Primary care practices play an important role in monitoring the health of women and their families, explains Sharleen L. O’Reilly, PhD. “Research has shown that the average woman visits her family physician/general practitioner five times during the first year after giving birth and maintains this relationship for a long period of time,” she says. “As a result, primary care physicians are in an excellent position to follow up with women with gestational diabetes mellitus (GDM) after pregnancy and provide preventative healthcare with the aim of reducing the risk for developing type 2 diabetes (T2D).”
Previous evidence has shown that quality improvement collaboratives enhanced T2D care and diabetes prevention in primary care practices, Dr. O’Reilly notes. “However, it was important to know if the same methodology could be applied to GDM, which affects a specific population with additional complexity due to practical challenges relating to information sharing with maternity and other services,” she says. “Women with previous GDM are also a relatively ‘invisible’ population because they are typically much younger than the average person at high risk for developing T2D.”
Unpacking the Intervention Implementation “Black Box”
For a study published in Family Practice, Dr. O’Reilly and colleagues sought to better understand the mechanisms behind diabetes prevention intervention for this population, and why they either succeed or fail. “We wanted to explore what was happening within primary care practices as they implemented diabetes prevention for women with previous GDM,” Dr. O’Reilly says. “To do this, we needed both qualitative and quantitative methods. Using Normalization Process Theory as the theoretical framework for the analysis was critical to unpacking the implementation ‘black box.’ It helped us identify, describe, and explain the key mechanisms that either inhibited or promoted the implementation of intervention processes.”
A mixed-methods investigation was conducted that included clinical audits, interviews, and focus groups within diverse primary care practices. Staff who provided services to women with prior GDM took part in a 12-month quality improvement collaborative intervention. “We compared diabetes screening and prevention activity planning with the strategies and factors identified through an evaluation of full-, moderate-, and low-active participating practices,” Dr. O’Reilly says.
Critical Improvement Factors Need to Be Created with Audit Feedback
Primary care practices can deliver quality diabetes prevention care and screening to women with previous GDM, but the critical improvement factors need to be proactively created with audit feedback if they are to be normalized into routine care. “We found that the quality improvement collaborative intervention doubled screening rates, and one in 10 women received a diabetes prevention planning consultation,” Dr. O’Reilly notes. “However, we are not sure these finding will be of value to endocrinologists. From my experience, the endocrinologist is engaged with the maternity service side of GDM care for more complex cases and not the postpartum period that this intervention covers, since it is about prevention rather than diabetes care.”
Dr. O’Reilly adds that this research is important from the perspective of improving tracking and communication between maternity services and primary care practices.
Intervention Helped to Form a Community of Practice
“A key takeaway from this study is that the intervention helped to form a community of practice that upheld their beliefs about what constituted high-quality care, provided clear leadership, shared beliefs about the intervention’s legitimacy, and created a common cause,” she says. “In addition, the work associated with the intervention brought together existing clinical techniques and accountability. No new skills were needed. The intervention was highly workable, fully integrated into practice, and did not disrupt other work (Table).”
Dr. O’Reilly and colleagues would like to see primary care clinicians incorporate mini-quality improvement collaboratives into their practices, using critical improvement factors to build them and conduct audits to enable practices in monitoring improvement. “This would help to ensure patients were engaging in regular diabetes screening, weight management, and lifestyle changes while providing the necessary feedback,” she says.
The study team was successful in receiving subsequent funding to scale this pilot intervention up to a fully powered randomized controlled trial, which will commence toward the end of 2022. “Future research needs to explore ways to make the implementation of diabetes prevention for women with previous GDM easier to roll out and scale up, particularly considering the change toward telehealth and more remote delivery of health services,” Dr. O’Reilly says.