Key words
gestational diabetes - S3 guideline - diagnosis - treatment - knowledge
Schlüsselwörter
Gestationsdiabetes - S3-Leitlinie - Diagnostik - Behandlung - Kenntnis
Introduction
According to a survey by the BQS (Institute for Quality & Patient Safety), the prevalence
of gestational diabetes (GDM) has more than doubled between 2002 (1.5 %) and 2010
(3.7 %) and is currently around 4.4 % for all of Germany [1]. This means that almost 30 000 pregnant women in Germany are affected annually.
If left untreated, maternal GDM leads to an oversupply of glucose to the fetus which
can lead to the development of fetal hyperinsulinism. The consequences include fetal
macrosomia, delayed surfactant production in the lungs and structural organ immaturity
with regard to gestational age. Postnatally, these children present with typical diabetes-related
complications such as respiratory adjustment disorders, hypoglycemia and hyperbilirubinemia.
The extent of these disorders is correlated to the insulin concentrations in umbilical
cord blood [2]. Moreover, maternal GDM can lead to abnormalities in fetal islet cell development
and in the regulation of satiety. Children whose mothers had GDM are at increased
risk of glucose tolerance disorders and obesity for the rest of their lives [3], [4], [5]. International studies such as the HAPO study showed a linear correlation between
maternal blood glucose levels and the incidence of neonatal and maternal obstetric
complications [6]. If maternal blood sugar levels are rigorously controlled and kept within normal
ranges, the obstetric complications do not materialize, and nor do the perinatal and
lifelong consequences for the children [7].
Epidemiological data on GDM additionally show an increased risk of maternal morbidity
after GDM. Compared to pregnant women without glucose tolerance disorders, women after
GDM have a 7 to 10-fold higher risk of developing diabetes mellitus type 2 later on
[8]. Moreover, patients who have glucose tolerance disorders in pregnancy have 1.7-fold
higher risk of developing cardiovascular disease in later life and a 2 to 5-fold higher
risk of developing a metabolic co-morbidity (obesity, pulmonary arterial hypertension,
dyslipoproteinemia) [9]. Epidemiological data have also shown that up to 35 % of women who had GDM go on
to develop depression or already suffer from it [12].
For children, early diagnosis and effective treatment of maternal GDM to prevent intrauterine
oversupply of glucose with all the consequences described above represents an effective
means of avoiding the long and short-term effects of intrauterine hyperinsulinism.
For mothers with GDM, detailed information about the associated health risks, rigorous
follow-up of maternal glucose tolerance and the inclusion of the patients in a preventive
healthcare program will result in a significant improvement in long-term health [10], [11]. The S3 guideline “Gestational Diabetes Mellitus, Diagnosis, Treatment and Follow-up”
was developed in 2011 in cooperation with the German Diabetes Society and the German
Society for Gynecology and Obstetrics. Medical guidelines are systematically developed
aids to decision-making about the appropriate approach for particular health problems
[17]. With the publication of the guideline in 2011, for the first time an evidence-based
guideline was available on the care for patients with GDM in Germany [19]. The new guideline replaced the previous recommendations on the diagnosis and treatment
of GDM dating from 2001. The recommendations formulated in the new guideline on the
rigorous follow-up of patients with GDM represent an important expansion of the recommendations
on the care of patients with GDM. The new guideline aims to optimize diagnostic accuracy
and improve the care and particularly the follow-up of patients with GDM and their
children. If the measures proposed in the guideline are to be effective, the guideline
would need to be widely disseminated, and its recommendations would need to be known
to and implemented by attending physicians.
The aim of this study was to evaluate the diagnosis, treatment and follow-up provided
to women with GDM by non-hospital-based gynecologists and diabetologists four years
after the publication of the new guideline and to assess the physiciansʼ own knowledge
of the guideline. To this end, we carried out an extensive questionnaire-based survey
of diabetologists and gynecologists in Lower Saxony and Thuringia. The results showed
the state of knowledge about the contents of the guideline and offered useful insights
which will be used to improve the wording of the recommendations when the guideline
is updated in 2017.
