Educating general practitioners about prenatal testing: approaches and challenges

Ensuring best practice in genomics education: A theory- and empirically informed evaluation framework

Implementation of genomic medicine into healthcare requires a workforce educated through effective educational approaches. However, ascertaining the impact of genomics education activities or resources is limited by a lack of evaluation and inconsistent descriptions in the literature. We aim to support those developing genomics education to consider how best to capture evaluation data that demonstrate program outcomes and effectiveness within scope. Here, we present an evaluation framework that is adaptable to multiple settings for use by genomics educators with or without education or evaluation backgrounds. The framework was developed as part of a broader program supporting genomic research translation coordinated by the Australian Genomics consortium. We detail our mixed-methods approach involving an expert workshop, literature review and iterative expert input to reach consensus and synthesis of a new evaluation framework for genomics education. The resulting theory-informed and evidence-based framework encompasses evaluation across all stages of education program development, implementation and reporting, and acknowledges the critical role of stakeholders and the effects of external influences.

Veterinarians' Competence in Applying Basic Genetic Principles and Daily Implementation of Clinical Genetics: A Study in a University Environment

Veterinarian competency in genetics is vital for a meaningful application of the rapidly growing number of genetic tests available for animals. We evaluated the use of genetic tests in the daily veterinary practice and the competency of university-employed veterinarians in applying basic principles of genetics in a clinical setting through an electronic survey with 14 cases and 7 statements on genetics. Ninety-one non-geneticist veterinarians from two veterinary faculties in two different countries responded. Almost half of the participants apply genetic tests during their daily work, with frequencies varying between weekly and once a year. The most common indication to request a genetic test was diagnostic testing of clinically ill patients. Although 80% of the veterinarians communicated the result of a genetic test themselves, only 56% of them found it "very to rather easy" to find the correct test, and only 32% of them always felt competent to interpret the result of the test. The number of correctly answered questions varied widely, with median scores of 9/14 (range 0-14) and 5/7 (range 0-7) for the cases and statements, respectively. Most difficulties were seen with recognition of pedigree inheritance patterns, while veterinarians scored better in breeding advice and probability of disease estimations. Veterinarians scored best on questions related to autosomal recessive inheritance, followed by complex, autosomal dominant, X-linked recessive, and X-linked dominant inheritance. This study exposed pain points in veterinarians' knowledge and has led to the formulation of recommendations for future education and communication between laboratories, geneticists, and veterinarians.

A systematic review of interventions to provide genetics education for primary care

BACKGROUND

At least 10 % of patients seen in primary care are said to have a condition in which genetics has an influence. However, patients at risk of genetic disease may not be recognised, while those who seek advice may not be referred or managed appropriately. Primary care practitioners lack knowledge of genetics and genetic testing relevant for daily practice and feel inadequate to deliver genetic services. The aim of this systematic review was to evaluate genetics educational interventions in the context of primary care.

METHODS

Following the process for systematic reviews developed by the Centre for Reviews and Dissemination, we conducted a search of five relevant electronic databases. Primary research papers were eligible for inclusion if they included data on outcomes of interventions regarding genetics education for primary care practitioners. The results from each paper were coded and grouped under themes.

RESULTS

Eleven studies were included in the review. The five major themes identified inductively (post hoc) were: prior experience, changes in confidence, changes in knowledge, changes in practice, satisfaction and feedback. In five of the studies, knowledge of practitioners was improved following the educational programmes, but this tended to be in specific topic areas, while practitioner confidence improved in six studies. However, there was little apparent change to practice.

CONCLUSIONS

There are insufficient studies of relevant quality to inform educational interventions in genetics for primary care practitioners. Educational initiatives should be assessed using changes in practice, as well as in confidence and knowledge, to determine if they are effective in causing significant changes in practice in genetic risk assessment and appropriate management of patients.

Noninvasive prenatal testing (NIPT) in Western Australia; considerations in clinical practice

With the rapid uptake of noninvasive prenatal testing (NIPT), certain technical and ethical limitations are becoming more widely recognised; however, there are still some salient issues that seem to be left by the wayside. As the consumer driven push for NIPT increases, healthcare providers need to ensure that they are providing testing appropriately and that patients understand the potential limitations and results as well as the benefits.

