The ADIPS pilot National Diabetes in Pregnancy Audit Project

A realist synthesis of multicentre comparative audit implementation: exploring what works and in which healthcare contexts

BACKGROUND

Multicentre comparative clinical audits have the potential to improve patient care, allow benchmarking and inform resource allocation. However, implementing effective and sustainable large-scale audit can be difficult within busy and resource-constrained contemporary healthcare settings. There are little data on what facilitates the successful implementation of multicentre audits. As healthcare environments are complex sociocultural organisational environments, implementing multicentre audits within them is likely to be highly context dependent.

OBJECTIVE

We aimed to examine factors that were influential in the implementation process of multicentre comparative audits within healthcare contexts-what worked, why, how and for whom?

METHODS

A realist review was conducted in accordance with the Realist and Meta-narrative Evidence Syntheses: Evolving Standards reporting standards. A preliminary programme theory informed two systematic literature searches of peer-reviewed and grey literature. The main context-mechanism-outcome (CMO) configurations underlying the implementation processes of multicentre audits were identified and formed a final programme theory.

RESULTS

69 original articles were included in the realist synthesis. Four discrete CMO configurations were deduced from this synthesis, which together made up the final programme theory. These were: (1) generating trustworthy data; (2) encouraging audit participation; (3) ensuring audit sustainability; and (4) facilitating audit cycle completion.

CONCLUSIONS

This study elucidated contexts, mechanisms and outcomes influential to the implementation processes of multicentre or national comparative audits in healthcare. The relevance of these contextual factors and generative mechanisms were supported by established theories of behaviour and findings from previous empirical research. These findings highlight the importance of balancing reliability with pragmatism within complex adaptive systems, generating and protecting human capital, ensuring fair and credible leadership and prioritising change facilitation.

Rural healthcare delivery and maternal and infant outcomes for diabetes in pregnancy: A systematic review

AIM

The aim of this systematic review was to examine the literature regarding rural healthcare delivery for women with any type of diabetes in pregnancy, and subsequent maternal and infant outcomes.

METHODS

Eight databases were searched in September 2020, including Medline, EMCare, CINAHL, EMBASE, Maternity and Infant Care, Cochrane, Rural and Remote Health and Aboriginal and Torres Strait Islander Health bibliography. Studies from high-income countries in rural, regional or remote areas with interventions conducted during the antenatal period were included. Intervention details were reported using the template for intervention description and replication template. Two reviewers independently assessed for risk of bias using the RoB2 and ROBINS I tools.

RESULTS

Three articles met the inclusion criteria: two conducted in Australia and one in the United States. A multidisciplinary approach was reported in two of the included studies, which were modified specifically for their respective rural settings. All three studies reported rates of caesarean section, birthweight (grams) and gestational age at birth as maternal and infant outcomes. One study was considered at moderate risk of bias, and two studies were at serious risk of bias.

CONCLUSION

There is a significant gap in research relating to healthcare delivery for women with diabetes in pregnancy in rural areas. This lack of research is concerning given that 19% of individuals in high-income countries reside rurally. Further research is required to understand the implications of healthcare delivery models for diabetes in pregnancy in rural areas.

The ADIPS Pilot National Diabetes in Pregnancy Benchmarking Programme

BACKGROUND

To test the feasibility of benchmarking the care of women with pregnancies complicated by hyperglycaemia.

METHODS

A retrospective audit of volunteer diabetes services in Australia and New Zealand involving singleton pregnancies resulting in live births between 2014 and 2020. Ranges are shown and compared across services.

RESULTS

The audit included 10,144 pregnancies (gestational diabetes mellitus (GDM) = 8696; type 1 diabetes (T1D) = 435; type 2 diabetes (T2D) = 1013) from 11 diabetes services. Among women with GDM, diet alone was used in 39.4% (ranging among centres from 28.8-57.3%), metformin alone in 18.8% (0.4-43.7%), and metformin and insulin in 10.1% (1.5-23.4%); when compared between sites, all p < 0.001. Birth was by elective caesarean in 12.1% (3.6-23.7%) or emergency caesarean in 9.5% (3.5-21.2%) (all p < 0.001). Preterm births (<37 weeks) ranged from 3.7% to 9.4% (p < 0.05), large for gestational age 10.3-26.7% (p < 0.001), admission to special care nursery 16.7-25.0% (p < 0.001), and neonatal hypoglycaemia (<2.6 mmol/L) 6.0-27.0% (p < 0.001). Many women with T1D and T2D had limited pregnancy planning including first trimester hyperglycaemia (HbA1c > 6.5% (48 mmol/mol)), 78.4% and 54.6%, respectively (p < 0.001).

CONCLUSION

Management of maternal hyperglycaemia and pregnancy outcomes varied significantly. The maintenance and extension of this benchmarking service provides opportunities to identify policy and clinical approaches to improve pregnancy outcomes among women with hyperglycaemia in pregnancy.

