Screening Strategy For Gestational Diabetes Mellitus Research Articles

Exploring Structural Uncertainty in Cost-Effectiveness Modeling of Gestational Diabetes Screening: An Application Example from Norway.

Screening pregnant women for gestational diabetes mellitus (GDM) has recently been expanded in Norway, although screening eligibility criteria continue to be debated. We aimed to compare the cost-effectiveness of alternative GDM screening strategies and explored structural uncertainty and the value of future research in determining the most cost-effective eligibility criteria for GDM screening in Norway. We developed a probabilistic decision tree to estimate the total costs and health benefits (i.e., quality-adjusted life-years; QALYs) associated with 4 GDM screening strategies (universal, current guidelines, high-risk, and no screening). We identified the most cost-effective strategy as the strategy with the highest incremental cost-effectiveness ratio below a Norwegian benchmark for cost-effectiveness ($28,400/QALY). We excluded inconclusive evidence on the effects of screening on later maternal type 2 diabetes mellitus (T2DM) in the primary analysis but included this outcome in a secondary analysis using 2 different sources of evidence (i.e., Cochrane or US Preventive Services Task Force). To quantify decision uncertainty, we conducted scenario analysis and value-of-information analyses. Current screening recommendations were considered inefficient in all analyses, while universal screening was most cost-effective in our primary analysis ($26,014/QALY gained) and remained most cost-effective when we assumed a preventive effect of GDM treatment on T2DM. When we assumed no preventive effect, high-risk screening was preferred ($19,115/QALY gained). When we assumed GDM screening does not prevent perinatal death in scenario analysis, all strategies except no screening exceeded the cost-effectiveness benchmark. In most analyses, decision uncertainty was high. The most cost-effective screening strategy, ranging from no screening to universal screening, depended on the source and inclusion of GDM treatment effects on perinatal death and T2DM. Further research on these long-term outcomes could reduce decision uncertainty. This article analyses the cost-effectiveness of 4 alternative gestational diabetes mellitus (GDM) screening strategies in Norway: universal screening, current (broad) screening, high-risk screening, and no screening.The current Norwegian screening recommendations were considered inefficient under all analyses.The most cost-effective screening strategy ranged from no screening to universal screening depending on the source and inclusion of GDM treatment effects on later maternal diabetes and perinatal death.The parameters related to later maternal diabetes and perinatal death accounted for most of the decision uncertainty.

1194-P: Impact of COVID-19 on Gestational Diabetes Mellitus (GDM) Screening and Outcomes

Background: To minimize COVID-19 exposure, a modified 1-step strategy (MS) option was offered in addition to the standard (SS) GDM screening strategies (definitions in Fig 1A). Objectives: To assess the use of, and obstetrical and neonatal outcomes associated with, modified GDM screening during COVID-19. Methods: Primiparous pregnancies in Alberta, Canada (N=35,836; Jan 1, 2020 to Dec 31, 2021) were categorized by GDM screening status. Results: 87.4% underwent SS, 10.1% MS, and 2.5% had no GDM screening. MS use was highest in 2020-Q3 (second wave; Fig 1B). There was no difference in GDM rates between SS (11.1%) and MS (12.7%). MS screened women with GDM had worse outcomes than those screened using SS (Table). Conclusions: GDM screening rates were not impacted by COVID-19. The uptake of MS was low to modest and appeared to identify higher-risk GDM women. Disclosure V.Liyanage: None. O.Barrett: None. D.P.Ngwezi: None. A.Savu: None. R.O.Yeung: Research Support; Novo Nordisk Foundation, Abbott, Canadian Institutes of Health Research, Alberta Agriculture and Forestry, Alberta Canola. S.Butalia: None. P.Kaul: None.

Exploring the Optimal Diagnostic Thresholds of Hyperglycemia During Pregnancy

Exploring the Optimal Diagnostic Thresholds of Hyperglycemia During Pregnancy

Diabetes screening in pregnancy failing women in rural Western Australia: An audit of oral glucose tolerance test completion rates.

