American Journal of Obstetrics and Gynecology (2005) 192, 227e32

www.ajog.org

Preconception care in managed care: The translatingresearch into action for diabetes study

Catherine Kim, MD, MPH,a Assiamira Ferrara, MD, PhD,b Laura N. McEwen, MPH,c

David G. Marrero, PhD,d Robert B. Gerzoff, MS,e William H. Herman, MD, MPH,c

the TRIAD Study Group

Departments of Internal Medicine and Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich,a Divisionof Research, Kaiser Permanente, Oakland, Calif,b Departments of Internal Medicine and Epidemiology, University ofMichigan, Ann Arbor, Mich,c Indiana University School of Medicine, Indianapolis, Ind,d and Division of DiabetesTranslation, Centers for Disease Control and Prevention, Atlanta, Gae

Received for publication February 18, 2004; revised June 13, 2004; accepted June 30, 2004

KEY WORDSPrepregnancy

counseling

Diabetes

Objectives: This study was undertaken to examine the rates of preconception counseling in

managed care for women with diabetes and associated patient and physician characteristics.Study design: Participants included women aged 18 to 45 years enrolled in a study of diabetescare in managed care. Women were asked if they recalled discussions regarding glucose control

before conception (n = 236) and use of family planning until glucose control was achieved(n = 227). Hierarchical logistic regression models accounted for patient and physiciancharacteristics.Results: Fifty-two percent of women recalled being counseled about glucose control and 37%

recalled family planning advice. In adjusted models, patient age (years) (odds ratio [OR] 0.91,95% CI 0.86-0.96) and body mass index (BMI) (kg/m2) (OR 0.96, 95% CI 0.93-0.99) remainedsignificant predictors of glucose control counseling. Similarly, patient age (years) (OR 0.94, 95%

CI 0.89-0.99) and BMI (kg/m2) (0.96, 95% CI 0.93-0.99) remained significant predictors of familyplanning counseling.Conclusions: Preconception counseling rates for diabetic women are low and associated with

younger age and lower BMI.� 2005 Elsevier Inc. All rights reserved.

In the United States, increasing numbers of womenwith diabetes are of child-bearing age1 and are alsomembers of managed care organizations.2 Preconcep-tion care for women with diabetes, defined as the

TRIAD was funded through the Centers for Disease Control and

Prevention (U48/CCU516410-02).

Reprints not available from the authors.

0002-9378/$ - see front matter � 2005 Elsevier Inc. All rights reserved.

doi:10.1016/j.ajog.2004.06.105

attainment of optimal glucose control before pregnancyand the use of contraception until pregnancy is desired,is associated with reduced incidence of congenital anom-alies,3 spontaneous abortions,4 and decreased length ofstay and cost.5 Therefore, the American College ofObstetricians and Gynecologists6 and the AmericanDiabetes Association recommend preconception carefor women of childbearing age with diabetes.7

Unfortunately, observational studies have demonstrated

228 Kim et al

that the majority of women with diabetes do not plantheir pregnancies and enter pregnancy with inadequateblood glucose control.8,9

Studies of pregnancy planning and diabetes care havenot examined managed care organizations, which havereported high performance rates of other diabetes pro-cesses of care such as rates of dilated retinal examina-tion,10 perhaps in part because of the presence ofdiabetes registries and other information technologiesmonitoring diabetes quality of care that could extend topreconception care. Janz et al8 found that women withdiabetes who received preconception care through a mul-tidisciplinary program were more likely to be married,employed, better educated, wealthier, and to have type 1diabetes rather than type 2 diabetes than women whohad no preconception care.8 Similarly, Holing et al9

demonstrated that women with diabetes who plannedtheir pregnancies also tended to be white, married, bettereducated, wealthier, privately insured, and to have hadcontact with an endocrinologist before their pregnancies.Although less than half of the pregnancies were planned,most women knew they should optimize their bloodglucose levels before pregnancy.9