Comparison of Pregnancy Outcomes Using Different Gestational Diabetes Diagnostic Criteria and Treatment Thresholds in Multiethnic Communities between Two Tertiary Centres in Australian and New Zealand: Do They Make a Difference?

Introduction: Australia, but not New Zealand (NZ), has adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria to diagnose gestational diabetes (GDM). We compared pregnancy outcomes using these different diagnostic approaches. Method: Prospective data of women with GDM were collected from one NZ (NZ) and one Australian (Aus) hospital between 2007–2018. Aus screening criteria with 2-step risk-based 50 g Glucose Challenge Testing (GCT) followed by 75 g-oral glucose tolerance testing (OGTT): fasting ≥ 5.5, 2-h ≥ 8.0 mmol/L (ADIPS98) changed to a universal OGTT and fasting ≥5.1, 1-h ≥ 10, 2-h ≥ 8.5 mmol/L (IADPSG). NZ used GCT followed by OGTT with fasting ≥ 5.5, 2-h ≥ 9.0 mmol/L (NZSSD); in 2015 adopted a booking HbA1c (NZMOH). Primary outcome was a composite of macrosomia, perinatal death, preterm delivery, neonatal hypoglycaemia, and phototherapy. An Aus subset positive using NZSSD was also defined. RESULTS: The composite outcome odds ratio compared to IADPSG (1788 pregnancies) was higher for NZMOH (934 pregnancies) 2.227 (95%CI: 1.84–2.68), NZSSD (1344 pregnancies) 2.19 (1.83–2.61), and ADIPS98 (3452 pregnancies) 1.91 (1.66–2.20). Composite outcomes were similar between the Aus subset and NZ. Conclusions: The IADPSG diagnostic criteria were associated with the lowest rate of composite outcomes. Earlier NZ screening with HbA1c was not associated with a change in adverse pregnancy outcomes.

Evaluation of a novel database for quality assurance at a head and neck service in New Zealand: an audit of free flap head and neck reconstruction

BACKGROUND

Clinical audit is a critical quality improvement exercise, yet efficient audit tools are lacking. The main objective of this study was to evaluate a recently deployed database in facilitating the process of clinical audit, and the secondary objective was to evaluate the outcomes of free flap reconstruction of the head and neck at our centre.

METHODS

A head and neck cancer-specific database was customized to suit the needs of our head and neck multidisciplinary team. Data has been entered prospectively into this database since March of 2018. An audit of free flap reconstruction of the head and neck over a 12-month period was performed using the database and analysed as a case study to examine its efficacy as a clinical audit tool. Additionally, the outcomes of free flap reconstruction at our centre were compared to those reported in the international literature.

RESULTS

The database allows flexible and specific queries, analysis and export of data, and can provide immediate results. However, issues with data quality and completeness were identified. In this audit, the overall 30-day complication rate and 30-day mortality in patients undergoing free flap reconstruction of the head and neck were 58% and 3%, respectively.

CONCLUSION

The database is fit for its intended purpose as an audit tool. Outcomes of free flap reconstruction of the head and neck at our centre are comparable to those of institutions overseas.

Designing Data Elements and Minimum Data Set (MDS) for Creating the Registry of Patients with Gestational Diabetes Mellitus

The prevalence of gestational diabetes mellitus (GDM) is increasing in Iran. Collection of patients’ data is commonly conducted through using medical records. However, for providing a structured reporting based on the information needs, a minimum data set is a fast, inexpensive, and suitable method. For exchanging high-quality data between different healthcare centers and health monitoring organization, the data are required to be uniformly collected and registered. The present study aims at designing an MDS for creating the registry of GDM. The present study is an applied one, conducted in two stages, with a qualitative Delphi method in 2018. In the first stage of the study, it was attempted to extract the data elements of mothers with GDM, through reviewing the related studies and collecting these patients’ data from the medical records. Then, based on the results of the first stage, a questionnaire including demographic, clinical, and pharmaceutical data was distributed among 20 individuals including gynecologists, pharmacists, nurses, and midwives. The validity of the questionnaire was examined by a team of experts and its reliability was examined by using Cronbach’s alpha. Data analysis was conducted using descriptive statistics (frequency, percentage, and mean) and excel. An MDS of gestational diabetes mellitus was developed. This MDS divided into three categories: administrative, clinical, and pharmaceutical with 4, 18, and 2 sections and 35, 199, and 12 data elements, respectively. Determining the minimum data sets of GDM will be an effective step toward integrating and improving data management of patients with GDM. Moreover, it will be possible to store and retrieve the data related to these patients.

A threefold increase in gestational diabetes over two years: review of screening practices and pregnancy outcomes in Indigenous women of Cape York, Australia

BACKGROUND

Australian Aboriginal women have a high prevalence of type 2 diabetes (T2DM) in pregnancy and gestational diabetes (GDM).

