Maternal Child Health and Chronic Disease

Transcription

1 Maternal Child Health and Chronic Disease The Odd Couple or A Marriage Made in Heaven? AMCHP Women and Perinatal Health Information Series July 17, 2008 Joan Ware, MSPH, RN, Consultant, Women s s Health Council, National Association of Chronic Disease Directors

2 Outline What is NACDD? Why chronic disease and MCH? Why gestational diabetes? What is the Gestational Diabetes Collaborative Project What can MCH programs do?

3 Collaborators PRAMS Pregnancy Risk Assessment and Monitoring System

4 Who is NACDD? The AMCHP for Chronic Disease More than 800 members from every US state and territory 16 Councils and special interest groups supporting state public health activities focusing on specific chronic disease and health promotion areas

5 Councils and Special Interest Groups Asthma Arthritis Cancer Diabetes Heart Disease and Stroke School Health Women s s Health Osteoporosis Obesity Healthy Aging Health Disparities Physical Activity Vision and Eye Health Tobacco Use Prevention Depression

6 Why Link MCH and Chronic Disease/Health Promotion? MC H Chronic Disease Preconception care is important, especially for women with chronic diseases Risk factors and conditions can be identified early and addressed Pregnancy can unmask a potential for chronic diseases Pregnancy is an entry point into health care and an opportunity for primary prevention of chronic diseases

7 Why Chronic Disease? Among women of child bearing age: Asthma (medication risk) 6.1% Hypertension/CVD 6.4% Diabetes 9.3% Smoke during pregnancy 11.4% Overweight or obese 55.0% 250,000 breast cancer survivors under age 40

8 Why Chronic Disease? Of women who are pregnant: 3-8% will develop gestational diabetes 10-15% 15% will develop postpartum depression If overweight prior to pregnancy, her offspring is 3 times more likely to be overweight by age 7 If preeclampsia developed in pregnancy there is an increased lifetime risk of metabolic syndrome, ischemic heart disease and stroke Postpartum state confers 5-fold 5 risk of new-onset rheumatoid arthritis, especially after first pregnancy

9 Why Now? The perinatal period is too late to modify maternal behaviors, health conditions and risk factors Rising prevalence of obesity and diabetes and the trend to delay child bearing until later in life mean women are more likely to have chronic disease risk factors which complicate pregnancy

10 Why Now? New Target Populations for Prevention of Chronic Disease Preconception Interpregnancy Postpartum Interconception

11 Collaboration Issue: Gestational Diabetes As defined by the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) Study Cooperative Research Group : Glucose intolerance with onset or first recognition during pregnancy.

12 Why Gestational Diabetes? Gestational diabetes (GDM) is the most common metabolic disorder of pregnancy GDM is a leading cause of maternal hospitalizations prior to delivery, and results in longer hospital stays Method to promote healthier moms and offspring, and prevent a major chronic disease at the same time

13 Prevalence of GDM Prevalence ranges between 1%-14% 14% 1 Complicates 4% of all pregnancies annually 1 Affects 150, ,000 pregnancies each year in the United States 2 1. Diagnosis and Classification of Diabetes Mellitus. ADA. Diabetes Care. Volume 30, Supplement 1, January CDC Division of Diabetes Translation, 2007 Teleconference Presentation to Connecticut Data Surveillance Work Group

14 What are the Concerns? 14% of risk of developing type 2 diabetes in 20 weeks after pregnancy 50-65% risk of GDM with next pregnancy 20-30% risk of type 2 in years 50-70% risk of type 2 progression in lifetime Increased risk of type 2 DM in children of mothers with GDM Kim, C., Newton, K.M., and Knopp, R.H Gestational diabetes and the Incidence of Type 2 Diabetes. Diabetes Care. 25:

15 The Risks of GDM Miscarriages and stillbirth Increased inductions and C-sectionsC Macrosomia Intrauterine developmental and growth abnormalities Preeclamsia Depression Birth and neonatal complications (e.g. shoulder dystocia) Offspring predisposed to obesity and type 2 diabetes

