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Introduction Hyperglycemia in pregnancy (HIP, including gestational diabetes and pre-existing type 1 and type 2 diabetes) is increasing, with associated risks to the health of women and their babies. Strategies to manage and prevent this condition are contested. Dynamic simulation models (DSM) can test policy and program scenarios before implementation in the real world. This paper reports the development and use of an advanced DSM exploring the impact of maternal weight status interventions on incidence of HIP.Methods A consortium of experts collaboratively developed a hybrid DSM of HIP, comprising system dynamics, agent-based and discrete event model components. The structure and parameterization drew on a range of evidence and data sources. Scenarios comparing population-level and targeted prevention interventions were simulated from 2018 to identify the intervention combination that would deliver the greatest impact.Results Population interventions promoting weight loss in early adulthood were found to be effective, reducing the population incidence of HIP by 17.3% by 2030 (baseline (‘business as usual’ scenario)=16.1%, 95% CI 15.8 to 16.4; population intervention=13.3%, 95% CI 13.0 to 13.6), more than targeted prepregnancy (5.2% reduction; incidence=15.3%, 95% CI 15.0 to 15.6) and interpregnancy (4.2% reduction; incidence=15.5%, 95% CI 15.2 to 15.8) interventions. Combining targeted interventions for high-risk groups with population interventions promoting healthy weight was most effective in reducing HIP incidence (28.8% reduction by 2030; incidence=11.5, 95% CI 11.2 to 11.8). Scenarios exploring the effect of childhood weight status on entry to adulthood demonstrated significant impact in the selected outcome measure for glycemic regulation, insulin sensitivity in the short term and HIP in the long term.Discussion Population-level weight reduction interventions will be necessary to ‘turn the tide’ on HIP. Weight reduction interventions targeting high-risk individuals, while beneficial for those individuals, did not significantly impact forecasted HIP incidence rates. The importance of maintaining interventions promoting healthy weight in childhood was demonstrated.

Introduction: There is a global agenda towards shared culture and practices between clinicians and a shift to integrated and more community-based healthcare. A crucial context in this agenda is clinicians’ practice with referral of vulnerable populations to community programs, as referral practices address necessary dimensions of integrated care (e.g. professional and normative integration). This study investigates clinicians’ referral practices for people attending diabetes outpatient clinics from culturally and linguistically diverse (CALD) backgrounds to identify possible challenges with making referrals to CALD specific programs. Methods: The study was conducted in four diabetes outpatient facilities in South Western Sydney Local Health District in Sydney, Australia. Fifty-three clinicians, including medical specialists, diabetes nurse educators and allied health professionals (e.g. dietitian, psychologist) participated by completing a questionnaire in June 2018. The response rate for the questionnaire was 75%. Data were analysed for frequency of health professional’s referral and rationale for referral and non-referral to three CALD specific programs. Results: Only twenty-five percent (13/53) of clinicians had referred to CALD specific education programs in the past 12 months. There were 10 referrals for the NSW Health Get Healthy Program (including an interpreter), three referrals for the community-based diabetes support group and nil referrals to the bilingual community educator diabetes education program run by the Health Promotion Department. The most common reason for non- referrals was clinician’s lack of awareness of the programs. Other rationales for non-referral were: inconvenience of the referral process (1 clinician), other health issues taking priority over making the referral (1 clinician) and the programs not being beneficial for the patient (1 clinician). Discussion: Clinicians’ lack of awareness of available community programs can be a bottleneck to integrating care for the vulnerable diabetes outpatients from CALD background. This situation is characteristic of lack of awareness of services outside of one’s own setting and indicate inadequacies in professional, functional and normative integration. As the study finds clinicians doubting benefits from CALD specific programs and not prioritising the referral, it is possible that multidisciplinary professionals in this setting are not convinced of the shared value of the CALD specific programs. Conclusions: Clinician’s referral to CALD specific community programs for diabetes outpatients of CALD background is not at a satisfactory level. The challenges are clinician’s lack of awareness of the program and vision of shared value of the programs. Shared culture and practices between the diabetes outpatient departments and providers of CALD specific education programs are necessary for integrating care for this cohort. Lessons learned: Clinician’s referral to CALD specific community programs was not at a satisfactory level, despite the programs being in operation for 3 or more years. Appropriate referral mechanisms and integration of care in multidisciplinary setting requires a long-term approach, addressing clinical governance, shared culture and practices of different professions. Limitations: This study was limited to the context of an outpatient service for people with type 2 diabetes. Suggestions for future research: Future research may investigate whether similar challenges in referral mechanisms occur in the case of other chronic conditions.