AIMS

To review how screening practice affects the pregnancy data of all Indigenous women and their newborns living in Cape York, Queensland.

METHODS

All medical charts of mothers and their neonates delivered in the regional hospital over two-one-year periods (2006 and 2008) were reviewed. Universal testing with an oral glucose tolerance test (OGTT) was introduced in 2007.

RESULTS

Gestational diabetes (GDM) increased from 4.7 to 14.2%, and T2DM was similar (2.4 and 2.3%). There were 127 deliveries in 2006 and 134 in 2008. Testing rates with OGTT improved from 31.4% in 2006 to 65.6% in 2008. Mothers with diabetes in pregnancy (DIP) were older and heavier than non-DIP mothers. Caesarean section rates were significantly higher in the DIP group compared with the non-DIP group (66 vs 25%) in both time periods. The booking weight of DIP mothers decreased 16 kg, their babies normalised their weight, length and head circumference; respiratory distress and Apgar scores improved comparing the two periods. In DIP, infants >40% had hypoglycaemia; however, rates of serious complications were low. Rates of breastfeeding were similar between groups. Follow-up rates for GDM improved from 16.6% in 2006 to 31.6% in 2008. Of those tested one-third were diagnosed with T2DM.

CONCLUSION

The rate of GDM tripled after implementation of universal testing. Outcomes improved. There is still need for improvement in testing and follow-up practices in relation to DIP.

Maternal and neonatal outcomes in the Torres Strait Islands with a sixfold increase in type 2 diabetes in pregnancy over six years

BACKGROUND

Torres Strait Islander population has a high prevalence of type 2 diabetes (T2DM).

AIMS

To review pregnancy data of women and their newborns living in the Torres Strait area.

METHODS

All medical charts of mothers and their neonates delivered in two one-year periods (1999 and 2005/2006) were reviewed. The initial screening test for diabetes in pregnancy (DIP) was a random blood glucose level followed by an oral glucose challenge test in 1999 and from 2000 an oral glucose tolerance test.

RESULTS

Diabetes in pregnancy increased by 4.3-13.3% and T2DM by 0.8-4.6%. During the two periods, 258 and 196 mothers delivered respectively 84-92% by midwives/general practitioners at the local hospital and 7-16% by midwives/obstetricians at the regional hospital; in 2005/2006, 58% of women with DIP delivered at the regional hospital. Screening increased from 89.2 to 99.5%. DIP mothers were older and heavier with more hypertension and previous miscarriages. Parity decreased in the DIP mother during the two periods. Caesarean section was five times more common for DIP in 2005/2006 versus non-DIP, while in 1999, there was no difference. In 1999, the DIP infants were heavier, longer (P = 0.053) and had a larger head circumference not seen 2005/2006. There was more neonatal trauma, hypoglycaemia and IV dextrose in the DIP infants. Breastfeeding numbers increased in DIP. In 2005/2006, follow-up of gestational diabetes occurred in 47% (all normal).

CONCLUSION

A massive increase in DIP was seen. The neonatal outcomes improved slightly. There is need for improvement in follow-up of gestational diabetes.

Maternal and neonatal outcomes following diabetes in pregnancy in Far North Queensland, Australia

BACKGROUND

Diabetes in pregnancy (DIP) is increasing and is associated with a number of adverse consequences for both the mother and the child.

AIMS

To compare local maternal and neonatal outcomes with state and national data.

METHODS

Chart audit of all DIP delivered during 2004 at a regional teaching hospital and compare outcomes with national benchmark, Queensland and national Indigenous data.

RESULTS

The local DIP frequency was 6.7%. The local compared to benchmark and state data demonstrated a higher frequency of Indigenous mothers (43.6% vs 6.8% vs 5.5%), caesarean sections (50.7% vs 26% vs 32.0%), hypoglycaemia (40.7% vs 19.5% vs 2.7%) and respiratory distress (16.6% vs 4.5% vs 2.3%) in infants, fewer normal birthweights (64.8% vs 82.6% vs 80.4%) and full-term deliveries. More local mothers compared to benchmark had type 2 diabetes mellitus (T2DM) (15.4% vs 8.7%) but fewer used insulin (31.0% vs 46.6%); compared to state data, fewer women had gestational diabetes (79.5% vs 91.2%), however, insulin use was higher (22.8%). Furthermore, Aborigines had fewer pregnancies compared to Torres Strait Islanders (3.0 vs 5.0) and less insulin use (21.9% vs 59.3%) (P = 0.008-0.024). In contrast, non-Indigenous versus Indigenous women showed fewer pregnancies, less T2DM (7.8% vs 23.7%), better glycaemic control, longer babies, more full-term deliveries and less severe neonatal hypoglycaemia. Comparing local and national Indigenous data, local showed poorer outcomes, however, only 11.8% had diabetes or hypertension nationally.

CONCLUSION

The local cohort had poorer outcomes probably reflecting a more disadvantaged. Few differences were found between local Indigenous groups.