Follow-up after gestational diabetes: a qualitative study of perspectives from general practices

Insufficient knowledge

Overall, many participants had sparse knowledge of the increased risk of T2DM after birth, which led to a rather weak focus. Although this was most noticeable among the GPs, it was true also for other staff members:

'I have to say, I actually feel lucky that you called … [Otherwise,] our patients would have fallen between the cracks for a long time. Because we had no idea.' (Q)

The staff participants linked the poor focus to a lack of general knowledge in their practice concerning women with previous GDM. In those general practices where staff were aware of women’s much higher risk, they followed clear instructions given by the GP or relied on interdisciplinary discussion and knowledge sharing in their clinic.

While some GPs were aware of women’s increased risk, they had no clear conception of recommendations concerning times for screening, testing, or the benefits of screening in general. In those cases, the insufficient knowledge was often associated with a hesitant or unconcerned approach to screening. The GPs tended to underestimate women’s risk and expressed their surprise at the seriousness of this during interviews. Overall, the participants often linked their underestimation of risk for T2DM to the women’s youth:

'I’m wondering … they’re young women and they don’t fit into our understanding of being at risk. I mean … I know it’s because they had GDM, but I think we could cut them some slack? … Their risk can’t possibly be that high?' (L)

This was the dominant view, which seemed to strengthen or rationalise the reluctant approach to the random screening, which was frequently offered only on the women’s insistence.

The participants also emphasised that screening measures were compromised by the maternity ward’s discharge summaries:

'It’s really, really important that, instead of such a ridiculous discharge summary from the maternity ward stating all those silly diagnostic codes … It should be simplified so that it says, “You need to be followed-up by your own GP” [stating clearly that the GP] must follow-up on this, that or the other …' (F)

The inadequate transfer of information and compromised communication lines between healthcare sectors seemed to create significant barriers, and the general practices found it challenging to stay updated.

Balancing contradicting risk perceptions

Differences in their understandings of health, risk, and disease also seemed to have a strong influence on the participants’ perspectives of GDM and their approach to women and the recommendation of screening.

Some participants found that the guidelines for follow-up care conflicted with their professional values and beliefs, making them reluctant to discuss the increased risk of T2DM after GDM and the issue of routine screening:

'The challenge is that these women are given an illness profile when they’re actually not ill. Erm … I feel a bit conflicted about this … because, yes, we must prevent disease and promote health, and we have to detect it early on and all that. But we certainly also need to be careful not to make them sick before they actually are. And that’s quite a balancing act.' (C)

While none of the participants directly rejected the highly increased risk of T2DM during interviewing or opposed the idea of early detection, they were concerned about a general medicalisation of this group of young and supposedly healthy women. Some explained that they navigated this challenge by simply giving lower priority to this aspect of care; others said they struggled to find the right way to discuss this risk with women, without causing them unnecessary stress. In contrast, other participants espoused a more biomedical perception of risk, favouring screening while expecting women to have a high level of self-care by booking a screening:

'If we have agreed that she [the woman] books a time, I’d expect her to do so. I won’t be keeping an eye on them to check if they’ve actually done it … because I mean, they are grown-ups — they must understand [the risk] … they do not suffer from dementia, unable to remember anything … so really, I’d actually not spend more time on that.' (I)

This group expected women to take responsibility for their own health and access screening, although they generally acknowledged that a life with small children and work could be challenging.

Overall, many participants felt highly ambivalent about screening and communicating with women with previous GDM. Such barriers had led some to refrain from discussing the risk with women, while others found it difficult and a source of frustration in a busy everyday clinic.

Systematising clinical procedures to improve quality of care

Many of the participating GPs were open to increased systematisation and standardisation of procedures, as they found it improved their ability to make the necessary clinical judgements. They believed a systematised focus would facilitate the screening of women with previous GDM:

'I think it’s about how well organised you are and what you focus on, making sure to say it’s a priority. Otherwise, it would be lost among all the other things in our busy everyday work. Because we’re … there’s so much to do … Over the last five years, we have become particularly attentive and got more routines for different things, including GDM women. I actually think it has made us better at our job as doctors.' (B)

This approach also seemed to contribute to increased job satisfaction, as they believed it had improved their work and made it less stressful. The large group practices were particularly responsive to the healthcare authorities’ recommendations for systematising screening in their practices. In some cases, they had formulated internal guidelines to support their GPs and staff in transferring information for the benefit of the clinical work and to ensure that important knowledge was retained over time. Such guidelines seemed to benefit from local adjustments. In the most successful cases, the process relied on interdisciplinary or peer discussion and pragmatic compromising.

In a few of the most dedicated general practices, the record systems had been programmed to give pop-up reminders of screening to GPs or designated staff, a procedure they found had strongly improved screening routines. The facility also tracked women who cancelled or failed to make the expected booking for screening. However, the practical implementation of pop-up reminders appeared to be challenged by issues such as insufficient information transfer on women’s GDM diagnosis from the specialised healthcare sector. All participants shared a positive attitude to the use of screening reminders if they were handled outside general practice. Delegating the responsibility for systematic enrolment of patients and testing to practice staff appeared to facilitate screening; however, not all general practices had achieved this level of organisation and some GPs had no wish to delegate responsibility.

Trusting own clinical skills without system interference

Some GPs showed a less overt resistance to systematisation and standardisation of their procedures in the practice. They demonstrated an unwavering professional pride and a desire to preserve their independence and integrity, while relying on their ability to make clinical judgements in each individual situation:

'We’re not happy about working directly to guidelines, because that’s not how our world is, anyway. I think you just adjust things according to your own ideas and your gut feeling … If you kind of know the overall guidelines … you just do what you think is best.' (L)

Expressing their weariness or outright frustration, these participants generally considered national guidelines as interference on the part of healthcare authorities, while making clear their strong wish to protect their independence. As reported by participating staff members, some GPs preferred to rely on the knowledge accumulated over decades in the job. However, this often appeared to lead to differences in the offered care, occasionally resulting in barriers to follow-up of women with previous GDM. Compared with the GPs who sought to systematise work in their clinics, those who disapproved of what they saw as system interference seemed to be less inclined to update their knowledge. Almost all participants relied primarily on national public Danish healthcare service e-portals for updated information.

Influence of recommended test

The participants generally agreed that the recommended test for screening had increased uptake. They found the HbA1c test convenient for women and perceived it as an improvement that had eradicated previous barriers, such as the discomfort of the OGTT or that fasting was needed. While they appreciated that the hospital laboratory test results arrived on the same day, some GPs argued that the process could be further improved:

'It would be great if we received the test results right away. Then we could look at them in relation to weight and blood pressure and see the bigger picture and how the woman is doing. The dialogue isn’t as good when they have to call in the next day … maybe one day we’ll have an [in-house] analyser.' (E)

Despite differences of opinion, many saw the potential of performing in-house analysis, as this might improve the communication with women about their health.