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 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 12  |  Issue : 5  |  Page : 59-65

Survey of diabetologists and obstetricians’ practice patterns related to care for gestational diabetes mellitus during the COVID-19 pandemic in India


1 Women’s College Hospital, Toronto, Canada
2 Seethapathy Clinic and Hospital, Chennai, India
3 Madras Diabetes Research Foundation, ICMR Centre for Advanced Research on Diabetes,Chennai, India; Dr. Mohan’s Diabetes Specialities Centre, IDF Centre of Excellence in Diabetes Care, Chennai, Tamil Nadu, India

Date of Submission10-Dec-2020
Date of Decision03-Mar-2021
Date of Acceptance04-Mar-2021
Date of Web Publication20-Jul-2021

Correspondence Address:
Balaji Bhavadharini
Women’s College Research Institute, 76 Grenville St, Toronto, ON M5S 1B2.
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_106_20

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  Abstract 

Aim: There are limited data on the management of gestational diabetes mellitus (GDM) during the coronavirus disease 2019 (COVID-19) pandemic. This survey was carried out in India to understand the practice patterns of diabetologists and obstetricians (OBs) during the pandemic. Materials and Methods: An online questionnaire was designed, and the link to the survey was shared with doctors through email. Questions were related to the diagnosis and management of GDM both before and during the COVID-19 pandemic. Results: A total of 117 diabetologists and 90 OBs from different parts of India participated in the survey. During the COVID-19 pandemic, diabetologists carried out higher random glucose and HbA1c tests and lower numbers of oral glucose tolerance tests (OGTTs), but differences compared with before COVID-19 were nonsignificant. The OBs reported doing a significantly lower number of OGTTs (85.6% vs. 95.6%, P = 0.02) and significantly more HbA1c tests (16.7% vs. 5.6%, P = 0.03) and self-monitoring of blood glucose (59.4% vs. 37.1%, P < 0.0001) during the pandemic, than earlier. Although 97% of all the doctors surveyed reported using some form of telemedicine, several challenges were identified. Conclusion: The COVID-19 pandemic has resulted in changes in the management of women with GDM. The use of digital technologies could help improve the care of women with GDM during such pandemics.

Keywords: COVID-19, COVID-19 survey, diabetologist OBs, gestational diabetes mellitus, India, practice pattern during pandemic, telemedicine for GDM


How to cite this article:
Bhavadharini B, Uma R, Anjana RM, Mohan V. Survey of diabetologists and obstetricians’ practice patterns related to care for gestational diabetes mellitus during the COVID-19 pandemic in India. J Diabetol 2021;12, Suppl S1:59-65

How to cite this URL:
Bhavadharini B, Uma R, Anjana RM, Mohan V. Survey of diabetologists and obstetricians’ practice patterns related to care for gestational diabetes mellitus during the COVID-19 pandemic in India. J Diabetol [serial online] 2021 [cited 2021 Jul 30];12, Suppl S1:59-65. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/5/59/321816




  Introduction Top


The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on healthcare systems, not only in India but also all over the world. Diabetes has been found to be one of the most important risk factors for worse outcomes/mortality in hospitalized patients with COVID-19.[1],[2] Indeed, reports from China have noted a higher prevalence of diabetes among severe cases of COVID-19 and among those who died.[3] This was also true in the case of hospitalized patients in Italy and the United States.[4]

With respect to gestational diabetes mellitus (GDM), a condition where diabetes is detected for the first time during pregnancy, the risk of acquiring the COVID-19 infection is high through household or community transmission, rather than specifically at blood collection centers.[5] However, there are very few reports on the care of GDM during the COVID-19, and virtually none from India. Specifically, there are very limited data on how diabetologists and obstetricians (OBs) in India have been handling women with GDM during the COVID-19 pandemic. We, therefore, carried out a nationwide survey of diabetologists and OBs to understand their practice patterns with respect to the diagnosis and management of GDM during COVID-19 in India.

Research design and methods

An online questionnaire was designed by using Google Forms. The questionnaire addressed several questions related to the diagnosis and management of GDM both before and during the COVID-19 pandemic, including the screening of GDM at 12 weeks, diagnostic criteria followed at 24 weeks, subsequent management of GDM, use of telemedicine, gaps in virtual care, and ultrasound scan. The survey was pilot tested with five diabetologists and five OBs, to get their inputs regarding relevance of the questions and either get additional ones that needed to be included or to suggest the ones to be deleted. Once the questionnaire was refined, post the pilot testing, the online survey was disseminated to diabetologists and OBs across India through email by using email ids from respective diabetes and obstetrics associations. The data collected through the survey were automatically connected to a spreadsheet, which was populated with the survey responses in real time.


  Results Top


Diabetologists and OBs who are members of medical professional societies in India were contacted through email. A total of 340 doctors (180 diabetologists and 160 OBs) were contacted across 18 states in India, among whom 207 doctors (117 diabetologists and 90 OBs) responded to our emails and completed the online survey (response rate = 61%). [Figure 1] shows the 18 states/union territories in India from where the respondents participated, showing a fairly good distribution from most parts of the country.
Figure 1: Respondents from 18 states in India

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Primary institution of practice

[Table 1] and [Table 2] show that more than half of the doctors who participated in the survey worked in private diabetes and OBs clinics, whereas the remaining worked in multispecialty hospitals and very few in government hospitals.
Table 1: Type of institutions where diabetologists practiced (n = 117)

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Table 2: Type of institutions where OBs practiced (n = 90)

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Screening test followed at 12 weeks before and during COVID-19

Screening at 12 weeks was carried out by OBs. Diabetologists generally do not have access to pregnant women during early pregnancy and therefore unsurprisingly no screening at 12 weeks was reported by diabetologists. The screening practice followed by OBs ranged from fasting plasma glucose (FPG), HbA1c, and random glucose testing to oral glucose tolerance tests (OGTTs). Although the number of OGTTs during COVID-19 was less than before COVID, there were no significant differences in the 12 weeks screening method used, that is, FPG, HbA1c, random glucose, or OGTT, both before and during COVID-19 [Table 3].
Table 3: Screening test followed at 12 weeks by obstetricians (n = 90)

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Screening and diagnosis at 24 weeks’ pregnancy before and during COVID-19

At 24 weeks of pregnancy, during the COVID-19 pandemic the diabetologists carried out marginally higher random glucose testing, higher HbA1c tests, and lower numbers of OGTTs; however, none of this was significantly different compared with the numbers before the COVID-19 pandemic [Table 4].
Table 4: Screening at 24 weeks by diabetologists (n = 117)

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Similarly, among OBs, however, at 24 weeks, there was a significantly lower number of OGTTs performed (85.6% vs. 95.6%, P = 0.02) and a higher use of HbA1c tests (16.7% vs. 5.6%, P = 0.02) than before COVID-19 [Table 5].
Table 5: Screening at 24 weeks by obstetricians (n = 90)

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Diagnostic criteria used by diabetologists and obstetricians

With respect to diagnostic criteria, 75% of the diabetologists reported following the International Association of Diabetes and Pregnancy Study Groups criteria, both before and during COVID-19 [Table 6]. Among the OBs, 57% reported using Diabetes in Pregnancy Study Group of India (DIPSI) criteria before COVID-19, whereas 58.6% reported using DIPSI during COVID-19 [Table 7]. There was no significant difference in the diagnostic criteria used by both the groups both before and during COVID-19.
Table 6: Diagnostic criteria at 24 weeks by diabetologists

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Table 7: Diagnostic criteria at 24 weeks by obstetricians

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Management of gestational diabetes mellitus before and during COVID-19

During COVID-19, self-monitoring of blood glucose (SMBG) was significantly higher than before COVID-19 (59.4% vs. 37.1%, P < 0.0001). However, laboratory testing was significantly lower during COVID-19 when compared with before the pandemic [Table 8].
Table 8: Management of GDM

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Obstetric scanning for women with gestational diabetes mellitus

Regarding obstetric scanning, 49% (n = 44) of the OBs responded that they were not able to do growth scans as often as they were able to do before the COVID-19 pandemic. Of the 44 OBs, 66% were able to perform serial growth scans only for those on medication, whereas the rest were able to perform only one growth scan for all women with GDM.