In earlier studies, it was unclear how much ofwomen’s preconception care was related to clinicianand health system characteristics. In general, any formof contraception information is significantly associatedwith increased odds of contraceptive use, but almosthalf of women in 1 health plan reported not receivingcounseling from their physicians.11 Holing et al9 foundthat women who had a positive relationship with theirclinicians were more likely to plan their pregnancies,whereas women who thought their clinicians discour-aged pregnancy were less likely to plan a pregnancy.This may also reflect the characteristics of the womenwith diabetes. Women with type 1 diabetes, who areoften younger and more socioeconomically advantagedthan women with type 2 diabetes, are more likely tobe cared for by endocrinologists than women with type2 diabetes and may receive more intensive diabetestherapy.12 Other studies examining markers of diabetesquality of care have found that clinicians and patientswith similar characteristics tend to cluster within pro-vider groups, and once adjustments are made for thisclustering, clinician characteristics are not significantlyassociated with quality of care.13 Increasing awarenessof the importance of quality of care has led to healthsystem changes aimed at improving the diabetes processmeasures,14 and this may have led to improved rates ofpreconception counseling from earlier reports.

Translating Research into Action for Diabetes(TRIAD) is a multicenter prospective cohort studydesigned to examine the associations between managedcare structure and organization and the processesand outcomes of diabetes care.15 Within TRIAD, weexamined associations between preconception care and

patient and clinician characteristics before and afteradjusting for clustering within provider groups andhealth plans. We hypothesized that women who re-ported preconception counseling would be better edu-cated and have characteristics associated with type 1diabetes, specifically they would be younger and morelikely to be of normal body mass index (BMI). We alsohypothesized that clinician characteristics would not besignificant after adjusting for patient characteristics andclustering of patients within health plans and providergroups.

Material and methods

Study setting and population

The TRIAD study has been previously described.15 Inbrief, 6 Translational Research Centers (TRCs) collab-orate with 10 managed care health plans and 68 providergroups that serve approximately 180,000 people withdiabetes. The health plans are geographically andethnically diverse (Hawaii, California, Texas, Indiana,Michigan, New Jersey, and Pennsylvania). TRIAD’sstudy population consisted of a stratified, randomsample of adults with diabetes. The study protocol wasreviewed and approved by the Institutional ReviewBoards (IRBs) at all 6 TRCs. All participants providedinformed consent. Study participants were 18 years andolder, community dwelling, English or Spanish speak-ing, continuously enrolled in the health plan for at least18 months, not pregnant, and with at least 1 claim forhealth services during the previous 18 months. Partic-ipants were sampled from provider groups that had atleast 50 participants with diabetes enrolled in the healthplan. Recruitment was completed in September 2001.

Information from participants was obtained witha survey that was administered either by computer-assisted telephone interview or in writing, and throughmedical record review and health plan administrativedata. Of contacted eligible people, 91% responded to thesurvey. TRIAD respondents and nonrespondents did notdiffer significantly by age, althoughahigher proportionofnonrespondents were men. Survey questions, adminis-tered in English and Spanish, assessed sociodemographiccharacteristics, recommended diabetes care services re-ceived, and inquired about general health status, qualityof life, and satisfaction among other variables. Informa-tion on primary care physician age, sex, degree, andspecialty and board training were obtained from healthplan records and linked to the patient responses.

Women 18 to 45 years (n = 302) at 3 TRCs (Indiana,California, and Michigan) were asked 2 questions re-garding preconception counseling: (1) Has your currenthealth care provider talked with you about the impor-tance of good glucose control before becoming pregnant?

Kim et al 229

Table Participant and physician characteristics by preconception counseling responses, means (SEs) or percentages

Glucose control counseling Family planning counseling

Participant characteristics No (n = 113) Yes (n = 123) P value No (n = 144) Yes (n = 83) P value

Age (mean) (y) 40.0 (0.5) 37.8 (0.5) .003 39.8 (0.4) 37.3 (0.7) .002Race or ethnicity (%) .24 .84White non-Hispanic 42 48 43 46Black non-Hispanic 27 17 24 18Hispanic 13 19 15 19Asian or Pacific Islander 8 10 10 8Other 10 7 8 8

Education (%) .49 .56Some high school 12 17 15 12High school/GED 31 27 26 34Some college 40 34 38 354-y college graduate 13 14 16 11O4 y of college 4 8 6 8

Annual household income (%) .078 .28!$15,000 25 28 25 29$15,000-$39,000 38 23 35 23$40,000-$74,999 23 32 25 33R$75,000 14 17 15 16

Diabetes treatment (%) .06 .009Insulin only 33 45 32 49Other types of treatment 67 55 68 51

Diabetes duration (mean y) 9.5 (0.8) 11.8 (0.8) .039 10.0 (0.7) 11.6 (1.0) .17Current smoker (%) 35 40 .40 39 33 .34BMI (kg/m2) (median, IQR) 35 (15) 30 (14) .008 35 (16) 28 (13) .002Health status (%) .69 .67Excellent 3 2 1 4Very good 19 22 19 24Good 31 37 35 31Fair 37 33 34 34Poor 11 7 10 7

Health plan (%) .96 .88A 40 41 41 43B 33 33 32 33C 27 26 27 24

Physician characteristicsAge (mean y) 42 (0.8) 42 (0.8) .91 42.1 (0.7) 42.4 (0.9) .78Internist (%) 85 90 .22 85 93 .10Female sex (%) 46 36 .11 40 42 .78

(glucose control counseling) and (2) has your currenthealth care provider talked with you about using familyplanning or birth control until good glucose control isreached? (family planning counseling). All women hadbeen seen at least once in the enrollment period by theirprimary care provider to be included in the analysis(n = 302). Seventy-eight percent (n = 236) of eligiblewomen answered the question regarding glucose controlcounseling, and 75% (n = 227) of eligible women an-swered the question regarding family planning counsel-ing. Women with missing responses were more oftenblack (51%) and had fewer mean years with diabetes(8 years) than women who responded to the survey.However, respondents and nonrespondents did not differon other characteristics.

Main outcome measures and covariates

The primary dependent variables were responses to the 2questions regarding glucose control and family planningcounseling. Patient covariates included age, race, educa-tion, income, duration of diabetes, type of diabetes treat-ment (insulin vs other treatment), current smoking, andhealth status (Table). Physician covariates included age,sex, and specialty. Physicians were classified as generalistsif they were board certified in osteopathic or familymedicine and as internists if they were board certified ininternal medicine; a few internal medicine specialists wereprimary care physicians and for the purposes of thisanalysis were classified as internists. In our dataset, noobstetrician-gynecologists or endocrinologists were listed

230 Kim et al

as primary care providers. In 1 health plan, only 8% ofwomen reported seeing an obstetrician-gynecologist inthe past 18 months for any reason.

Each response to a preconception question wasexamined in its own model. To avoid overfitting thefinal model, we first modeled the relations betweenpreconception care and patient characteristics in a step-wise logistic regression model. Next, we modeled therelations between preconception care and physiciancharacteristics in another stepwise logistic regressionmodel. Covariates needed to be significant at 0.20 to beincluded and at 0.10 to be excluded. Significant variableswere then entered into hierarchical logistic regressionmodels (SAS GLIMMIX Macro with penalized quasi-likelihood estimation method) with random interceptsfor health plans to account for the clustered study design(health plan, provider group, and participant levels) andthe correlation among participant characteristics withinhealth plans and provider groups.

In stepwise regression equations, patient character-istics associated with glucose control counseling in-cluded age, body mass index (BMI), and income, andpatient characteristics associated with family planningcounseling included age and BMI. In stepwise regres-sion equations, physician characteristics associated withglucose control counseling included male primary carephysician gender, and physician characteristics associ-ated with family planning counseling included internalmedicine specialty. Of note, no correlations greater than0.4 existed among any of the covariates. For comparison,we also created stepwise logistic regression models withboth patient and physician characteristics and obtainedsimilar results. We then created the hierarchical logisticregression models to adjust for clustering within providergroups and health plans containing the covariates fromthe stepwise equations. In a sensitivity analysis, weexamined women younger than 40 years, because wethought it possible that women between 40 and 45 yearsand their physicians may not have perceived themselvesat risk for pregnancy. In another sensitivity analysis, westratified by hemoglobin A1C (HbA1C), as we thought itpossible that women with better glucose control (!8)may have been counseled differently than women withworse glucose control (R8). All analyses were performedwith SAS version 8.02 (Research Triangle Institute,Research Triangle Park, NC).

Results

The unadjusted characteristics of participants by theirrecall of preconception counseling are shown in Table.Twenty-four percent of women were aged 18 to 34 years,26% were 35 to 39 years, and 50% were 40 to 45 years.Approximately half of the women recalled discussionsregarding the importance of attaining good glucose

control and a little more than a third recalled discussionsregarding the importance of family planning. Womenwho were younger, with lower weight and longerduration of diabetes, and who used only insulin fortreatment were more likely to report glucose controlcounseling. Similarly, women who were younger, nor-mal weight, had longer duration of diabetes, and usedonly insulin for treatment were more likely to reportfamily planning counseling. Male primary care phys-icians were more likely than female primary care phys-icians to counsel on glucose control, and internal medicinephysicians were more likely than family practitionersto counsel on family planning, although neither ofthese associations was significant at P! .05 (Table).

In models adjusting for clustering of participantswithin patient and provider groups, patient age (years)(odds ratio [OR] 0.91, 95% CI 0.86-0.96) and BMI(kg/m2) (OR0.96, 95%CI 0.93-0.99) remained significantpredictors of glucose control counseling. Similarly, pa-tient age (years) (OR 0.94, 95% CI 0.89-0.99) and BMI(kg/m2) (OR0.96, 95%CI 0.93-0.99) remained significantpredictors of family planning counseling. After adjust-ment for clustering, physician characteristicswere still notsignificantly associated with preconception counseling.

When we excluded women 40 years and older, we didnot find any significant changes in the point estimates forthe covariates. In particular, physician characteristicswere still not associated with either glucose or familyplanning counseling. Lower age (OR 0.94, 95% CI 0.84-1.04) and lower BMI (OR 0.96, 95% CI 0.93-1.00) werestill associated with glucose control counseling, and lowerage (OR 0.92, 95% CI 0.83-1.02) and lower BMI (OR0.94, 95% CI 0.90-0.98) were still associated with familyplanning counseling, although because of the smallersample size, not all of the associations were still signif-icant. Similarly, in unadjusted analyses, we found thatwomen whose most recent HbA1C level was less than 8reported glucose control counseling (42%) and familyplanning counseling (36%), less often than women whosemost recentHbA1C level was greater than or equal to 8. Inadjusted analyses, women whose last HbA1C was lessthan 8 were similarly likely to report glucose controlcounseling (OR 1.62, 95% CI 0.82-3.21) like womenwhose last HbA1C was greater than or equal to 8, andwomen whose last HbA1C was less than 8 were similarlylikely to report family planning counseling (OR0.95, 95%CI 0.49-1.85) like women whose last HbA1C was greaterthan or equal to 8. The relationships between patient ageand BMI and the outcome measures was not significantlydifferent for women whose HbA1C was less than 8 versusgreater than or equal to 8.