Physician liability and non-invasive prenatal testing

Although non-invasive prenatal testing (NIPT) marks a notable development in the field of prenatal genetic testing, there are some physician liability considerations raised by this technology. As NIPT is still emerging as the standard of care and is just starting to receive provincial funding, the question arises of whether physicians are obligated to disclose the availability of NIPT to eligible patients as part of the physician-patient discussion about prenatal screening and diagnosis. If NIPT is discussed with patients, it is important to disclose the limitations of this technology with respect to its accuracy and the number of disorders that it can detect when compared with invasive diagnostic options. A failure to sufficiently disclose these limitations could leave patients with false assurances about the health of their fetuses and could raise informed consent and liability issues, particularly if a child is born with a disability as a result.

What are pregnant women told about models of maternity care in Australia? A retrospective study of women's reports

OBJECTIVE

To describe women's reports of the model of care options General Practitioners (GPs) discussed with them at the first pregnancy consultation and women's self-reported role in decision-making about model of care.

METHODS

Women who had recently given birth responded to survey items about the models of care GPs discussed, their role in final decision-making, and socio-demographic, obstetric history, and early pregnancy characteristics.

RESULTS

The proportion of women with whom each model of care was discussed varied between 8.2% (for private midwifery care with home birth) and 64.4% (GP shared care). Only 7.7% of women reported that all seven models were discussed. Exclusive discussion about private obstetric care and about all public models was common, and women's health insurance status was the strongest predictor of the presence of discussions about each model. Most women (82.6%) reported active involvement in final decision-making about model of care.

CONCLUSION

Although most women report involvement in maternity model of care decisions, they remain largely uninformed about the breadth of available model of care options.

PRACTICAL IMPLICATIONS

Strategies that facilitate women's access to information on the differentiating features and outcomes for all models of care should be prioritized to better ensure equitable and quality decisions.

Sociocultural challenges of beta-thalassaemia major birth in carriers of beta-thalassaemia in Iran

Objective

Despite premarital screening, prenatal diagnosis and the option for voluntary termination of pregnancy, some Iranian couples continue a pregnancy with a fetus affected with beta-thalassaemia major (β-TM). We examined the reasons for this decision, to evaluate the sociocultural challenges these couples face.

Methods

A retrospective evaluation of medical records of all fetuses aborted was conducted to identify those with β-TM, to determine the frequency of β-TM births and to establish the number of couples with β-thalassaemia who declined prenatal diagnosis or a termination of pregnancy in this period. We investigated the reasons for declining these options.

Results

The birth prevalence of β-TM decreased from 39.38 to 2.68 in 100,000 live births from 2005 to 2010. Terminations of pregnancy for affected fetuses increased from 67 in 2005 to 135 in 2010. We identified eight couples as β-thalassaemia carriers who declined prenatal diagnosis or a termination of pregnancy. All but one couple already had a child with β-TM. The reasons for declining prenatal diagnosis were strong religious beliefs, superstition and faith in a supernatural solution in six couples. Economic and cultural factors, and previous termination of pregnancy were also mentioned as reasons by the other two couples.

Conclusion

Although most of the couples had a β-TM child and related socioeconomic problems, their reasons for refusing prenatal diagnosis or termination remain a challenge for the healthcare system in Iran. Couple screening and educational programmes have effectively decreased the rates of refusal in at-risk couples in recent years.

Development of a questionnaire for evaluating genetics education in general practice

To support developments in genetics education, we constructed the GPGeneQ questionnaire to assess skills required for the practice of genetics by general practitioners (GPs). We describe the process of developing and validating this questionnaire to provide a detailed guide in the construction for questionnaires in the application of evaluating genetics education. The GPGeneQ was developed through a multi-step process with the initial draft based on a theoretical framework and literature review. The subsequent draft instrument contained three scales pertaining to GPs' knowledge, self-reported behaviour and attitudes regarding genetics in medicine. Content and ecological validity were measured by an iterative Delphi process involving experts, GPs and consumers of health services. Piloting to assess construct and criterion validity was conducted with a sample of GPs attending an educational workshop that was presented on a number of separate occasions in Victoria, Australia. Results from evaluations of 145 GPs participating in ten workshops revealed evidence for validity and reliability of the GPGeneQ: knowledge change (p < 0.001; CI, -1.63 to -0.68), behaviour change (p < 0.001; CI, -4.15 to -2.21), attitudinal change (p = 0.002; CI, -2.68 to -0.62). This paper details the procedures involved in developing and validating an assessment questionnaire for genetics education. The GPGeneQ is the first validated questionnaire covering a broad range of topics that is designed to provide a reliable measure for the evaluation of genetics education specifically in general practice. The procedures used are transferable to the construction of any instrument for use in genetics or other medical education.

