Bridging the Gap in Gestational Diabetes: An Interdisciplinary Approach to Improving GDM Using a Chronic Care–Based Clinical Framework

Gestational diabetes mellitus (GDM) affects 2 to 10% of pregnancies and is associated with a 35 to 60% chance of developing type 2 diabetes mellitus (T2DM) in the proceeding 10 to 20 years.[1] Women with GDM are at increased risk for preeclampsia and cesarean delivery, and are more likely to have recurrence of GDM in subsequent pregnancies.[2] [3] [4] [5] Neonates born to mothers with GDM are more likely to have shoulder dystocia, neonatal hypoglycemia, birth trauma, hyperbilirubinemia, large for gestational age, and spend time in the neonatal intensive care unit.[3] [6] Incidence has increased with increasing obesity, as well as with racial/ethnic health disparities, with minority women at highest risk of GDM and subsequent T2DM.[7] [8] [9] In the 3 months after birth, many patients are lost to follow-up because of variation in practice standards and inadequate coordination between obstetrics during pregnancy and primary care following delivery.[10]

Women with GDM often do not attend routine preventative care and postpartum diabetes screening.[7] The postpartum visit is underutilized, with only an estimated one-third of women with GDM completing the recommended postpartum oral glucose tolerance test (OGTT).[11] Gaps in care for people with T2DM can promote microvascular disease progression, hypertension, dyslipidemia, and other worsened health outcomes.[12] Furthermore, many GDM women face socioeconomic barriers preventing them from accessing care relative to those receiving recommended postpartum glucose testing.[11] These vulnerable patients must be cared for with innovative clinical care models that allow convenient access to relevant services that meet their medical and social needs.

Due to increased risk for the development of T2DM requiring increased need for surveillance, GDM is a condition that benefits from chronic management approaches. The chronic care model (CCM) provides infrastructure for systematic, patient-centered approaches to clinical management of GDM during and following pregnancy.[13] This model has successfully been applied to conditions such as congestive heart failure (CHF), asthma, chronic obstructive pulmonary disease (COPD), and diabetes to improve processes of care, outcomes, and reduce health care costs; yet, this model has not been applied to GDM.[14] [15] [16] [17] [18] [19] Compared with usual care, CCM management models have demonstrated outcomes such as reduction in health care costs among patients with CHF[16] [18]; improvement in asthma-related quality of life measurements[17]; decreased COPD-related hospitalization, length of stay, and emergency room utilization[19]; and reduction of hemoglobin A1c levels and 10-year cardiovascular disease risk scores in patients with T2DM.[15] [19] In light of these improvements, application of CCM holds great promise in improving guideline-based health outcomes in GDM.

Originally published in 1998 and developed based on a synthesis of literature and review of interventions to improve care for chronically ill populations, the CCM has been widely implemented to improve primary care in the United States.[18] [20] The CCM outlines six factors essential for approaching chronic illness within primary care, including health systems, the community, self-management support (i.e., developing skills to independently address chronic illness), delivery system design, decision support (i.e., reminders for physicians on evidence-based guidelines), and clinical information systems.[20] [21] [22] CCM interventions longitudinally aligned with stages of pregnancy (prenatal, delivery, and the neonatal period) can improve delivery of guideline-based care for GDM. We use a conceptual framework approach to propose a CCM for postpartum women with GDM.

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