Comment

Although multiple measures of the quality of dia-betes care have improved over the past decade, this

Kim et al 231

improvement has not extended to preconception care.TRIADhas previously reported increased rates of dilatedeye examination, lipid measurement, influenza vaccina-tion, foot examination, HbA1C measurement, and bloodpressure measurement compared with earlier studies.10

This report demonstrates low preconception counselingrates persist from previous reports that noted approxi-mately a third of women with diabetes had receivedpreconception care before a pregnancy.3,8 In our study,only about half of women recalling discussions regardingthe importance of optimal glucose control before preg-nancy and only a third recalling discussions about familyplanning until such glucose control was attained. This isproblematic, as more pregnancies will be affected bydiabetes because of the increasing prevalence of type 2diabetes16,17 and older possible maternal age at concep-tion.18

There are several possible explanations for the lowrates of preconception counseling. Preconception coun-seling is part of family planning counseling and rates offamily planning counseling are low in general. In a studyconducted in 1997, only about half of managed careplans in mature managed care environments informedenrollees about coverage of contraceptive services, andfewer plans informed enrollees insured as dependents.Indeed, as many as a quarter of women did not knowwhether their plan covered oral contraceptives andabout one third reported difficulties in obtaining con-traceptive services.19 In addition, we defined child-bearing age as between 18 and 45 years. Many womenin our sample were 40 years and older, and these olderwomen and their physicians may have misperceivedthemselves at not at risk for pregnancy and may havebeen less likely to recall or provide such discussions.However, when we examined women younger than 40years, our results were similar. Finally, women withdiabetes may fail to ask about or avoid oral contra-ceptives, with the misperception that they would in-crease their risk of diabetes complications.

For similar reasons, younger, thinner women mayhave been more likely to receive counseling than older,heavier women. Younger, thinner women may havebeen perceived as more likely to be sexually active or ina partnered relationship, and marital status has pre-dicted preconception counseling in other analyses.9 Inaddition, women who use insulin only may receive moreintense care than women who receive other therapies,characterized by greater number of health care visits andendocrinology contact that in turn increases the likeli-hood of such counseling. In 1 study of managed careenrollees, women aged 40 to 44 were less likely thanyounger women to receive counseling and also to usecontraception, even if they were otherwise at risk for anunintended pregnancy.11

Unlike previous reports,8,9 we did not find thatwomen’s education or income was associated with recall

of glucose control counseling or family planning coun-seling. We examined a managed care population, andinsurance status and managed care may have minimizedthe effects of these socioeconomic indicators. We alsodid not find that women physicians provided morefamily planning counseling, although other researchhas suggested that women physicians perform othergender-specific services at higher rates.20 Women whoalso see obstetrician-gynecologists in addition to theirprimary care physician may be more likely to receivepreconception counseling; a 1998 survey indicated thatapproximately 40% of gynecologists include womenwith type 2 diabetes in their nonpregnant patientpopulation,21 and women who see gynecologists as wellas their primary care physician are more likely to receivePapanicolaou smears and other preventive clinicalservices.22

Our analyses have several limitations. We examineda select group of health plans across a limited number ofgeographic locations, so our results may reflect character-istics of the location or specific plans. Also, we onlyexamined a limited set of preconception care questionsthat were based on patient recall. These measures havelimitations in that they may not capture the subtleties ofthe patient-physician relationship found in other analy-ses8,9 and may have also underestimated rates of physi-cian counseling as responses were based on patient recall.We were unable to examine the presence and extent ofendocrinology and gynecology contact at all the sites. Inprinciple, family planning counseling should be per-formedbyprimary care providers aswell as gynecologists.It is possible that rates of preconception counselingwouldhave been significantly higher had we asked if the patienthad received counseling from a gynecologist, althoughonly 8%of diabetic women saw a gynecologist over an 18-month period at 1 of the sites.

We conclude that recall of preconception counselingin women with diabetes could be vastly improved.Managed care is an ideal venue for such improvementsgiven its existing infrastructure for other diabetes qualityof care initiatives. Greater efforts on the part of healthplans to publicize their family planning and contracep-tive services and to facilitate access to such services forall women could improve outcomes for women withdiabetes. Further research into differences in patient andphysician attitudes and self-efficacy regarding precon-ception care could facilitate integration of family plan-ning services and chronic disease management. Increaseduse of gynecology services in women with diabetesshould also be explored.

Acknowledgments

We thank the TRIAD participants who made this studypossible. We also thank Kathy Welch for her assistancein the statistical analysis.

232 Kim et al

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