In-person visits vs. telemedicine during COVID-19 (n = 201)

Overall, 97% of the doctors used some type of telemedicine for consultation purposes; 58% of the doctors used telemedicine, in addition to seeing patients in person [Figure 2].
Figure 2: In-person visits vs. telemedicine during coronavirus disease 2019 (COVID-19; n = 201)

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Type of remote monitoring/telemedicine system used by the diabetologists and obstetricians

Almost all doctors invariably used some alternative to in-person visits, due to the pandemic situation. Majority of the doctors (24.6%) used a combination of telephone calls, video calls, text messaging, email, and WhatsApp to connect with patients for consultation. In addition, 24% of doctors relied only on telephone calls, whereas some others used only video calling to follow-up with patients. Very few doctors (1.5%) used a dedicated telemedicine platform to connect with patients [Figure 3].
Figure 3: Type of remote monitoring/telemedicine system used by diabetologists and obstetricians (OBs). App = application, GYN = gynecologists

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[Table 9] shows some of the important gaps in the current virtual care system identified by doctors. More than 60% of the doctors felt that they found it difficult to change from in-person appointments to remote tele consultations. Nearly 50% of the doctors felt that it was difficult to conduct GDM education classes to help women with GDM understand the different aspects of management of GDM. Forty-four percent of the doctors found it difficult to share patient records with their healthcare team for follow-up care due to lack of electronic medical records etc. Other issues quoted include difficulty in integrating glucose data into hospital records, software, and systems for booking appointments and reminders for follow-up. Some doctors also expressed difficulty in not being able to carry out physical examinations such as fetal monitoring.
Table 9: Challenges in the current “virtual care” system in the care of patients with GDM

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  Discussion Top


The significant findings from this survey were as follows: 1. There was a reduction in the number of OGTTs and an increase in the use of HbA1c tests for the screening and diagnosis of GDM during COVID-19 (by OBs). 2. There were no significant differences in the type of screening and diagnostic tests used. 3. There were difficulties in performing serial growth scans. 4. Majority of the doctors used some form of telemedicine to remotely monitor and follow-up women with GDM. However, there were challenges to deliver education and treatment via telemedicine.

Although the OGTT has been considered the gold standard for diagnosis, most guidelines have now accepted the need to reduce OGTTs during pregnancy and postpartum follow-up, to limit the risk of exposure during antenatal visits. In response to the growing concern regarding the COVID-19 pandemic, several professional societies across the world have released statement or guidance suggesting modifications in the diagnosis and management of GDM during the COVID-19 pandemic.[6] Given that several women would be unwilling to undergo the OGTT due to risk of longer exposure to the clinic/hospital, and increased COVID-19 risk, the statements from the United Kingdom and Canada suggest avoiding OGTT.[7],[8] The United Kingdom recommends risk factor–based testing. Women with HbA1c ≥5.7% or FPG ≥100 mg/dL (5.6 mmol/L) or random ≥162 mg/dL (9 mmol/L) were considered to be “at risk.”[7] In Canada, the guidelines are slightly different, with HbA1c ≥5.7% and/or random ≥200 mg/dL (11.1 mmol/L) to be used for screening GDM during the pandemic.[8] In Australia, unlike the United Kingdom and Canada, the need for OGTT is not completely eliminated. Instead, their guidelines state that an FPG between 85 and 90 mg/dL (4.7–5.0 mmol/L) warrants a full OGTT, whereas an FPG above 92 mg/dL (5.1 mmol/L) confirms GDM and FPG <85 mg/dL (4.7 mmol/L) is considered non-GDM.[9] Our survey showed that there was a significant increase in HbA1c testing and lower OGTTs during the pandemic than earlier.

SMBG was also higher during than before COVID-19. This corroborates with the results from a recent study from south India, which reported that SMBG among patients with type 2 diabetes increased from 15% to 51% during the pandemic.[10] In their official statement released in March 2020, the International Federation of Gynecology and Obstetrics states that managing women with diabetes during pregnancy requires careful consideration to prevent risk of secondary infections due to poor glycemic control.[11]

In March 2020, the Government of India proactively implemented a nationwide lockdown in an attempt to reduce the spread of COVID-19 infection. The lockdown lasted several weeks, with access to only essential services. One of the major concerns during this lockdown period was access to health care, especially in the case of high-risk pregnancies, with comorbid conditions such as GDM. Several healthcare providers in India have tried to minimize face-to-face contact and resorted to offering consultations remotely via telemedicine.

The use of telemedicine during pregnancy has been shown to beneficially impact glycemic level and pregnancy complications in women with GDM. In a recent meta-analysis of 32 randomized controlled trials, with 5108 women with GDM, telemedicine was shown to have significant improvements in HbA1c, FPG, and 2-h postprandial blood glucose compared with women in the standard care group.[12] With respect to pregnancy outcomes, the telemedicine group recorded lower cesarean section, neonatal hypoglycemia, preeclampsia, and polyhydramnios than the standard care group. Although the National Medical Council of India has recently published appropriate guidelines to help streamline telemedicine practice,[13] the acceptance and uptake of telemedicine has been shown to be poor among patients with diabetes in India. A recent study from south India showed that the acceptance of telemedicine among Asian Indians during COVID-19 for the management of diabetes is still suboptimal.[10] Further, with no formal or special training for doctors in telemedicine, several doctors themselves find it difficult to monitor patients remotely. Although 97% of doctors in our survey reported using telemedicine, 58% of them still saw patients face to face for their consultations.

Our survey also highlights several challenges in the current telemedicine care system. More than 50% of the physicians who participated in our survey reported that they found it difficult to educate women about GDM and its management through telemedicine. Usually, when women attend antenatal clinics in person, they are seen by physicians, nurses, and diabetes educators who provide the much-needed support and help women understand the importance of GDM management. With the pandemic situation arising all too sudden, many doctors and hospitals in India were not fully prepared. Many do not have the required technology and software systems in place for seamless transition from face-to-face appointments to remote monitoring and follow-up. Forty-four percent of doctors who participated in the survey reported that sharing patient records within the healthcare team was difficult. This, in addition to the lack of electronic medical record systems, makes it difficult to implement telemedicine successfully.

Synchronous communication is an essential part of telemedicine services, especially with diabetes management. Timely transmission of glucose data from patient to doctor through telemedicine needs to be achieved by synchronous data transfer through an Internet-enabled telemedicine system between both patients and the doctor. Twenty-eight percent of the doctors reported not being able to integrate a patient’s glucose data into their hospital medical records. Though the Internet has definitely reached remote corners of India, remote transmission of glucose data from patient to doctor is not necessarily a simple step. Often, patients record their glucose readings in a diary, which first needs to be transferred through email or text to the physician. The healthcare team will then have to manually enter the glucose data into an electronic database for review by the doctor. Several glucometer devices are now Bluetooth enabled, which enables synchronous transfer of data from a patient’s glucometer to their phone. However, unless the hospital/clinic has proper software in place for automatic transfer of glucose from the patient’s phone to their electronic medical system, synchronous communication cannot be achieved and the entire process of data transmission can therefore be quite daunting.

Although it has several advantages, implementing telemedicine technology may not be entirely feasible in certain scenarios, such as in the case of an ultrasound scan. Several OBs reported that they could not carry out routine scans for women with GDM during the pandemic. Almost all societies brought out guidance to reduce the third trimester scans to the minimum necessary[14] or only if clinically indicated.[15] In addition, the lockdown made it hard for women to access hospitals or scanning centers. Some doctors reported that a detailed physical examination was not possible through telemedicine and that the doctor–patient relationship is not the same without seeing the patient in person. Despite several challenges identified by the doctors, it is heartening to note that many of them reported using even the simplest technology available to them to remotely connect with their patients during the pandemic. More than 50% of the doctors who participated in our survey reported using telephone calls, text messaging and email, and even WhatsApp video calls to monitor patients during the pandemic.

To our knowledge, this is the first survey on GDM, surveying both diabetologists and OBs in India during the COVID-19 pandemic and it highlights some of the changes in the practice pattern of doctors across India with respect to the diagnosis and management of GDM. The limitations of the study include small sample size and average response rate.

In conclusion, the COVID-19 pandemic resulted in changes in the screening, diagnosis, and management of GDM in India. Following up women with GDM diagnosed using the COVID-19 pandemic will be important to understand their pregnancy outcomes and assess their future risk of diabetes. The use of telemedicine and digital technology for the timely management of GDM in India needs to be addressed especially during pandemics, such as COVID-19. In the absence of high-end software and database management systems, diabetologists and obstetrician/gynecologists can still use simple technologies such as electronic medical records or telephones to monitor and follow-up patients during such pandemics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Author contributions

B. Bhavadharini carried out the data analysis and drafted the article; V. Mohan reviewed the initial drafts; and R. Uma and R. M. Anjana provided a critical review of the article.



 
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