Annals of Internal Medicine tip sheet for May 28, 2013

The oral glucose challenge test (OGCT) and testing for fasting plasma glucose levels may be the best way to rule out gestational diabetes mellitus (GDM) in women who are at about 24 weeks' gestation. The OGCT may be better for diagnosing women who have GDM. GDM puts babies at risk for having a high birth weight, low blood sugar, and jaundice. GDM is also associated with seizures or still birth. Women who are diagnosed with GDM can control their glucose levels and decrease risks for complications, making screening an important consideration. In 2008, the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to assess the benefits and harms of screening women for GDM. To update its previous screening recommendations, researchers reviewed 51 cohort studies that assess the test characteristics of various screening methods for GDM. There is no gold standard glucose level threshold for diagnosing GDM, which makes comparing tests difficult. However, the researchers found that using the OGCT with a glucose threshold of 7.2 mmol/L had a sensitivity of 99 percent and a specificity of 77 percent, which would accurately identify patients who do not have GDM. Measuring fasting plasma glucose level was shown to be a good alternative for OGCT, especially for women who cannot tolerate a glucose drink. At a threshold of 4.7 mmol/L, it has a sensitivity similar to OGCT, but is not as good at predicting an abnormal oral glucose tolerance test (OGTT) result. For women found to have GDM, published evidence suggests that treatment reduces preeclampsia, shoulder dystocia, and high birth weight, and is associated with few harms. The researchers found limited evidence to support GDM screening at less than 24 weeks, but early screening may be justified in women at high risk for overt diabetes. There was not enough compelling evidence to recommend for or against risk factor-based screening. A draft recommendation statement will be posted for public comment at http://www.uspreventiveservicestaskforce.org on May 27 at 5:00 p.m. Final recommendations will be published in Annals of Internal Medicine.

Note: For an embargoed PDF, please contact Megan Hanks or Angela Collom. To interview the lead author, please contact Bruce Conway at or bruce.donovan@albertahealthservices.ca 403-943-1212. For a copy of the draft recommendations, please contact Ana Fullmer at ana.fullmer@edelman.com or 202-351-6668.

Now that the Affordable Care Act (ACA) is the law, renowned health care reform advocates, Bob Kocher, MD, and Ezekiel Emanuel, MD, PhD, propose a "transparency imperative" to achieve higher quality and cost control under the new health care system. According to Drs. Kocher and Emanuel, the lack of price and quality transparency in U.S. health care promotes high costs, but not necessarily high quality care. They propose that all data on price, utilization, and quality be made publicly available unless there is a compelling reason to keep it confidential. To achieve transparency, the Federal Government will need to relax restrictions on public access to Medicare data. The authors write that all payers should make claims data publically available, with privacy protections, to enable quality measurement. Patients should know how many procedures a physician has performed (utilization), and have access to outcomes data for hospitals (quality). Personalized pricing information also should be made available so that patients can make comparisons. Currently, it is almost impossible for patients to obtain pricing information for health care services. Within local markets, different hospitals may have price disparities of more than 200%, with little or no correlation between cost and quality. The authors conclude that "transparency is essential for patients to consume care from providers who deliver greater value." They assert that the transparency approach will promote competition and is the best way to overcome local monopoly pricing power by providers.

Note: For an embargoed PDF, please contact Megan Hanks or Angela Collom. To interview Dr. Kocher, please contact Adam Williams at adwilliams@apcoworldwide.com or 202-297-5121. To interview Dr. Emanuel, please contact Katie Delach at katie.delach@uphs.upenn.edu or 215-349-5964.