Poster Presentation Australasian Diabetes in Pregnancy Annual Scientific Meeting 2012

Implementing GDM Medical Nutrition Therapy guidelines: the evidence-practice gap (#51)

Shelley A Wilkinson 1 2 , Sally McCray 3 , Michael Beckmann 1 4 , Annette Parry 5 , Sam Drew 6 , H David McIntyre 1 7
  1. Mothers' and Babies Theme, Mater Medical Research Institute, Brisbane, Queensland, Australia
  2. Senior Research Dietitian/NHMRC TRIP Fellow, Mater Mothers' Hospital, Brisbane, Queensland, Australia
  3. Director, Nutrition & Dietetics, Mater Health Services, Brisbane, Queensland, Australia
  4. Director, Obstetrics & Gynaecology, Mater Mothers' Hospital, Brisbane, Queensland, Australia
  5. Diabetes Educator, Mater Mothers' Hospital, Brisbane, Queensland, Australia
  6. NUM, Ambulatory Services, Mater Mothers' Hospital, Brisbane, Queensland, Australia
  7. Director of Obstetric Medicine, Mater Mothers' Hospital, Brisbane, Queensland, Australia

Reduced insulin requirements and improved BGL control have been documented in a study validating American Nutrition Practice Guidelines (NPG) that included a Dietitian appointment schedule (minimum 4 appointments)(1). No Australian GDM NPGs exist and systematic delivery of dietetic care for GDM does not occur (2,3).

Dissemination of guidelines alone does not change practice(4). The assessment of influencing factors and implementation and evaluation design must be systematic and theory-driven(5). This paper describes assessment of an evidence-practice gap and the planned intervention to implement a schedule of Dietitian consults for Mater Mothers’ Hospital GDM patients.

The Theoretical Domains Framework(5) guided investigation of barriers at individual, team, organisational levels(6). Data sources included routinely collected hospital data (2009-11), staff surveys, and clinic observation. Dietetic visits were compared with American NPG. GDM clinic staff (n=42) were surveyed about NPG knowledge and belief in the influence of dietetic counselling on previously reported positive associated outcomes.

Women’s lack of awareness of the benefits of scheduled contact with a dietitian and staff’s unfamiliarity with NPGs and current practice was identified. Most staff believed regular dietetic contact could influence diet, but fewer believed contact could influence BGLs, pharmacotherapy requirements, and care costs, and only about half felt contact could influence GWG or macrosomia. There was a significant shortfall in Dietitian resources to allow all GDM patients to be reviewed. Other barriers included lack of dedicated clinic space and exclusion from the clinic carepath. The MMH Dietitian saw 88%, 94.7%, and 92.5% of GDM women for an initial consult (2009-11) and few had a subsequent appointment (<1%, 5.6%, and 5%).

Behaviour change theories(6,7) have been mapped onto the identified barriers. Project funding has been obtained for Dietitian time. The primary process outcome will be uptake of the new dietetic schedule and the primary clinical outcome will be effect of the NPG schedule on requirement for pharmacotherapy.

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  2. Wilkinson, S. and D. Tolcher, Nutrition and maternal health: What women want and can we provide it? Nutrition & Dietetics, 2010. 67(1): p. 18-25.
  3. Morrison, M., Collins, C. Lowe, J.M. Dietetic practice in the management of gestational diabetes mellitus: A survey of Australian dietitians. Nutrition & Dietetics, 2011. 68(3):p189-194.
  4. Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. BMJ, 2004. 180:s57-60.
  5. French, S.D., et al., Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implementation Science, 2012. 7(38): p. 24 April.
  6. Francis, J.J., D. O'Connor, and J. Curran, Theories of behaviour change synthesised into a set of theoretical groupings: introducing a thematic series on the theoretical domains framework. Implementation Science, 2012. 7(35): p. 24 April.
  7. Michie, S., M.M. van Stralen, and R. West, The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 2011. 6(42): p. 23 April.