16 GDM Screening Screening recommended at weeks gestation, even if no high risk factors Some guidelines recommend earlier screening if high risk to rule out type 2 diabetes First screening test should be 1-hr 1 GCT 1 If elevated level, then women undergo a 2-hr 2 or 3-hr 3 OGTT to confirm 1 1. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, Volume 30, Supplement I, January 2007, pp S42-S47

17 Screening Recommendations High Risk for GDM Age > 35 years BMI > 29 kg/m 2 before pregnancy Personal history of GDM Previous macrosomic infant History of GDM related obstetric complications Racial/ethnic group with high prevalence of GDM First degree relative with diabetes

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19 Goals of the Project Compare PRAMS data to medical records Examine routinely collected data to assess quality of data Summarize findings Make recommendations for improving quality of data systems and applications to improve care Enhance collaboration among public health programs

20 Why Did DDT Fund This Project? Establish 6-state 6 collaboration to identify, catalogue, and validate routinely collected data about GDM Identify gaps in quality of GDM prevalence data Develop recommendations for improving data quality Determine implications for care

21 Five State Collaborative Michigan North Carolina Oklahoma Utah West Virginia

22 Background Prevalence rates of gestational diabetes from Utah 2004 PRAMS and 2004 birth certificates were compared 6.1% reported high blood sugar level according to PRAMS weighted data 2.4% had GDM recorded on birth certificates

23 PRAMS 2004 Questions on Blood Sugar Did you have any of these problems during your most recent pregnancy? High blood sugar (diabetes) that started before this pregnancy Yes No High blood sugar (diabetes) that started during this pregnancy Yes No

24 Study Question How does gestational diabetes identified on PRAMS and NOT on the birth certificate compare with medical records?

25 2004 Utah PRAMS Surveys Elevated Blood Sugar on PRAMS N=136 GDM on Birth Certificate 46 (34%) GDM Not on Birth Certificate 90 (66%)

26 Validation Methods Selected all 90 women reporting high blood sugar levels during most recent pregnancy on 2004 PRAMS survey but GDM not recorded on birth certificate Of these, 80 hospital medical records were available for review Conducted IRB-approved review of hospital records to validate GDM data

27 Definition of GDM used in Medical Record Review 2 abnormal values on the 3-hour 3 OGTT (Carpenter/Coustan diagnostic criteria) Physician or other health care provider wrote gestational diabetes diagnosis in chart

28 Women who reported GDM on PRAMS but GDM was not Indicated on the BC (n=80) Medical Record Review GDM No GDM No information Total 25.0% 62.5% 12.5% 100.0%

29 Documentation of GDM Tests Results and Follow-up Medical Record Review 1 hr screen and 3-hr 3 OGTT documented on chart review Inadequate documentation (e.g. No testing or results information; no follow-up test on elevated 1-hr 1 GTT tests) Total 72.5% 27.5% 100.0%

30 Conclusions 1. The PRAMS survey question is not specific for GDM, and should not be used as a source for prevalence of gestational diabetes in Utah. 2. Birth certificate data underestimated the prevalence of GDM

31 Problems with GDM Surveillance There are no universally accepted Gold Standard guidelines. Guideline conflicts affect the prevalence of GDM. Inconsistencies in reporting and data coding Lack of documentation of testing and results Lack of follow-up on elevated screening levels

32 Public Health Implications Opportunity for MCH and chronic disease program collaboration to: -Validate existing data sources -Improve quality of data collection -Promote appropriate GDM testing, diagnosis and care -Promote postpartum follow-up care -Prevent onset of type 2 diabetes

33 MCH Opportunities for Collaboration Include chronic disease prevention and health promotion in your intervention strategies Invite chronic disease and health promotion team members to participate in planning and intervention efforts Invite input for analysis and application of chronic disease or health promotion data from PRAMS survey Leverage the expertise of chronic disease and health promotion programs to develop intervention strategies, especially for healthy weight, gestational diabetes, hypertension and tobacco related activities Consult the NACDD website for more ideas from other states

34 For More Information Please contact: Joan Ware, Consultant National Association of Chronic Disease Directors (NACDD) Women s s Health Council Telephone: l2353l ware@chronicdisease.org Web: