The identification and treatment of women with hyperglycaemia in pregnancy: an analysis of individual participant data, systematic reviews, meta-analyses and an economic evaluation

Gestational diabetes mellitus (GDM) is associated with a higher risk of important adverse outcomes. Practice varies and the best strategy for identifying and treating GDM is unclear. To estimate the clinical effectiveness and cost-effectiveness of strategies for identifying and treating women with G...

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Published in:	Health technology assessment (Winchester, England) England), 2016-11, Vol.20 (86), p.1-348
Main Authors:	Farrar, Diane, Simmonds, Mark, Griffin, Susan, Duarte, Ana, Lawlor, Debbie A, Sculpher, Mark, Fairley, Lesley, Golder, Su, Tuffnell, Derek, Bland, Martin, Dunne, Fidelma, Whitelaw, Donald, Wright, John, Sheldon, Trevor A
Format:	Article
Language:	eng
Subjects:	associations Blood Glucose - analysis Cost-Benefit Analysis cost-effectiveness Decision Trees Diabetes, Gestational - diagnosis Diabetes, Gestational - drug therapy Diabetes, Gestational - ethnology Diet economic analysis Female gestational diabetes Humans hyperglycaemia Hyperglycemia - diagnosis Hyperglycemia - drug therapy Hyperglycemia - ethnology Hypoglycemic Agents - therapeutic use Mass Screening - economics meta-analysis Pregnancy Pregnancy Outcome - epidemiology Prevalence Quality-Adjusted Life Years Risk Factors State Medicine systematic review treatments United Kingdom value of information analysis
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Summary:	Gestational diabetes mellitus (GDM) is associated with a higher risk of important adverse outcomes. Practice varies and the best strategy for identifying and treating GDM is unclear. To estimate the clinical effectiveness and cost-effectiveness of strategies for identifying and treating women with GDM. We analysed individual participant data (IPD) from birth cohorts and conducted systematic reviews to estimate the association of maternal glucose levels with adverse perinatal outcomes; GDM prevalence; maternal characteristics/risk factors for GDM; and the effectiveness and costs of treatments. The cost-effectiveness of various strategies was estimated using a decision tree model, along with a value of information analysis to assess where future research might be worthwhile. Detailed systematic searches of MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations , EMBASE, Cumulative Index to Nursing and Allied Health Literature Plus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment database, NHS Economic Evaluation Database, Maternity and Infant Care database and the Cochrane Methodology Register were undertaken from inception up to October 2014. We identified 58 studies examining maternal glucose levels and outcome associations. Analyses using IPD alone and the systematic review demonstrated continuous linear associations of fasting and post-load glucose levels with adverse perinatal outcomes, with no clear threshold below which there is no increased risk. Using IPD, we estimated glucose thresholds to identify infants at high risk of being born large for gestational age or with high adiposity; for South Asian (SA) women these thresholds were fasting and post-load glucose levels of 5.2 mmol/l and 7.2 mmol/l, respectively and for white British (WB) women they were 5.4 and 7.5 mmol/l, respectively. Prevalence using IPD and published data varied from 1.2% to 24.2% (depending on criteria and population) and was consistently two to three times higher in SA women than in WB women. Lowering thresholds to identify GDM, particularly in women of SA origin, identifies more women at risk, but increases costs. Maternal characteristics did not accurately identify women with GDM; there was limited evidence that in some populations risk factors may be useful for identifying low-risk women. Dietary modification additional to routine care reduced the risk of m
ISSN:	1366-5278 2046-4924