A universal carrier test for the long tail of Mendelian disease

Mendelian disorders are individually rare but collectively common, forming a 'long tail' of genetic disease. A single highly accurate assay for this long tail would allow the scaling up of the Jewish community's successful campaign of population screening for Tay-Sachs disease to the general population, thereby improving millions of lives, greatly benefiting minority health and saving billions of dollars. This need has been addressed by designing a universal carrier test: a non-invasive, saliva-based assay for more than 100 Mendelian diseases across all major population groups. The test has been exhaustively validated with a median of 147 positive and 525 negative samples per variant, demonstrating a multiplex assay whose performance compares favourably with the previous standard of care, namely blood-based single-gene carrier tests. Because the test represents a dramatic reduction in the cost and complexity of large-scale population screening, an end to many preventable genetic diseases is now in sight. Moreover, given that the assay is inexpensive and requires only a saliva sample, it is now increasingly feasible to make carrier testing a routine part of preconception care.

The missing element: consanguinity as a component of genetic risk assessment

PURPOSE

There are no clinical practice data regarding collecting information on consanguinity as part of family history, despite its relevance for identifying at-risk pregnancies. We determined current practice and influencing factors in documenting consanguinity as part of pregnancy assessment by midwives, key health professionals in socialized medicine.

METHODS

Data were gathered from midwives in Victoria, Australia, which contains an ethnically heterogeneous population. Current practice and issues influencing practice including frequency of enquiry and attitudes regarding collecting consanguinity and family history information were documented.

RESULTS

Family history is collected by midwives, but is restricted to medical information only. Although 65.1% of midwives collect family history, only 6.4% ask about consanguinity. Direct questioning about consanguinity was seen to be difficult, reflecting social taboos, with discussion usually prompted by patient disclosure. The factor significantly associated with clinical practice in multivariate analysis was midwives' lack of confidence (adjusted odds ratio: 5.3 [95% confidence interval 1.3-22.1]) in discussing consanguinity.

CONCLUSIONS

Organizational and social barriers prevent collecting information about consanguinity in midwifery practice, restricting identification of at-risk pregnancies. Change theory is applied to inform strategies to enhance the identification of consanguineous couples.

Evaluation of a decision aid for prenatal testing of fetal abnormalities: a cluster randomised trial [ISRCTN22532458]

BACKGROUND

By providing information on the relative merits and potential harms of the options available and a framework to clarify preferences, decision aids can improve knowledge and realistic expectations and decrease decisional conflict in individuals facing decisions between alternative forms of action. Decision-making about prenatal testing for fetal abnormalities is often confusing and difficult for women and the effectiveness of decision aids in this field has not been established. This study aims to test whether a decision aid for prenatal testing of fetal abnormalities, when compared to a pamphlet, improves women's informed decision-making and decreases decisional conflict.

METHODS/DESIGN

A cluster designed randomised controlled trial is being conducted in Victoria, Australia. Fifty General Practitioners (GPs) have been randomised to one of two arms: providing women with either a decision aid or a pamphlet. The two primary outcomes will be measured by comparing the difference in percentages of women identified as making an informed choice and the difference in mean decisional conflict scores between the two groups. Data will be collected from women using questionnaires at 14 weeks and 24 weeks gestation. The sample size of 159 women in both arms of the trial has been calculated to detect a difference of 18% (50 to 68%) in informed choice between the two groups. The required numbers have been adjusted to accommodate the cluster design, miscarriage and participant lost--to--follow up. Baseline characteristics of women will be summarised for both arms of the trial. Similarly, characteristics of GPs will be compared between arms. Differences in the primary outcomes will be analysed using 'intention-to-treat' principles. Appropriate regression techniques will adjust for the effects of clustering and include covariates to adjust for the stratifying variable and major potential confounding factors.

DISCUSSION

The findings from this trial will make a significant contribution to improving women's experience of prenatal testing and will have application to a variety of maternity care settings. The evaluation of a tailored decision aid will also have implications for pregnancy care providers by identifying whether or not such a resource will support their role in providing prenatal testing information.