To quantify screening rate for gestational diabetes mellitus and completion of oral glucose tolerance test in rural and remote Western Australia. Retrospective audit of 551 antenatal records from women of 16 years and older without pre-existing diabetes and with singleton pregnancies delivered in 2013. Number of women recorded screened for gestational diabetes mellitus in second or third trimester using oral glucose tolerance test or other tests; gestational diabetes mellitus rate. Only 278 (50.5%) women were screened with oral glucose tolerance test; 113 (20.5%) had no record of any screening related to gestational diabetes mellitus. In a nested mixed-effects logistic regression model, women with a previous gestational diabetes mellitus diagnosis, two or more risk factors (excluding ethnicity) or high-risk gestational diabetes mellitus ethnicity other than Australian Aboriginal were more likely to be screened, while Australian Aboriginal women were less likely to be screened with oral glucose tolerance test. Clinicians reported patient and clinician factors and logistical difficulties as reasons for the oral glucose tolerance test not being completed at their site. Of those screened with oral glucose tolerance test, a high rate of gestational diabetes mellitus was diagnosed (14.7% versus Western Australia state-wide average of 7.4%). Adherence to oral glucose tolerance test screening in rural Western Australia is inadequate for effective screening for gestational diabetes mellitus. Screening was not acceptable or available for a significant proportion of women at risk. Efforts to improve oral glucose tolerance test adherence and exploration of alternative gestational diabetes mellitus screening strategies are required.

Risk factors for gestational diabetes mellitus among women screened with the two-step and one-step methods: A before-and-after study

ObjectiveTo compare the risk profiles for gestational diabetes mellitus (GDM) using a one-step and two-step screening method and diagnostic criteria. Materials and methodsA retrospective cohort study was conducted among women screened using Carpenter and Coustan's (C&C) criteria (two-step method) and the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria (one-step method). All deliveries after 28 weeks of gestation, except for pregnancies complicated by pre-pregnancy diabetes mellitus, were analyzed. Multiple logistic regression was used to assess the associations between GDM and various potential risk factors. ResultsRisk factors for C&C-defined GDM were pre-pregnancy body mass index >24.2 kg/m2 (adjusted odds ratio [OR] 2.49, 95% confidence interval [CI] 1.92–3.23), maternal age at delivery >34 years (adjusted OR 2.46, 95% CI 1.96–3.09), history of fetal death (adjusted OR 2.56, 95% CI 1.37–4.78), and chronic hypertension (adjusted OR 3.66, 95% CI 1.50–8.91). In addition to these factors, conception assisted by reproductive technology (adjusted OR 1.64, 95% CI 1.19–2.25) and genetic amniocentesis (adjusted OR 1.19, 95% CI 1.03–1.38) were IADPSG-defined GDM risk factors. ConclusionRisk factors for GDM differ with the diagnostic criteria used. This information is important when changing GDM screening strategies from the two-step approach to the one-step approach.

Comparison of Two Screening Strategies for Gestational Diabetes (GDM2) Trial: Design and rationale

Gestational diabetes mellitus (GDM) affects approximately 5 to 7% of pregnancies and is associated with increased risk for fetal overgrowth, cesarean delivery, birth trauma, and pre-eclampsia. GDM is commonly diagnosed in the US using a two-step screening and confirmatory approach, whereas a one-step approach is commonly used outside the US. Recent guidelines have suggested that the one-step approach should be used to diagnose GDM, although concern that this may increase the prevalence of GDM to approximately 18%—as well as the lack of clinical trials-based evidence regarding the difference in perinatal outcomes–has led to skepticism about adopting the one-step approach. The Comparison of Two Screening Strategies for Gestational Diabetes (GDM2) Trial is a single-center, parallel-arm, comparative effectiveness trial of one-step versus two-step GDM screening strategies on the rate of adverse perinatal outcomes including: large-for-gestational age (LGA) deliveries (primary outcome), small-for-gestational age (SGA), macrosomia, cesarean delivery, fetal growth and body composition, and maternal and neonatal composite outcomes. This paper describes the design and analysis plan of the GDM2 Trial as well as overall challenges in assessing the impact of screening and diagnosis strategy on adverse pregnancy outcomes. We will also assess whether the additional women diagnosed with the one-step approach benefit from treatment as assessed by metabolic profiles at one year postpartum. Ultimately, this study will provide the necessary evidence for establishing universal guidelines for GDM diagnosis and implementation into clinical care.