Method
Study and questionnaire design
The questionnaire consisted of seven sets of questions with a total of 23 questions
and was developed by two gynecologists who actively treat pregnant women with GDM.
Under a number of headings, the questionnaire systematically surveyed the knowledge
of the physician completing the questionnaire about the recommendations in the guideline
on the “Diagnosis, Treatment and Counselling of Women with Gestational Diabetes”.
In addition, the questionnaire included fake questions on long-term risks such as
malignancy, allergies and varicose veins, which have no relationship with gestational
diabetes. The responses were obtained using scaled questions, where the responder
could select an answer on a 4-point Likert scale (“strongly agree”, “agree”, “disagree”,
“strongly disagree”). After receiving the approval of the Ethics Committees of the
Medical University of Hanover and of Jena University Hospital, the study was carried
out in Lower Saxony and Thuringia between October 2013 and November 2014.
The first set of questions focused on the demographic data of respondents (years of
professional experience working as a specialist, age range of patients treated in
the respective doctorʼs office, percentage of patients who had previously given birth
to at least one child). The next set of questions investigated whether the respondents
followed the recommended screening procedures in the guideline [19] with regard to familial risk, and medical, prior, and current obstetric risk factors
for developing GDM when examining and interviewing patients. The third set of questions
looked at the respondentsʼ approach to screening high-risk patients prior to the 24th
week of gestation and the implementation of generalized screening between the 24th
and 28th week of gestation using either the 75 g oral glucose tolerance test (oGTT)
or the 50 g challenge test. The next set of questions evaluated the respondentsʼ knowledge
of the risks facing mother and child after a diagnosis of GDM, including long-term
maternal risks and the acute and long-term consequences for the child if diabetes
is not controlled during pregnancy. Another set of questions confronted respondents
with questions about the counselling they provided after making a diagnosis and post
partum. In the final set of questions, the respondents were asked to evaluate their
own state of knowledge respecting the current GDM guideline [19] and the guideline on the treatment of neonates born to diabetic mothers [20].
Study population
The participants in the study were randomly selected from the publicly available database
of physicians maintained by the Medical Associations of Lower Saxony and Thuringia;
at the time of the survey the respondents were working as non-hospital-based gynecologists
or diabetologists. 774 gynecologists were randomly selected out of a total of 1292
gynecologists listed in the database, and 76 diabetologists were selected out of a
total of 286 listed diabetologists. The distribution between female and male participants
(64.5 % female) was comparable to that of the overall population in the database (65 %
female). A cover letter and a prepaid return envelope were sent out by mail together
with the questionnaire. Physicians who had not responded after two months were sent
a reminder letter. Answers were anonymized in the study center after the completed
questionnaire had been returned.
Statistical evaluation
Statistical evaluation was descriptive, and included frequency, mean and standard
deviation. Analysis was carried out using SPPS for Windows, Version 21 (SPSS Inc.
Chicago, USA). Comparisons of groups of nominal items in the questionnaire was done
by χ2-test (all fields of the fourfold table ≥ 5) or Fisherʼs exact test (one field < 5).
Differences in the number of correctly answered questions were analyzed by t-test
for independent samples; data classified as demographic (e.g. years) were analyzed
using Mann-Whitney U-test for differences between groups. Groups were grouped together
if there was not much difference in the answers between the different groups (e.g.
years of clinical experience: under 10 years and over 10 years). For statistical analysis,
the answers “strongly agree” and “agree” were summarized as the respondent having
a good knowledge of the guideline. A poor knowledge of the guideline was indicated
by grouping together the answers “disagree” and “strongly disagree”. The percentage
of respondents with a good or a poor knowledge of the guideline were compared with
respect to demographic data, professional characteristics, their approach to taking
the patientʼs medical and familial history and to screening and counselling. Differences
were considered significant when p-values were < 0.05.
