsignificant decrease in glomerular filtration rate (weighted mean difference, 1.4 mL/min [0.02 mL/s]; 95% CI, -2.6 to 0.2). Addition of an ARB resulted in a further decrease in proteinuria (weighted mean difference, 440 mg/d; 95% CI, 289 to 591) compared with an ACE inhibitor alone. This effect was observed in patients with diabetic (210 mg/d; 95% CI, 84 to 336) and nondiabetic (582 mg/d; 95% CI, 371 to 793) renal disease. In conclusion, the combination of ACE-inhibitor and ARB therapy in patients with chronic proteinuric renal disease is safe, without clinically meaningful changes in serum potassium levels or glomerular filtration rates. Combination therapy also was associated with a significant decrease in proteinuria, at least in the short term. Additional trials with longer follow-up are needed to determine whether the decrease in proteinuria will result in significant preservation of renal function.

Complication of a percutaneous endoscopic gastrostomy tube causing duodenal ischemia.

A 33-year-old woman with a percutaneous endoscopic gastrostomy tube was admitted with bilious vomiting, 1 month after her feeding tube was replaced by a temporary Foley catheter. A computed tomography scan of her abdomen revealed a 4.5 cm by 7.5 cm fluid-filled structure in the distal duodenum surrounding the Foley feeding tube. Approximately 100 mL of fluid was aspirated from the Foley's balloon port. We hypothesized that the Foley catheter was flushed inappropriately through the balloon port, causing an iatrogenic ischemic duodenal injury. Conservative management was successful in the intensive care unit. This case highlights an unusual complication of percutaneous endoscopic gastrostomy tubes. In addition, it emphasizes the temporary nature of Foley catheters as replacement gastrostomy tubes, and the importance of training in the handling of feeding tubes.

Effect of a nurse team coordinator on outcomes for hospitalized medicine patients.

PURPOSE: Several randomized trials have found that discharge planning improves outcomes for hospitalized patients. We do not know if adding a clinical nurse specialist (CNS) to physician teams in hospitals that already have discharge planning services makes a difference. METHODS: In 2 teaching hospitals, patients were randomly assigned to regular hospital care or care with a clinical nurse specialist. The clinical nurse specialist facilitated hospital care by retrieving preadmission information, arranging in-hospital consultations and investigations, organizing postdischarge follow-up visits, and checking up on patients postdischarge with a telephone call. In-hospital outcomes included mortality and length of stay. Postdischarge outcomes included time to readmission or death, patient satisfaction, and the risk of adverse event. Adverse events were poor outcomes due to medical care rather than the natural history of disease. RESULTS: A total of 620 sequential patients were randomized (CNS n = 307, control n = 313), of which 361 were followed after discharge from hospital (CNS n = 175, control n = 186). The groups were similar for the probability of in-hospital death (CNS 9.3% vs control 9.7%) or being discharged to the community (58.0% vs 60.0%). The groups did not differ for postdischarge outcomes including readmission or death (21.6% vs 15.6%; P = 0.16) or risk of adverse event (23.6% vs 22.8%). Mean [SD] patient ratings of overall quality of care on a scale of 10 was higher in the clinical nurse specialist group (8.2 [2.2] vs 7.6 [2.4]; P = 0.052). CONCLUSION: The addition of a clinical nurse specialist to a medical team improved patient satisfaction but did not impact hospital efficiency or patient safety.

Measured creatinine clearance from timed urine collections substantially overestimates glomerular filtration rate in patients with liver cirrhosis: a systematic review and individual patient meta-analysis.

