Deltagelse i follow-up screening efter gestationel diabetes

Abstract

Resume Introduktion: Et dansk follow-up studie viser, at 40 % af kvinder med tidligere GDM mellitus (GDM) udvikler type 2 diabetes inden for en ti-årige periode. Kvinderne anbefales at få foretaget follow-up screening 1-2 år fremadrettet efter fødsel. På baggrund af en registerundersøgelse blev der fundet lav deltagelse i den anbefalede follow-up screening blandt kvinder med tidligere GDM i region Nordjylland. Registerundersøgelsen viser, at kvinder der deltog i follow-up screeningen havde en større mulighed for diagnosticering af diabetes og initiering af behandling med antidiabetika. Deltagende kvinder havde ydermere en øget mulighed for tidlig opsporing både ift. tidligere diagnose og behandling. I forbindelse hermed er der således et uudnyttet forebyggelsespotentiale, hvilket kan betragtes som utilfredsstillende, da dette kan medføre helbredsmæssige konsekvenser for de ikke deltagende kvinder. Mål: At opnå indsigt i de forløbsrelaterede årsager til den lave deltagelse i follow-up screening, blandt kvinder med tidligere GDM i region Nordjylland. Således at en udviklingsindsats til øget deltagelse i follow-up screening tager udgangspunkt i kvindernes oplevelser, for her at være en del af den fremtidige håndtering, implementering og organisering af follow-up screening efter GDM i Danmark. Metode: Et single case ’’embedded’’ design til undersøgelse af forløb med GDM på Klinik kvinde-barn og urinvejskirurgi, gynækologisk-obstetrisk afdeling, Aalborg Universitets hospital – der undersøges igennem kvinderes oplevelser af deres forløb. Til indsamling af empiri anvendes semistrukturerede forskningsinterview som metode. I samarbejde med gynækologisk-obstetrisk afdeling på Aalborg sygehus Nord blev 40 kvinder med tidligere GDM inviteret til deltagelse i undersøgelsen. Heraf deltog 7 informanter i den endelige undersøgelse. Resultat: Kvinderne oplevede manglende sammenhæng ved overgange hvilket tilskrives tab af information og manglende koordinering samt tvivl om ansvaret for follow-up screening. Ydermere gav kvinderne udtryk for manglende fokus, afklaring og inddragelse af deres individuelle behov og præferencer i deres forløb, hvilket medførte at kun få af kvinderne oplevede uddybende information, ’’shared decision making’’ og patientcentrering. Kvinderne anser follow-up screeningen som vigtigt og ønsker deltagelse heri, men der er mulighed for at indholdet i information om deltagelse i follow-up screening ikke medvirker til at kvinderne tilslutter sig hertil. Kvinderne udtrykte ønske om at blive mødt med udgangspunkt i deres individuelle situation samt at blive påmindet om follow-up screeningen, da det mentes at kunne bidrage til ro og tryghed. Diskussion: Ud fra et systemperspektiv på kvindernes forløb imødekommer procedurerne ikke i tilstrækkelig grad kontinuitet og dermed sammenhæng for kvinderne, hvilket kan skyldes at de kliniske procedurer ikke sikrer informationsoverlevering ved overgangene i de sårbare og sociale processer der forekommer her. Dette kan resultere i, at kvinderne ikke informeres om den videre forløb på de forskellige afdelinger og hos praktiserende læge. Med udgangspunkt i en patientcenteret tilgang kan kvindernes behov og ønsker om mere mening og sammenhæng i det forløb imødekommes og kvinderne kan i højere grad inddrages i forbindelse med informationen i deres forløb. Konklusion: En udviklingsindsats til øget deltagelse i follow-up screening kan tage udgangspunkt i organisering af påmindelse til kvinderne igennem brevremindere, hvilket kan øge deltagelse i follow-up screening, og fungere som en barrier for den mangelfulde information. Øget patientcentrering i kvindernes samlede forløb, herunder beslutningsstøtte, kan bidrage til øget meningsfuldheden i kvindernes forløb. Styrkes kvindernes oplevelser af sammenhæng og meningsfuldhed i deres forløb, igennem inddragelse i beslutningsprocesser, er der mulighed for at det på sigt kan medvirke til øget deltagelse i follow-up screening.