Results
Descriptive data for the cohort of surveyed physicians
460 (54.2 %) out a total of 849 physicians who received the questionnaire returned
a completed questionnaire; the figure was 418 (54.1 %) out of 774 for gynecologists
and 42 (55.3 %) out of 76 for diabetologists. When the two groups were compared, gynecologists
were more commonly women (74.2 vs. 33.3 %; p < 0.001) and cared for a younger patient
population (women of child-bearing age 41.1 vs. 14.3 %; p < 0.001) than the participating
diabetologists. More than 90 % of respondents considered that they had a good knowledge
of the guideline. Additional descriptive data are summarized in [Table 1].
Table 1 Demographic data.
|
|
Gynecologists (n = 418)
|
Diabetologists (n = 42)
|
p-value*
|
|
* Comparison of gynecologists with diabetologists
|
|
Response rate (dispatched questionnaires)
|
54.1 % (418 von 773)
|
55.3 % (42 von 76)
|
|
|
|
40.1 % (108 von 269)
|
53.8 % (28 von 52)
|
|
|
|
61.6 % (310 von 504)
|
58.3 % (14 von 24)
|
|
|
Distribution between the sexes
|
|
|
< 0.001
|
|
|
108 (25.8 %)
|
28 (66.7 %)
|
|
|
|
310 (74.2 %)
|
14 (33.3 %)
|
|
|
Years of working as a medical specialist
|
|
|
0.71
|
|
|
24 (5.8 %)
|
0 (0 %)
|
|
|
|
72 (17.4 %)
|
7 (16.7 %)
|
|
|
|
142 (34.4 %)
|
18 (42.9 %)
|
|
|
|
175 (42.4 %)
|
17 (40.5 %)
|
|
|
Patient age
|
|
|
< 0.001
|
|
|
172 (43.7 %)
|
6 (15.0 %)
|
|
|
|
208 (52.8 %)
|
6 (15.0 %)
|
|
|
|
14 (3.6 %)
|
28 (70.0 %)
|
|
|
Percentage of patients who had given birth to at least one child previously
|
|
|
0.92
|
|
|
10 (2.5 %)
|
5 (15.2 %)
|
|
|
|
116 (29.3 %)
|
7 (21.2 %)
|
|
|
|
162 (40.9 %)
|
8 (24.2 %)
|
|
|
|
108 (27.3 %)
|
13 (39.4 %)
|
|
|
Knowledge of the S3 guideline on GDM
|
|
|
0.08
|
|
|
236 (57.4 %)
|
31 (73.8 %)
|
|
|
|
158 (38.4 %)
|
8 (19.0 %)
|
|
|
|
13 (3.2 %)
|
1 (2.4 %)
|
|
|
|
4 (1.0 %)
|
2 (4.8 %)
|
|
Overall evaluation of responses to the questionnaire
Based on the recommendations in the guideline, possible answers to the set of questions
7 to 20 were divided into “corresponds with the guideline” and “does not correspond
with the guideline” (Fig. S1, highlighted in green), and the possible answers “strongly agree” and “agree” were
grouped together as “yes” while “disagree” and “strongly disagree” were grouped together
as “no”. A total of 64 individual questions were evaluated. An average of 47.6 (± 5.5)
questions were answered correctly.
Comparative analysis of responses from gynecologists and diabetologists
In both groups, an average of 47 out of 64 questions were answered correctly; only
a few individual questions showed significant deviations ([Table 2]). Diabetologists, for example, reported significantly more often that they evaluated
even non-pregnant patients for diabetes during the general medical examination (100.0
vs. 85.7 %; p = 0.005), and diabetologists were also more likely to test pregnant
patients for dyslipidemia (90.2 vs. 69.6 %; p = 0.004) ([Table 2]).
