The easy-to-do audit series: An audit of pre-conception counselling in women of childbearing age with diabetes

Diabetes in pregnancy is associated with a number of risks to the mother and to the developing fetus. Miscarriage, pre-eclampsia, pre-term labour, stillbirth, congenital malformations, macrosomia, birth injury, perinatal mortality and postnatal adaptation problems, such as hypoglycaemia, are more common in babies born to women with pre-existing diabetes (National Collaborating Centre for Women’s and Children’s Health, 2008).

Whilst the rates of adverse pregnancy outcome in women with both type 1 and type 2 diabetes have greatly improved, as was highlighted recently in an article in this journal, rates remain significantly higher than in the background population (Noctor and Dunne, 2014).

In February 2015, NICE (2015a) published updated guidance on Diabetes in pregnancy: management from preconception to the postnatal period. The overarching aim of this guidance is to empower women with diabetes to have a positive experience of pregnancy and childbirth.

The recommendations around pre-conception counselling have particular relevance for those of us working in the primary care setting because many women with diabetes, especially those with type 2 diabetes, are not under the care of a specialist diabetes team. Furthermore, the number of women of childbearing age with diabetes is growing as type 2 diabetes is being diagnosed at an earlier age. In 2013, 44.9% of women with pre-existing diabetes complicating pregnancy had type 2 diabetes (Health and Social Care Information Centre, 2014).

Pre-conception counselling has been shown to be associated with a decrease in adverse outcomes including stillbirth, neonatal death and congenital malformations, from 7.8% in non-attendees compared with 1.3% in attendees (Murphy et al, 2010). The purpose of this audit is to identify those within a practice of childbearing potential with diabetes and then to assess whether they have been offered pre-conception counselling according to the recommendations laid out in the new NICE (2015a) guidance as shown in Table 1.

The audit
Initial search
Perform a search to identify all women in the practice with type 1 and type 2 diabetes of childbearing potential.

• Select sex: female
• Select current age: 15–54 years
• Select diabetes diagnosis code:
  Type 1 diabetes (X40J4/C10E)*
  Type 2 diabetes (X40J5/C10F)

[*SystmOne Read codes in italic, EMIS Read codes in bold. Note that both terms and specific codes from SystmOne and EMIS systems are included throughout, but you may prefer to search using the Terms alone.]There may be women within the search results who need to be identified and excluded. Given that the search is likely to produce fairly small numbers it may be possible to simply review the patient summary to identify the women who need to be excluded. Useful groups to identify include:

• Hysterectomy.
• Laparoscopic tubal ligation/contraception: female sterilisation.
• Sterilisation.
• Tubal occlusion.
• Infertile/infertility problem.

Tip: Remember to include all “children” codes within the Read code cluster.

The term “infertile” may have been applied during investigations for unexplained infertility, so care needs to be taken not to exclude women where there is even the slightest possibility of conceiving. It is, however, important to be aware that giving advice about pre-conception could cause considerable distress to a woman who is unable to conceive.

Women who have passed the menopause can also be excluded providing they have had no periods for at least 2 years and are under the age of 50, and for at least 1 year if they are over 50. This information may not be routinely recorded in a patient’s record and may only become apparent after discussion with the individual.

Results
This involves reviewing the patient record to establish if and when the woman has been offered pre-conception counselling. The quickest way to do this is to go to the New Journal and enter the search term “pre-conception”. This will highlight any previous consultations where pre-conception was discussed and recorded. Another option is to search within the Read code journal for the code Pre-conception advice (XaIwm/67IJ) or Pre-conception advice for diabetes (XaX9n/67IJ1). Record the number of women who have received pre-conception counselling results in the table available for download at www.diabetesandprimarycare.co.uk/audits.

Pre-conception counselling
Undertake pre-conception counselling in those who have not received it in the past 6-month period, and it is important to note the date the advice was given. NICE (2015a) does recommend that pre-conception advice is offered at every contact. What constitutes satisfactory pre-conception counselling is an important consideration and should be assessed in relation to the recommendations set down by NICE (2015a; Table 1). Table 2 is a quick reference guide that includes the key actions that should be undertaken during a pre-conception consultation. Where the counselling does not meet these recommendations the individual should be invited to attend for pre-conception counselling.

With a number of issues to discuss, a standardised pro forma or checklist facilitates the process and helps to ensure that all of the relevant information is recorded. Teams may want to consider building a pre-conception template such as Figure 1 if there is not already one available in the software. This will ensure that all the relevant topics are discussed and captured within the patient’s electronic record. Alternatively, teams may want to photocopy and laminate Figure 1 to use for pre-conception counselling. If an electronic template is not used, once pre-conception counselling is complete, the “Pre-conception advice for diabetes given” codes should be added, as this will be used for the re-audit.

Tip: Setting an annual recall, as well as a reminder to discuss at every other contact, makes it easier for clinicians to recognise those eligible for pre-conception counselling in the future.

Re-audit
The purpose of the re-audit is to determine how many of the women identified in the baseline audit have attended and received pre-conception counselling. This should be conducted 6 months later to allow sufficient time for interventions to be implemented.

Your turn
You can download the full-size audit form from www.diabetesandprimarycare.co.uk/audits to fill in and retain. The audit should take no more than a few hours to complete.

After you have completed the first data collection, you can send in your top-line aggregated data to [email protected].

Instructions to complete the audit
Aim
The purpose of this audit is to identify those within a practice of childbearing potential with diabetes and then to assess whether they have been offered pre-conception counselling according to the recommendations laid out in the new NICE guidance.

Audit method
This will be a two-step audit completed in a primary care centre in the UK. The first data collection will be between 1 November and 31 December 2016 and the follow-up data collection will be completed 6 months later.

Criterion
Women between 15 and 54 years of ages with diabetes have been offered pre-conception counselling (or discussion about pregnancy planning) unless they have reached menopause, had sterilisation or a hysterectomy, or are definitely infertile.

Standard
All eligible women with diabetes planning pregnancy must have pre-conception counselling.

N.B. Set a reminder on the practice’s electronic calendar to repeat the audit 6 months later.

Download the full-size audit form at: www.diabetesandprimarycare.co.uk/audits