Prevalence of gestational diabetes mellitus based on various screening strategies in western Kenya: a prospective comparison of point of care diagnostic methods

BackgroundEarly diagnosis of gestational diabetes mellitus (GDM) is crucial to prevent short term delivery risks and long term effects such as cardiovascular and metabolic diseases in the mother and infant. Diagnosing GDM in Sub-Saharan Africa (SSA) however, remains sub-optimal due to associated logistical and cost barriers for resource-constrained populations. A cost-effective strategy to screen for GDM in such settings are therefore urgently required. We conducted this study to determine the prevalence of gestational diabetes mellitus (GDM) and assess utility of various GDM point of care (POC) screening strategies in a resource-constrained setting.MethodsEligible women aged ≥18 years, and between 24 and 32 weeks of a singleton pregnancy, prospectively underwent testing over two days. On day 1, a POC 1-h 50 g glucose challenge test (GCT) and a POC glycated hemoglobin (HbA1c) was assessed. On day 2, fasting blood glucose, 1-h and 2-h 75 g oral glucose tolerance test (OGTT) were determined using both venous and POC tests, along with a venous HbA1c. The International Association of Diabetes in Pregnancy Study Group (IADPSG) criteria was used to diagnose GDM. GDM prevalence was reported with 95% confidence interval (CI). Specificity, sensitivity, positive predictive value, and negative predictive value of the various POC testing strategies were determined using IADPSG testing as the standard reference.ResultsSix hundred-sixteen eligible women completed testing procedures. GDM was diagnosed in 18 women, a prevalence of 2.9% (95% CI, 1.57% - 4.23%). Compared to IADPSG testing, POC IADPSG had a sensitivity and specificity of 55.6% and 90.6% respectively while that of POC 1-h 50 g GCT (using a diagnostic cut-off of ≥7.2 mmol/L [129.6 mg/dL]) was 55.6% and 63.9%. All other POC tests assessed showed poor sensitivity.ConclusionsPOC screening strategies though feasible, showed poor sensitivity for GDM detection in our resource-constrained population of low GDM prevalence. Studies to identify sensitive and specific POC GDM screening strategies using adverse pregnancy outcomes as end points are required.Trials registrationClinical trials.gov: NCT02978807, Registered 29 November 2016.

Incremental Cost-Effectiveness Analysis of Gestational Diabetes Mellitus Screening Strategies in Singapore.

The objective of this study was to conduct an incremental cost-effectiveness analysis from the payer's perspective in Singapore of 3 gestational diabetes mellitus screening strategies: universal, targeted, or no screening. A decision tree model assessed the primary outcome: incremental cost per quality-adjusted life year (QALY) gained. Probabilities, costs, and utilities were derived from the literature, the Growing Up in Singapore Towards healthy Outcomes (GUSTO) birth cohort study, and the KK Women's and Children's Hospital's database. Relative to targeted screening using risk factors, universal screening generates an incremental cost-effectiveness ratio (ICER) of $USD10,630/QALY gained. Sensitivity analyses show that disease prevalence rates and intervention effectiveness of glycemic management have the biggest impacts on the ICERs. Based on the model and best available data, universal screening is a cost-effective approach for reducing the complications of gestational diabetes mellitus in Singapore as compared with the targeted screening approach or no screening.

Development of a model to assess the cost-effectiveness of gestational diabetes mellitus screening and lifestyle change for the prevention of type 2 diabetes mellitus

Gestational diabetes mellitus (GDM) is increasingly recognized as an opportunity for early prevention of diabetes and other diseases over the lifespan, and may be responsible for up to 30% of cases of type 2 diabetes. A newly developed mathematical model (the GDModel) provides provisional estimates of the cost and health impact of various GDM screening and management choices, and calculates averted disability-adjusted life-years (DALYs). The model was piloted in 5 different healthcare facilities in India and Israel. Universal screening of pregnant women followed by postpartum lifestyle management yielded net savings of US$78 per woman with GDM in India and US$1945 per woman in Israel. The estimated DALYs averted were 2.33 in India and 3.10 in Israel. With lower GDM prevalence, intervention efficacy, and type 2 diabetes incidence, the intervention had a net cost in India, with a cost per DALY averted of US$11.32. This was far below the WHO definition of “very cost-effective,” set at annual GDP per capita. The intervention in Israel remained cost-saving. GDM screening and postpartum lifestyle management are either cost-saving or have a net cost but an attractive cost-effectiveness ratio. Some input values are currently being refined. Nevertheless, the current findings of cost-savings or favorable cost-effectiveness are robust to a wide range of plausible input values, including highly unfavorable values. The GDModel will be further developed into a user-friendly tool that can guide policy-makers on decisions regarding GDM screening strategies and guidelines.

Universal two-step screening strategy for gestational diabetes has weak relevance in French Mediterranean women: Should we simplify the screening strategy for gestational diabetes in France?

AimCurrently, there is no international consensus for gestational diabetes mellitus (GDM) diagnosis. This is a report of our experience of GDM screening according to the 1996 French guidelines. MethodsFor 5years, all pregnant women followed at our hospital (n=11,545) were prospectively screened for GDM between weeks 24 and 28 of pregnancy with a two-step strategy: the O'Sullivan test (OS) with a threshold at 130mg/dL, followed by a 100-g OGTT if positive. GDM was diagnosed according to Carpenter and Coustan criteria. ResultsPrevalence of GDM was 4.26% [344/1451 of patients with an OS of 130–199mg/dL (12.1%); and 148 patients with an OS greater than 200mg/dL]. The false-positive rate for the OS was 76.8%. Compared with 140mg/dL, a threshold of 130mg/dL caused 401 additional negative OGTTs in 90% of cases. In 80.7% GDM patients, fasting glucose was less than 95mg/dL. The time lag between OS and OGTT was 3weeks (1–84days). Risk factors associated with GDM were maternal age, preconception overweight and obesity, parity, personal history of GDM or macrosomia, and familial history of obesity (P<0.05), but not diabetes. Also, 20% of GDM patients had no risk factors, whereas they were present in 75% of patients without GDM. ConclusionIn our population, a two-step screening strategy for GDM was neither relevant nor efficient. It could be simplified with a single-step definitive screening strategy using a 75-g OGTT, as used in the HAPO study, and as recommended by the IADPSG and the recent French Expert Consensus. At present, there are still no evidence-based arguments to help in deciding between selective or universal screening for GDM.

264: Cost-effectiveness analysis of screening for GDM

Treatment of gestational diabetes mellitus (GDM) reduces the risk of perinatal and maternal complications associated with GDM, but data on the effectiveness of treatment have not been integrated with data on the accuracy of screening for GDM. The aim of this study was to assess the cost-effectiveness of screening for GDM. We developed a decision model to evaluate costs and effects of six screening strategies for GDM at several moments during pregnancy: random glucose measurement, fasting glucose measurement, 50 g glucose challenge test, risk factor assessment, risk factor assessment combined with a 50 g glucose challenge test (all followed by an oral glucose tolerance test (OGTT) if indicated) and universal screening with an OGTT. Costs and effects of the screening strategies were compared to a strategy without testing. Data on costs, accuracy measures and probabilities were extracted from the literature. The outcome measure of effect was a composite outcome of neonatal death, shoulderdystocia, and birth trauma. We calculated the costs to prevent one serious neonatal complication. Analyses were performed from the perspective of the healthcare system. All screening strategies reduced the risk of serious perinatal complications. At 24 weeks of pregnancy the most effective strategy was screening all women with an OGTT, however at the highest costs. Use of risk factor assessment combined with a 50 g glucose challenge test, and subsequent OGTT if indicated was the most cost-effective strategy. The incremental cost-effectiveness ratio ranged from ϵ23, 479 per prevented neonatal complication with risk factor assessment combined with the 50 g glucose challenge test to ϵ37, 037 per prevented neonatal complication for use of the 50 g glucose challenge test in all women. Screening for GDM with risk factor assessment combined with a 50 g glucose challenge test and an OGTT if indicated is the most cost-effective strategy.

Screening for Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM), defined as carbohydrate intolerance of variable degree with onset or first recognition during pregnancy, is the most common medical condition of pregnancy. GDM affects ∼190,000 (4–5%) of the >4 million births occurring annually in the U.S. and is associated with several maternal and infant complications (1). Worldwide, the three primary screening strategies for GDM are the sequential strategy (initial 50-g glucose challenge test followed by, in those who test positive, a 100-g glucose tolerance test [GTT]), the 75-g GTT strategy, and the 100-g GTT strategy (2). The efficacy of these strategies, however, is debated. There are few randomized trials on the effectiveness of GDM screening (3). Yet, the majority of U.S. obstetricians provide universal screening for GDM (4). We conducted a cost-effectiveness analysis to compare four screening strategies for universal screening of GDM, including the sequential strategy, the 75- and 100-g GTT, and a no-screening strategy. We assessed the relative cost and effectiveness (quality-adjusted life-years [QALYs]) of each strategy relative to the sequential strategy using a decision model. We performed a decision and cost-effectiveness analysis from a societal perspective that incorporates all health effects and medical resources consumed regardless of who pays (5). Separate cost-effectiveness ratios were estimated for mothers and infants. Maternal outcomes were hypertensive disease, polyhydramnios, cesarean or vaginal delivery, …