BACKGROUND: Accurate glomerular filtration rate (GFR) assessment in patients with liver cirrhosis is important for prognostication, chronic kidney disease staging, drug dosing and identifying combined liver-kidney transplantation candidates. The objective of this study was to review the accuracy of measured creatinine clearance (MCrCl) from timed urine collections for estimating true GFR. METHODS: A systematic review and individual patient meta-analysis was performed. MEDLINE, old MEDLINE, Index Medicus and Cochrane library bibliographic databases and conference proceedings were searched up to June 2004. Reference lists of relevant studies were searched and experts were contacted. Comparative diagnostic studies describing stable adult patients with cirrhosis categorized according to the Child-Pugh classification were included if a gold standard GFR measurement was performed within 3 days of MCrCl. Individual patient data were abstracted from graphs of primary articles to allow a pooled analysis of agreement between renal measures. RESULTS: Seven studies of 193 patients from 1974 to 2002 were summarized. MCrCl overestimated inulin clearance (CIn) by a mean of +13 ml/min/1.73 m2 and the limits of agreement (mean of the differences+/-2 SD) were +60 ml/min/1.73 m2 and -34 ml/min/1.73 m2. This overestimation was highest in patients with lower GFR. The mean clearance ratios [95% confidence interval (CI)] between MCrCl and CIn in the high (> or =60 ml/min/1.73 m2) and low (<60 ml/min/1.73 m2) GFR subgroups were 1.18 (1.12-1.23) and 1.49 (1.33-1.66), respectively (P<0.0001). Fourteen percent of patients with a MCrCl > or =60 ml/min/1.73 m2 had a CIn of <30 ml/min/1.73 m2. CONCLUSIONS: For patients with liver cirrhosis, MCrCl from timed urine collections consistently overestimates the true GFR. For patients requiring complete clinical evaluation, GFR assessment by CIn is justified.

Cystatin-C and beta trace protein as markers of renal function in pregnancy.

OBJECTIVE: To assess the validity of Cystatin-C (Cys-C) and beta trace protein (BTP) as clinical markers of glomerular filtration rate (GFR) in pregnant women. DESIGN: Prospective cross sectional study. SETTING: Obstetric unit of a tertiary care hospital. POPULATION: One hundred and thirty-seven normal pregnant women and 13 women postpartum. METHODS: Twenty-four hour creatinine clearance (CrCl), serum creatinine, Cys-C and BTP concentrations were measured on normal pregnant women in the first trimester (n= 5), second trimester (n= 68) and third trimester (n= 64) and in 13 women postpartum. Data are given as median (2.5th centile, 97.5th centile). MAIN OUTCOME MEASURES: Serum concentrations of Cys-C and BTP compared with creatinine clearance and serum creatinine. RESULTS: The median serum creatinine throughout gestation was 53 micromol/L (39, 71), and median CrCl was 143 mL/minute (91 to 216). Postpartum, creatinine rose to 74 micromol/L (58, 86) and CrCl decreased to 104 mL/minute (71, 159). For Cys-C, the median concentration was 0.70 mg/L (0.46, 1.32), and 0.54 mg/L (0.36, 0.96) for BTP. Comparing the second and third trimesters, there was no significant difference between CrCl (median 145 vs 141 mL/minute) and BTP concentrations (median 0.51 vs 0.55 mg/L), while median Cys-C was significantly higher in the third trimester (0.61 vs 0.88 mg/L; P < 0.001). Unlike creatinine and BTP, Cys-C levels decreased to 0.72 mg/L (0.57, 0.95) postpartum. The only significant relationship of either of these markers to the standard used for GFR was between Cys-C and CrCl in the third trimester, and the correlation was weak (r= 0.27 for 1/Cys-C vs CrCl). CONCLUSION: These data demonstrate that despite claims to the contrary, Cys-C is a poor marker of GFR during pregnancy. Similarly, BTP shows little promise.

Detection of chronic kidney disease with laboratory reporting of estimated glomerular filtration rate and an educational program.