Table 2 Intergroup comparison of the results of the survey. Comparison between gynecologists
and diabetologists (all results).
|
|
Gynecologists (max. n = 418)
|
Diabetologists (max. n = 42)
|
p-values
|
|
Total number of correctly answered questions (mean for 64)
|
47.6
|
47.5
|
0.97
|
|
Initial medical examination
|
|
|
|
|
|
85.7 % (n = 354)
|
100.0 % (n = 40)
|
0.005
|
|
|
99.8 % (n = 412)
|
100.0 % (n = 42)
|
1.00
|
|
|
69.6 % (n = 286)
|
90.2 % (n = 37)
|
0.004
|
|
|
93.5 % (n = 386)
|
97.6 % (n = 41)
|
0.50
|
|
|
100.0 % (n = 412)
|
100.0 % (n = 42)
|
–
|
|
|
98.5 % (n = 407)
|
100.0 % (n = 40)
|
1.00
|
|
|
50.1 % (n = 207)
|
57.1 % (n = 24)
|
0.42
|
|
Knowledge of the risk factors for developing GDM
|
|
|
|
|
|
97.8 % (n = 404)
|
100.0 % (n = 41)
|
1.000
|
|
|
98.8 % (n = 405)
|
97.6 %(n = 40)
|
0.44
|
|
|
100.0 % (n = 413)
|
100.0 % (n = 41)
|
–
|
|
|
99.3 % (n = 410)
|
100.0 % (n = 41)
|
1.00
|
|
|
75.4 % (n = 309)
|
89.2 % (n = 33)
|
0.07
|
|
|
60.3 % (n = 246)
|
89.5 % (n = 34)
|
< 0.001
|
|
|
54.3 % (n = 221)
|
86.5 % (n = 32)
|
< 0.001
|
|
Screening (women with normal risk of diabetes)
|
|
|
|
|
|
82.5 % (n = 254)
|
55.2 % (n = 16)
|
< 0.001
|
|
|
72.1 % (n = 225)
|
30.0 % (n = 9)
|
< 0.001
|
|
|
11.5 % (n = 39)
|
58.6 % (n = 17)
|
< 0.001
|
|
|
95.3 % (n = 382)
|
17.2 % (n = 5)
|
< 0.001
|
|
|
57.1 % (n = 190)
|
97.3 % (n = 36)
|
< 0.001
|
|
|
98.6 % (n = 292)
|
79.3 % (n = 23)
|
< 0.001
|
|
Screening (women with increased risk of diabetes)
|
|
|
|
|
|
36.2 % (n = 117)
|
63.3 % (n = 19)
|
0.004
|
|
|
48.7 % (n = 164)
|
77.4 % (n = 24)
|
0.002
|
|
|
13.5 % (n = 47)
|
53.6 % (n = 15)
|
< 0.001
|
|
|
45.8 % (n = 159)
|
82.1 % (n = 23)
|
< 0.001
|
|
|
52.3 % (n = 179)
|
89.2 % (n = 33)
|
< 0.001
|
|
Counselling and monitoring of patients diagnosed with GDM
|
|
|
|
|
|
98.3 % (n = 404)
|
92.1 % (n = 35)
|
0.04
|
|
|
63.7 % (n = 256)
|
64.7 % (n = 22)
|
0.91
|
|
|
97.3 % (n = 399)
|
97.5 % (n = 39)
|
1.00
|
|
|
99.5 % (n = 408)
|
100.0 % (n = 40)
|
1.00
|
|
|
85.0 % (n = 345)
|
100.0 % (n = 39)
|
0.005
|
|
|
99.5 % (n = 411)
|
97.5 % (n = 39)
|
0.24
|
|
|
93.1 % (n = 380)
|
100.0 % (n = 39)
|
0.16
|
|
|
63.0 % (n = 255)
|
63.9 % (n = 23)
|
0.91
|
|
|
92.9 % (n = 379)
|
97.4 % (n = 38)
|
0.50
|
|
|
70.0 % (n = 282)
|
92.7 % (n = 38)
|
0.002
|
|
|
70.9 % (n = 288)
|
85.4 % (n = 35)
|
0.049
|
|
|
71.9 % (n = 291)
|
69.2 % (n = 27)
|
0.73
|
|
Knowledge of the risks and long-term consequences of GDM for the child
|
|
|
|
|
|
81.9 % (n = 322)
|
100.0 % (n = 40)
|
0.001
|
|
|
99.5 % (n = 407)
|
100.0 % (n = 41)
|
1.00
|
|
|
72.1 % (n = 282)
|
89.2 % (n = 33)
|
0.03
|
|
|
76.2 % (n = 298)
|
80.6 % (n = 29)
|
0.56
|
|
|
98.0 % (n = 399)
|
97.5 % (n = 39)
|
0.57
|