Abstract Introduction: A Danish follow-up study, shows that 40% of women with a history GDM mellitus (GDM) develops type 2 diabetes mellitus within a ten-year period. The women are recommend follow-up screening every 1-2 years after birth. Low participation in the recommended follow-up screening among women with previous GDM, was found in the region of North Jutland. Women who participated in the follow-up screening had a greater possibility of diagnosis with diabetes and initiation of treatment with glucose lowering agents. Participating women furthermore had an increased possibility of early detection in relation to both earlier diagnosis and treatment. In this context, there is an unexploited potential in prevention of diabetes among the women, which is unsatisfying with regard to the health consequences among the non-participating women. Aim: To gain insight into reasons for the low participation in the follow -up screening related to treatment and care among women with previous GDM in the region of North Jutland. The women’s experiences can be the offset for the development of an intervention to increase the participation in follow-up that can be a part of the future management, implementation and organization of follow -up screening for GDM in the region and possibly Denmark. Method: A single case '' embedded '' design to investigate women with previous GDM experiences with their treatment and care at the clinic of women- child and urinary surgery the department of gynecology and obstetrics at Aalborg University Hospital examined through women experiences of patient care. The data collection method was semi-structured research interviews. In cooperation with the department at Aalborg Hospital University Hospital North 40 women with previous GDM, was invited to participate in the study. Seven informants participated in the final study. Result: The women experienced inconsistency in transitions, which was cause by insufficient information and lack of coordination and clear responsibility for follow-up screening. Furthermore, the women expressed a lack of focus, clarity and inclusion of their individual needs and preferences of patient care and general lack of “shared decision- making'', including lack of patient centeredness. The women consider follow-up screening as important and want to participate, but is a possibility that the content of information on participation in follow-up screening is not adapted to their own behavior. The women expressed needs regarding consideration of their individual situation and to be reminded of follow-up screening, as it was believed to contribute to peace and comfort for the women. Discussion: From a system perspective on the women's experiences of patient care the procedures are not sufficiently contributing to continuity of care for the women, which can be related to the clinical procedures that does not ensure the transfer of information in vulnerable and social processes that occurs in transitions. This can result in women not being informed about their treatment and care at the various departments and at their general practitioner. The women’s experiences shows grounds for a patient centered approach to ensure focus on and consideration of the women's needs and desires for more meaning and continuity in treatment and care. Conclusion: A development effort or intervention to increase participation in follow-up screening can be based on the postal reminders to women, which can increase the participation in follow-up screening, and act as a barrier for the insufficient information. Increased patient centeredness in the women's overall patient care, including support in decision making can contribute to increased meaningfulness in the women's experience of patient care. Involvement of the women's experiences of continuity and meaning in patient care are involved it can strengthened their decision-making process, which eventually can contribute to increased participation in follow-up screening Abstract Background: Women whose pregnancy was complicated by gestational diabetes have a 7-fold higher risk of developing diabetes, primarily type 2. Early detection can prevent or delay the onset of late complications, for which follow-up screening is important. This study investigated the extent of participation in follow-up screening and the possible consequences of nonattendance. Method: In Danish national registers covering the years 1994-2011 we identified 2171 birthing women whose pregnancy was complicated by first-time gestational diabetes. Control visits to general practitioners and biochemical departments after giving birth were charted. Following national guidelines we defined four intervals for assessment of participation in follow-up screening. Diagnosis of diabetes or treatment with glucose-lowering agents after giving birth were also identified. Participation in follow-up screening and risk of diabetes was calculated. Time to obtaining diagnosis of diabetes or initiating treatment was analysed by Cox regression models. All models were adjusted for age, ethnicity and income. Results: High attendance was found during the first control interval, after which attendance decreased with time after giving birth for both controls at general practitioners and biochemical departments. All differences in proportions were statistically significant. Women attending controls at general practitioners had a significantly higher risk of diabetes diagnosis and treatment after gestational diabetes than women not attending. The results for women attending testing at biochemical departments also showed an increased risk of initiation of treatment. Women attending at least one general practitioners control had a significantly higher risk of early diabetes diagnosis or treatment. Time to initiation of treatment was significantly higher for testing at biochemical departments. Women with high incomes had a significantly lower risk of diabetes diagnosis or initiation of treatment compared to low-income women. Conclusion: Participation in follow-up screening after gestational diabetes is low. Follow-up screening ensures early detection of diabetes and initiation of treatment. Our results emphasize the importance of stimulating participation for early detection and prevention of diabetes after gestational diabetes.

A master thesis from Aalborg University

Deltagelse i follow-up screening efter gestationel diabetes - et forløbsperspektiv

[Participation in follow-up screening after gestational diabetes - a treatment and care perspective]