BACKGROUND: Serum creatinine concentration is an inadequate screening test for chronic kidney disease, especially in elderly patients. We hypothesized that laboratory reporting of estimated glomerular filtration rate (GFR) accompanied with an educational intervention would improve recognition of chronic kidney disease (CKD). METHODS: We conducted a before-and-after study at an outpatient family medicine practice. Patients 65 years or older for whom a Cockcroft-Gault GFR could be calculated from their medical record were included. The intervention consisted of automatic reporting of estimated GFR by the hospital laboratory along with an educational intervention directed toward the primary care physicians. The primary outcome was the recognition of CKD (defined as a Cockroft-Gault GFR <60 mL/min [<1.0 mL/s]) by the primary care physician. Factors associated with the recognition of CKD were also determined. RESULTS: The study population comprised 324 patients. Prior to the study intervention, 22.4% of patients with CKD were recognized, which increased to 85.1% after the intervention. Before the intervention, recognition was more likely in male subjects (odds ratio, 4.3; 95% confidence interval, 1.9-9.8) and patients with diabetes (odds ratio, 3.4; 95% confidence interval, 1.6-7.6). These associations were no longer statistically significant after the intervention. CONCLUSION: Laboratory reporting of estimated GFR coupled with an educational program markedly improves the recognition of CKD in the primary care setting.

Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital.

BACKGROUND: Adverse events are poor patient outcomes that are due to medical care. Studies of hospital patients have demonstrated that adverse events are common, but few data describe the timing of them in relation to hospital admission. We evaluated characteristics of adverse events affecting patients admitted to a Canadian teaching hospital, paying particular attention to timing. METHODS: We randomly selected 502 adults admitted to the Ottawa Hospital for acute care of nonpsychiatric illnesses over a 1-year period. Charts were reviewed in 2 stages. If an adverse event was judged to have occurred, a physician determined whether it occurred before or during the index hospitalization. The reviewer also rated the preventability, severity and type of each adverse event. RESULTS: Of the 64 patients with an adverse event (incidence 12.7%, 95% confidence interval [CI] 10.1%-16.0%), 24 had a preventable event (4.8%, 95% CI 3.2%-7.0%), and 3 (0.6%, 95% CI 0.2%-1.7%) died because of an adverse event. Most adverse events were due to drug treatment, operative complications or nosocomial infections. Of the 64 patients, 39 (61%, 95% CI 49%-72%) experienced the adverse event before the index hospitalization. INTERPRETATION: Adverse events were common in this study. However, only one-third were deemed avoidable, and most occurred before the hospitalization. Interventions to improve safety must address ambulatory care as well as hospital-based care.

Adverse events among medical patients after discharge from hospital.

BACKGROUND: Adverse events (AEs) are adverse outcomes caused by medical care. Several studies have indicated that a substantial number of patients experience AEs before or during hospitalization. However, few data describe AEs after hospital discharge. We determined the incidence, severity, preventability and ameliorability of AEs in patients discharged from the general internal medicine service of a Canadian hospital. METHODS: At a multisite Canadian teaching hospital, we prospectively studied patients who were consecutively discharged home or to a seniors' residence from the general internal medicine service during a 14-week interval in 2002. We used telephone interview and chart review to identify outcomes after discharge. Two physicians independently reviewed each outcome to determine if the patient experienced an AE. The severity, preventability and ameliorability of all AEs were classified. RESULTS: During the study period, outcomes were determined for 328 of the 361 eligible patients, who averaged 71 years of age (interquartile range 54-81 years). After discharge, 76 of the 328 patients experienced at least 1 AE (overall incidence 23%, 95% confidence interval [CI] 19%-28%). The AE severity ranged from symptoms only (68% of the AEs) or symptoms associated with a nonpermanent disability (25%) to permanent disability (3%) or death (3%). The most common AEs were adverse drug events (72%), therapeutic errors (16%) and nosocomial infections (11%). Of the 76 patients, 38 had an AE that was either preventable or ameliorable (overall incidence 12%, 95% CI 9%-16%). INTERPRETATION: Approximately one-quarter of patients in our study had an AE after hospital discharge, and half of the AEs were preventable or ameliorable.

What factors are associated with a woman's decision to take hormone replacement therapy? Evaluated in the context of a decision aid.

