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RE HMOs and GTTsFrom: MS GAIL M HART (YTDP43A@prodigy.com)Fri Mar 29 20:31:03 1996
-- [ From: Gail Hart * EMC.Ver #2.10P ] -- Hi, I am no freind of HMOs, and I agree with you that the cost accountants should not be dictating medical care. The doctor is a far better judge of his client/patients medical needs than is an HMO policy dictator.. But re the HMO which has decided that routine screening GTTs are not needed..... (Now don't you'all yell at me OK?<G> I'm about to question a sacred cow, and just really your collective oppinion)... Routine screening GTTs are not "standard" in other than USA, and prehaps not even in all regions of the USA -- there is still controversy over exactly what constitutes gestational diabetes. Perhaps the non-US physicians would speak to this.<....?..> But, here is my dillemma... ACOG guidelines are to do GTT screening, yes? Yet the Guide to Effective Care in Pregnancy and Childbirth (based on Cochrane database) is quite negative about GTTs - indeed about the whole concept of gestational diabetes as defined by poor GTT. The authors say that history and clinical assesment are """more predictive of fetal macrosomia than is the GTT""", and """There is no convincing evidence that treatment of women with an abnormal GTT will reduce perinatal mortality or morbidity. Trials of dietary regulation for GD do not demonstrate a signigicant effect on any outcome, including macrosomia"""", and controlled diet plus insulin """show a decrease in macrosomia, but no significant effect on other outcomes""". the authors conclude with """""The available data provide no evidence to support the wide recommedndation that all pregnant women shoule be screened for 'gestational diabetes', let alone that they should be treated with insulin.""""" Currently, our protocols call for GTT only for women with risk factors or for indications arrising in pregnancy, rather than for universal screening. Are we wrong? Are the GECPC's conclusions or thier analysis of the data incorrect? Can we support universal GTT screens by other evidence? How firmly based in RCT data is the ACOG recommendation for GTT screening? I want to make sure we're doing the right thing (by doing GTTs only for indications)... I'll happily change to universal screening if needed; but how do I reconcile GECPC with ACOG? Gail Hart (LDEM) Oregon, USA
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