|
|
85.1 % (n = 338)
|
82.4 % (n = 28)
|
0.66
|
|
|
96.8 % (n = 395)
|
97.6 % (n = 40)
|
1.00
|
|
|
45.3 % (n = 180)
|
62.9 % (n = 22)
|
0.046
|
|
|
66.4 % (n = 253)
|
83.9 % (n = 26)
|
0.045
|
|
|
66.6 % (n = 257)
|
75.8 % (n = 25)
|
0.28
|
|
Knowledge of the long-term consequences of GDM for the mother
|
|
|
|
|
|
100.0 % (n = 411)
|
100.0 % (n = 41)
|
–
|
|
|
98.3 % (n = 401)
|
100.0 % (n = 41)
|
1.00
|
|
|
81.7 % (n = 331)
|
83.3 % (n = 30)
|
0.81
|
|
|
93.6 % (n = 378)
|
86.1 % (n = 31)
|
0.09
|
|
|
77.3 % (n = 303)
|
85.3 % (n = 29)
|
0.28
|
|
State of knowledge on follow-up care
|
|
|
|
|
|
84.3 % (n = 337)
|
95.1 % (n = 39)
|
0.07
|
|
|
78.6 % (n = 313)
|
95.0 % (n = 38)
|
0.01
|
|
|
80.9 % (n = 321)
|
92.1 % (n = 35)
|
0.12
|
|
|
82.3 % (n = 331)
|
70.3 % (n = 26)
|
0.07
|
|
|
85.2 % (n = 346)
|
77.8 % (n = 28)
|
0.24
|
|
|
98.3 % (n = 402)
|
100.0 % (n = 41)
|
1.00
|
|
|
22.0 % (n = 87)
|
24.3 % (n = 9)
|
0.75
|
|
Familiarity with guidelines and interest in further training
|
|
|
|
|
|
42.6 % (n = 175)
|
42.9 % (n = 18)
|
0.97
|
|
|
87.7 % (n = 357)
|
97.4 % (n = 38)
|
0.11
|
|
|
91.3 % (n = 376)
|
97.6 % (n = 41)
|
0.23
|
More than 95 % of respondents in both groups showed a good knowledge of the risk factors
described in the guideline. Diabetologists significantly more often knew about specific
obstetric risk factors such as propensity for recurrent miscarriage (89.5 vs. 60.3 %;
p ≤ 0.001) and a prior history of serious congenital malformations (86.5 vs. 54.3 %;
p ≤ 0.001) ([Table 2]).
The guideline describes a number of different approaches to examine pregnant women
for GDM. For patients at risk, the guideline recommends following a step-by-step scheme
when examining patients for GDM. The guideline recommends that a 75 g oGTT is done
between 24 + 0 and 27 + 6 weeks of gestation in all pregnant women with no increased
risk for GDM. The guideline considers a two-stage approach, starting with a 50 g glucose
challenge test (GCT), to be acceptable as long as the test and its interpretation
are done correctly, but this approach is not explicitly recommended. The answers of
the surveyed study population about the methods used to diagnose GDM varied greatly
([Table 2]). Overall, we found no uniform approach, nor did either of the medical specialties
use a specific approach to diagnose GDM. Contrary to the recommendations, 54.2 % of
gynecologists and 17.9 % of diabetologists (p < 0.001) carried out a 50 g glucose
challenge test in patients at increased risk of GDM. Based on the recommendations
of the guideline, diabetologists were more likely (89.2 vs. 52.3 %; p < 0.001) to
carry out the 75 g oGTT as the primary diagnostic test in patients at risk ([Table 2]).