OBJECTIVES: To understand the factors associated with a post-menopausal woman deciding to take hormone replacement therapy (HRT) after reviewing a decision aid (DA) and having a counselling visit with her physician as well as the factors associated with the act of taking HRT 2 months after the counselling interview. DESIGN: A secondary analysis of data collected for a randomized controlled trial evaluating two DAs. MAIN OUTCOME RESULTS: Although 28% of women were uncertain regarding their decision after the counselling interview, only 2.4% of women, at the assessment at 2 months, had not made a decision. The most significant factor associated with the decision to take HRT, after the physician visit, was the physician preference (OR: 62, 95% CI: 13.3, 289.7). Physician preference (OR: 78, 95% CI: 6.2, 975) remained the most significant factor for taking HRT 2 months after the counselling interview followed by low uncertainty about the decision (OR: 0.4, 95% CI: 0.2, 0.7). CONCLUSION: Physician preference was the factor that was most associated with the woman's decision following counselling and 2 months later. Qualitative evaluation of the interview process involving the patient and physician would determine whether the patient and physician are reaching a shared decision or is the physician preference influencing the patient.

Serum creatinine is an inadequate screening test for renal failure in elderly patients.

BACKGROUND: Serum creatinine is the most commonly used screening test for renal failure. We hypothesized that serum creatinine would underestimate the degree of renal failure in elderly people because they have a reduced muscle mass. If so, this would lead to underrecognition and thus suboptimal care of patients with severe renal failure. METHODS: We conducted a retrospective medical record review of all patients 65 years or older in an outpatient academic family medicine practice. The glomerular filtration rate was calculated using the Cockcroft and Gault formula and was used to evaluate the testing characteristics of serum creatinine for the detection of renal failure. RESULTS: We screened 1510 patients, 854 (56.6%) of whom met the inclusion criteria. Renal failure (glomerular filtration rate, 150 micro mol/L) had a sensitivity of 12.6% and a specificity of 99.9% for the detection of renal failure. For the detection of severe renal failure, the sensitivity was 45.5%, with a 99.1% specificity. Only 15 (27.3%) of the 55 patients with severe renal failure were referred to a nephrologist. Moreover, 34 (85%) of the 40 nonreferred patients with severe renal failure were incompletely evaluated regarding the metabolic complications associated with kidney dysfunction. CONCLUSION: Serum creatinine is a poor screening test for renal failure in elderly patients, leading to marked underinvestigation and underrecognition of renal failure in this population.

Did publication of a clinical practice guideline recommendation to screen for type 2 diabetes in women with gestational diabetes change practice?

OBJECTIVE: To determine whether women with previous gestational diabetes mellitus (GDM) were screened postpartum for type 2 diabetes according to the Canadian Diabetes Association (CDA) guidelines. RESEARCH DESIGN AND METHODS: The 1998 CDA guidelines recommend that all women diagnosed with GDM be screened postpartum for type 2 diabetes using a 2-h 75-g oral glucose tolerance test (OGTT). The impact of and compliance with this expert opinion-based recommendation is unknown. All women who delivered at the Ottawa Hospital in 1997 (pre-guideline) and 2000 (post-guideline) with confirmed GDM were identified. Using population-based administrative databases, we determined the proportion of these women who had an OGTT, serum glucose test, or glycated hemoglobin (GHb) test in the first postpartum year. Women who had not undergone any blood work were excluded. RESULTS: There were 131 women in 1997 and 123 women in 2000 with confirmed GDM. Of these, only 69 women in 1997 and 52 women in 2000 had blood work recorded in the database. None of these women had an OGTT performed in either period. We found a significant increase in the measurement of serum glucose (50 women pre-guideline [72.1%], 48 women post-guideline [92.3%], P < 0.05) and GHb (8 women pre-guideline [11.6%], 20 women post-guideline [38.5%], P < 0.01). CONCLUSIONS: In our region, physicians are not following the CDA recommendations to screen women with GDM postpartum with an OGTT. However, we did find a significant increase in the measurement of serum glucose and GHb. Publication of expert opinion-based guidelines did not change the postpartum use of an OGTT in these women but may have increased the use of less reliable screening tests for type 2 diabetes.