Patterns of Postpartum Primary Care Follow-up and Diabetes-Related Care After Diagnosis of Gestational Diabetes

Abstract

ImportanceGestational diabetes (GD) affects up to 10% of pregnancies and increases lifetime risk of type 2 diabetes 10-fold; postpartum diabetes evaluation and primary care follow-up are critical in preventing and detecting type 2 diabetes. Despite clinical guidelines recommending universal follow-up, little remains known about how often individuals with GD access primary care and type 2 diabetes screening.ObjectiveTo describe patterns of primary care follow-up and diabetes-related care among individuals with and without GD in the first year post partum.Design, Setting, and ParticipantsThis cohort study used a private insurance claims database to compare follow-up in the first year post partum between individuals with GD, type 2 diabetes, and no diabetes diagnosis. Participants included postpartum individuals aged 15 to 51 years who delivered between 2015 and 2018 and had continuous enrollment from 180 days before to 366 days after the delivery date. Data were analyzed September through October 2021 and reanalyzed November 2022.Main Outcomes and MeasuresPrimary care follow-up visits and diabetes-related care (blood glucose testing and diabetes-associated visit diagnoses) were determined by evaluation and management, Current Procedural Terminology, and International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes, respectively.ResultsA total of 280 131 individuals were identified between 2015 and 2018 (mean age: 31 years; 95% CI, 27-34 years); 12 242 (4.4%) had preexisting type 2 diabetes and 18 432 (6.6%) had GD. A total of 50.9% (95% CI, 49.9%-52.0%) of individuals with GD had primary care follow-up, compared with 67.2% (95% CI, 66.2%-68.2%) of individuals with preexisting type 2 diabetes. A total of 36.2% (95% CI, 35.1%-37.4%) of individuals with GD had diabetes-related care compared with 56.9% (95% CI, 55.7%-58.0%) of individuals with preexisting diabetes. Only 36.0% (95% CI, 34.4%-37.6%) of individuals with GD connected with primary care received clinical guideline concordant care with blood glucose testing 12 weeks post partum.Conclusions and RelevanceIn this cohort study of postpartum individuals, individuals with GD had lower rates of primary care and diabetes-related care compared with those with preexisting type 2 diabetes, and only 36% of those with GD received guideline-recommended blood glucose testing in the first 12 weeks post partum. This illustrates a missed opportunity for early intervention in diabetes surveillance and prevention and demonstrates the need to develop a multidisciplinary approach for postpartum follow-up.

Future diabetes risk can be predicted by the number of abnormal oral glucose tolerance test values during pregnancy

“…Given the low rate of compliance with postpartum follow‐up and testing in patients with GD, 9,10 the results of our study are clinically relevant. Women can be counselled and provided with an individualized risk assessment for future T2D based on their metabolic variables and the number and timing of abnormal OGTT values.…”

“…Given the low rate of compliance with postpartum follow-up and testing in patients with GD, 9,10 In conclusion, GD is a heterogenous disease, with varying degrees of glucose intolerance and subsequent T2D risk. Postpartum…”

“…8 However, compliance is low and most do not continue long-term follow-up. 9,10 Considering the large number of women diagnosed with GD, it becomes crucial to identify those individuals who are at a higher risk of developing T2D and require tighter long-term follow-up. We speculated that the severity of GD, using the number of pathological values in the OGTT performed during pregnancy as a correlate, might contribute to future diabetes prediction.…”

Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association

“…Women with gestational diabetes should be screened for dysglycemia at 4 to 12 weeks postpartum with a 2-hour 75-g oral glucose tolerance test, as recommended by the American Diabetes Association. 25 Given the low rates of oral glucose tolerance test uptake, 98,99 glucose screening with hemoglobin A1c or fasting glucose should be considered within the first year postpartum for those who do not complete an oral glucose tolerance test. Early postpartum oral glucose tolerance test testing (ie, before hospital discharge) is another promising strategy to improve diabetes screening.…”

Gestational Diabetes and Cardiovascular Health—Reply

“…Furthermore, many postpartum individuals who had GDM do not transition to primary care for continued cardiovascular disease prevention. Recent commercial claims data suggest that only 51% of individuals with GDM had primary care follow-up, and only 36% who had a primary care visit within 12 weeks of delivery received guideline-concordant care with blood glucose testing . Additionally, recent data from the Pregnancy Risk Assessment Monitoring System from 2016 to 2020 show that only 60% of individuals with cardiovascular disease risk factors or adverse pregnancy outcomes including GDM reported receiving cardiovascular health counseling at their postpartum visit …”