Doctorsʼ knowledge of the topics which the guideline recommends to address during
the first meeting with a patient was high in both specialist groups and barely differed
between the groups. Gynecologists significantly less often included the risk of nicotine
consumption in their talk with a patient after making the diagnosis (85.0 vs. 100.0 %;
p = 0.005). Only 63.7 % of gynecologists and 64.7 % of diabetologists (p = 0.91) talked
to their patients about the importance of breastfeeding for GDM during their first
meeting with the patient ([Table 2]).
Overall, knowledge of the long-term effects on children was good. However, only 43.3 %
of gynecologists and 62.9 % of diabetologists gave the right answer of “no” (p = 0.046)
in response to the false statement: “postpartum hyperglycemia represents a risk for the child”; 77.3 % of gynecologists and 85.3 % of diabetologists
(p = 0.281) answered correctly with respect to the increased risk of varicose veins
for the mother. More than 95 % of the respondents were aware of the increased risk
of the mother developing type 2 diabetes and hypertension after GDM. Only 22.0 and
24.3 % respectively (p = 0.748) examined the patient for postpartum depression ([Table 2]).
Comparative analysis on the level of knowledge of the guidelines in the respective
federal states
Although overall, the level of knowledge respecting the guidelines was good, a comparison
of the two federal states highlighted some differences between the two states. The
patients of colleagues working in Thuringia were older (p = 0.014) and a higher percentage
of them had previously given birth to at least one child (p = 0.005) (data not shown).
Physicians in Lower Saxony listed s/p stillbirth of a child (p = 0.001) and tendency
to recurrent miscarriage (p < 0.001) significantly more often as risks for developing
GDM. Colleagues practicing in Lower Saxony knew about the increased risk of postnatal
hyperbilirubinemia (p = 0.01) and of disorders of surfactant production (p < 0.001)
in neonates significantly more often. Physicians practicing in Thuringia affirmed
the increased risk of diabetes for the child significantly more often (p = 0.003)
and counselled women on their increased risk of developing cardiovascular disease
more often (p = 0.03) ([Table 3]).
Table 3 Intergroup comparison of results. Comparison between the two federal states (only
significant results shown).
|
|
Lower Saxony (max. n = 304)
|
Thuringia (max. n = 156)
|
p-value
|
|
Total number of questions answered correctly (mean of 64)
|
47.8
|
47.2
|
0.30
|
|
Knowledge of the risk factors for developing GDM
|
|
|
|
|
|
81.1 % (n = 240)
|
67.5 % (n = 102)
|
0.001
|
|
|
68.5 % (n = 203)
|
51.0 % (n = 77)
|
< 0.001
|
|
Knowledge of the risks and long-term consequences of GDM for the child
|
|
|
|
|
|
77.4 % (n = 223)
|
65.7 % (n = 92)
|
0.01
|
|
|
84.6 % (n = 241)
|
60.6 % (n = 86)
|
< 0.001
|
|
|
53.8 % (n = 155)
|
32.6 % (n = 47)
|
< 0.001
|
|
|
95.3 % (n = 283)
|
100.0 % (n = 152)
|
0.003
|
|
Follow-up
|
|
|
|
|
|
81.9 % (n = 240)
|
89.9 % (n = 134)
|
0.03
|
Familiarity with the guideline
Physicians who reported that they were familiar with the guideline answered correctly
more often. The average number of questions answered correctly differed significantly
between groups (47.9 vs. 39.8; p = 0.009). Questions which focused specifically on
newly formulated recommendations in the S3 guideline were answered correctly significantly
more often by physicians familiar with the guideline. At the initial medical examination
of the patient, physicians familiar with the guideline were more likely to ask pregnant
patients whether their mothers had had GDM and to inquire about the patientsʼ own
birth weight (p = 0.009), and to inform patients during the first meeting after making
a diagnosis about the importance of breastfeeding (p = 0.046) and the benefits of
regular physical activity (p = 0.001). Similarly, physicians familiar with the guideline
informed patients more often about the increased risk after GDM of developing cardiovascular
disease in later life (p = 0.037), about the necessity of carrying out a 75 g oGTT
postpartum (p = 0.027), about the importance of an annual follow-up to monitor for
diabetes if the results of the postpartum 75 g oGTT were abnormal (p = 0.003), and
about the importance of being checked for diabetes every 2–3 years even if the results
of the postpartum test were normal (p = 0.041) ([Table 4]). Likewise, this group of physicians offered counselling on metabollically neutral
contraception (p = 0.013), the increased risk of cardiovascular disease (p = 0.041)
and diabetes (p = 0.029) significantly more often (data not shown). The majority of
gynecologists (85.4 %) and diabetologists (90.4 %) considered the guideline to be
helpful for general practice.
Table 4 Intergroup comparison of the results of the survey. Familiarity with the current
guidelines.
|
|
Yes (max. n = 433)
|
No (max. n = 20)
|
p-value
|
|
Total number of questions answered correctly (mean of 64)
|
47.9
|
39.8
|
< 0.001
|
|
Initial medical examination and interview
|
|
|
|
|
|
52.2 % (n = 226)
|
21.1 % (n = 4)
|
0.009
|
|
Screening (women with normal risk of diabetes)
|
|
|
|
|
|
91.0 % (n = 373)
|
64.7 % (n = 11)
|
< 0.001
|
|
Screening (women with increased risk of diabetes)
|
|
|
|
|
|
52.1 % (n = 182)
|
23.5 % (n = 4)
|
0.03
|
|
Counselling and monitoring of women diagnosed with GDM
|
|
|
|
|
|
64.9 % (n = 270)
|
41.2 % (n = 7)
|
0.046
|
|
|
98.1 % (n = 422)
|
77.8 % (n = 14)
|
0.001
|
|
Knowledge of the risks and long-term consequences of GDM for the child
|
|
|
|
|
|
84.3 % (n = 349)
|
64.7 % (n = 11)
|
0.03
|
|
Knowledge about follow-up care
|
|
|
|
|
|
73.0 % (n = 311)
|
50.0 % (n = 9)
|
0.03
|
|
|
73.1 % (n = 310)
|
47.1 % (n = 8)
|
0.02
|
|
|
72.6 % (n = 307)
|
50.0 % (n = 9)
|
0.03
|
|
|
86.0 % (n = 361)
|
66.7 % (n = 12)
|
0.03
|
|
|
80.8 % (n = 337)
|
61.1 % (n = 11)
|
0.04
|
|
|
82.9 % (n = 343)
|
55.6 % (n = 10)
|
0.003
|
|
|
98.8 % (n = 424)
|
88.9 % (n = 16)
|
0.03
|
Discussion
The results of our questionnaire-based survey presented here on the knowledge and
implementation of the recommendations of the S3 guideline published at the end of
2011 on the diagnosis, treatment and follow-up of GDM showed a clear correlation between
a good knowledge of the guideline (self-assessment) and the implementation of the
recommendations of the guideline on the care of pregnant women. A correlation between
the implementation of recommendations of the guideline and the federal state (Thuringia
or Lower Saxony) or medical specialty (gynecology/obstetrics or diabetology) was only
found for a few individual questions. Overall, more than 90 % of respondents claimed
to have a good knowledge of the guideline. A survey published in 2005 on the application
of guidelines by Berlin family doctors found that only 40 % of assessed physicians
were familiar with guidelines and implemented their recommendations [13]. Even if questionnaire-based surveys have the fundamental weakness that they generate
socially desirable answers, knowledge of the guideline – which was reported as 90 %
– shows that the guideline on GDM is well known and generally accepted. The response
rate of 54 % shows the great importance which respondents attached to the guideline.
In an analysis of published studies based on questionnaires sent by post, Anseel et
al. found an average response rate of 41 %. With a rate of 54 %, the response rate
for our study places our study in the top third of this comparison [14].
The rules of the AWMF [15] recommend that the wording of recommendations in guidelines must show the level
of evidence and importance. A strong recommendation (evidence level A) is expressed
by the words “must/must not”; a simple recommendation (evidence level B) is indicated
by the words “should/should not”, while an open recommendation is expressed by the
words “can/cannot”. In the most current version of the guideline, there are no recommendations
for the topics Screening and Diagnostic Approach for Pregnant Women at Risk which
used the words “should”/“should not” or “can”/“cannot”. This is due to the fact that
at the time when the guideline was being compiled in 2011, the discussion about the
introduction of mandatory testing for GDM in the maternity policy guidelines had not
yet ended. The authors therefore gave a comprehensive and neutral overview of the
existing literature but abstained from making explicit recommendations. This background
explains the heterogeneous results with regard to the set of questions on screening
and diagnostic approaches. In an online survey Nast et al. investigated the perceived
binding nature of recommendations depending on the wording [16]. The authors came to the conclusion that terms such as “should”, “must” and “must
not” were perceived as binding, but found it more difficult to discriminate between
“should” and “can”. The results of our study could contribute to formulating clear
and unambiguous recommendations for Screening and Diagnosis in the forthcoming 2016
revision of the guideline.
However with regard to Follow-up Care after GDM, the guideline formulated clear, evidence-based,
unambiguous “SHOULD” recommendations. This was one area, in particular, where our
study showed highly significant differences in the knowledge of the guidelineʼs recommendations
between the respondents who had a good knowledge of the guideline and those who did
not, whereas there were no significant differences between medical specialties or
federal state.
With regard to follow-up care, the study clearly showed that the risk of postpartum
depression after GDM is not widely known. Only 20 % of respondents examined their
patients for depression. The recommendation in the guideline proposes that evaluation
of the risk for depression should be done when the patient presents to the doctorʼs
office for her postpartum oGTT. But the follow-up rate of women after GDM is only
30 % [18]. As up to one third of women go on to develop depression after GDM [12], the implementation of this recommendation would appear to be inadequate, and examination
should perhaps also be carried out at a later point in time. This is an area where
more training is necessary, particularly in view of the fact that more than 90 % of
gynecologists and 70 % of diabetologists stated that they would be interested in further
training on GDM.
To monitor the quality of guideline implementation, the AWMF has proposed setting
up quality targets to investigate the quality of results. The guideline on GDM states
in this context: “It is recommended that the quality of GDM therapy be checked at
regular intervals based on the prevalence of morbidities reported in the HAPO study.
The goal is to lower the prevalence of morbidities by the year 2020 until prevalences
are approximately equal to those of the ‘No GDM’ group.” What this means is that the
extent to which the guideline is implemented must be measured by the extent to which
the incidence of GDM-related complications during pregnancy and in neonates approaches
that of healthy controls. A diagnosis of GDM in itself would then no longer be associated
with increased peripartum and perinatal morbidity. This goal can only be achieved
in the longer term if the recommendations given in the evidence-based guideline are
complied with, and can only be managed with the close cooperation of diabetologists,
gynecologists, pediatricians, diabetes advisors and midwives. The results of the present
study show that a well-drafted S3 guideline can make a significant contribution towards
achieving this goal.
Conclusions for Clinical Practice
Conclusions for Clinical Practice
The overall knowledge of gynecologists and diabetologists in Thuringia and Lower Saxony
regarding the contents of the S3 guideline on gestational diabetes is very good and
shows a good implementation of the guidelineʼs recommendations. Irrespective of the
medical specialty or federal state, self-assessments that the respondent had a “good
knowledge of the guideline” were found to be significantly correlated with care of
patients with GDM being commensurate with the recommendations in the guideline. Particularly
with regard to the follow-up care of women after pregnancy, better care was found
to be correlated with a better knowledge of the guideline. All of the respondents
showed gaps in their knowledge with regard to the increased risk of patients with
GDM for developing depression and with regard to the importance of breastfeeding for
GDM.
