A multidisciplinary approach for improving services in primary care: randomised controlled trial of screening for haemoglobin disorders

Reducing health inequalities through general practice: a realist review and action framework

Background

Socio-economic inequalities in health have been in the public agenda for decades. General practice has an influential role to play in mitigating the impact of inequalities especially regarding chronic conditions. At the moment, general practice is dealing with serious challenges in relation to workforce shortages, increasing workload and the impact of the COVID-19 pandemic. It is important to identify effective ways so that general practice can play its role in reducing health inequalities.

Objectives

We explored what types of interventions and aspects of routine care in general practice decrease or increase inequalities in health and care-related outcomes. We focused on cardiovascular disease, cancer, diabetes and/or chronic obstructive pulmonary disease. We explored for whom these interventions and aspects of care work best, why, and in what circumstances. Our main objective was to synthesise this evidence into specific guidance for healthcare professionals and decision-makers about how best to achieve equitable general practice.

Design

Realist review.

Main outcome measures

Clinical or care-related outcomes by socio-economic group, or other PROGRESS-Plus criteria.

Review methods

Realist review based on Pawson's five steps: (1) locating existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting and organising data and (5) synthesising the evidence.

Results

Three hundred and twenty-five studies met the inclusion criteria and 159 of them were selected for the evidence synthesis. Evidence about the impact of general practice interventions on health inequalities is limited. To reduce health inequalities, general practice needs to be: • connected so that interventions are linked and coordinated across the sector; • intersectional to account for the fact that people's experience is affected by many of their characteristics; • flexible to meet patients' different needs and preferences; • inclusive so that it does not exclude people because of who they are; • community-centred so that people who receive care engage with its design and delivery. These qualities should inform action across four domains: structures like funding and workforce distribution, organisational culture, everyday regulated procedures involved in care delivery, interpersonal and community relationships.

Limitations

The reviewed evidence offers limited detail about the ways and the extent to which specific interventions increase or decrease inequalities in general practice. Therefore, we focused on the underpinning principles that were common across interventions to produce higher-level, transferrable conclusions about ways to achieve equitable care.

Conclusions

Inequalities in general practice result from complex processes across four different domains that include structures, ideas, regulated everyday procedures, and relationships among individuals and communities. To achieve equity, general practice needs to be connected, intersectional, flexible, inclusive and community-centred.

Future work

Future work should focus on how these five essential qualities can be better used to shape the organisational development of future general practice.

Study registration

This trial is registered as PROSPERO CRD42020217871.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130694) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information.

Reducing health inequalities through general practice

Although general practice can contribute to reducing health inequalities, existing evidence provides little guidance on how this reduction can be achieved. We reviewed interventions influencing health and care inequalities in general practice and developed an action framework for health professionals and decision makers. We conducted a realist review by searching MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library for systematic reviews of interventions into health inequality in general practice. We then screened the studies in the included systematic reviews for those that reported their outcomes by socioeconomic status or other PROGRESS-Plus (Cochrane Equity Methods Group) categories. 159 studies were included in the evidence synthesis. Robust evidence on the effect of general practice on health inequalities is scarce. Focusing on common qualities of interventions, we found that to reduce health inequalities, general practice needs to be informed by five key principles: involving coordinated services across the system (ie, connected), accounting for differences within patient groups (ie, intersectional), making allowances for different patient needs and preferences (ie, flexible), integrating patient worldviews and cultural references (ie, inclusive), and engaging communities with service design and delivery (ie, community-centred). Future work should explore how these principles can inform the organisational development of general practice.

Improving Decision Making about Genetic Testing in the Clinic: An Overview of Effective Knowledge Translation Interventions

Background

Knowledge translation (KT) interventions are attempts to change behavior in keeping with scientific evidence. While genetic tests are increasingly available to healthcare consumers in the clinic, evidence about their benefits is unclear and decisions about genetic testing are thus difficult for all parties.

Objective

We sought to identify KT interventions that involved decisions about genetic testing in the clinical context and to assess their effectiveness for improving decision making in terms of behavior change, increased knowledge and wellbeing.

Methods

We searched for trials assessing KT interventions in the context of genetic testing up to March 2014 in all systematic reviews (n = 153) published by two Cochrane review groups: Effective Practice and Organisation of Care (EPOC) and Consumers and Communication.

Results

We retrieved 2473 unique trials of which we retained only 28 (1%). Two EPOC reviews yielded two trials of KT interventions: audit and feedback (n = 1) and educational outreach (n = 1). Both targeted health professionals and the KT intervention they assessed was found to be effective. Four Consumers and Communication reviews yielded 26 trials: decision aids (n = 15), communication of DNA-based disease risk estimates (n = 7), personalized risk communication (n = 3) and mobile phone messaging (n = 1). Among these, 25 trials targeted only health consumers or patients and the KT interventions were found to be effective in four trials, partly effective in seven, and ineffective in four. Lastly, only one trial targeted both physicians and patients and was found to be effective.

Conclusions

More research on the effectiveness of KT interventions regarding genetic testing in the clinical context may contribute to patients making informed value-based decisions and drawing the maximum benefit from clinical applications of genetic and genomic innovations.

Characteristics of Academic Detailing: Results of a Literature Review

BACKGROUND

Academic detailing is an evidence-based strategy to improve patient care. Efforts to understand the intervention and to use it strategically require an understanding of its important characteristics. A recent systematic review and a subsequent reporting framework call for more accurate and complete reporting of continuing medical education interventions.

OBJECTIVES

Building on a previously published systematic review of 69 studies, we sought to determine how an expanded set of 106 academic detailing studies, including many recently published articles, fared with respect to reporting of important data about this intervention.

METHODS

We conducted a search of MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (clinical) database, and Scopus, from which we identified 38 additional randomized controlled trials published from August 2007 through March 2013. Including the original 69 studies, we abstracted 106 available English-language studies and quantitatively analyzed information about 4 important characteristics of academic detailing: content of visits, clinicians being visited, communication process underlying visits, and outreach workers making visits.

RESULTS

We found considerable variation (36.5%-100%) in the extent of reporting intervention characteristics, especially about the communication process underlying visits and the outreach workers making visits. The best overall documentation of intervention characteristics of any single study was 68%. Results also demonstrate wide variation in the approach to academic detailing.

CONCLUSIONS

This study demonstrates the need for a standardized approach to collecting and reporting data about academic detailing interventions. Our findings also highlight opportunities for using academic detailing more effectively in research and quality-improvement efforts.

The effectiveness of a semi-tailored facilitator-based intervention to optimise chronic care management in general practice: a stepped-wedge randomised controlled trial

Background

The Danish health care sector is reorganising based on disease management programmes designed to secure integrated and high quality chronic care across hospitals, general practitioners and municipalities. The disease management programmes assign a central role to general practice; and in the Capital Region of Denmark a facilitator-based intervention was undertaken to support the implementation of the programmes in general practice. The purpose of the study was to assess the effectiveness of this semi-tailored facilitator-based intervention.

Method

The study was a stepped-wedge, randomised, controlled trial among general practices in the Capital Region of Denmark. The intervention group was offered three one-hour visits by a facilitator. The intervention was semi-tailored to the perceived needs as defined by each general practice, and the practices could choose from a list of possible topics. The control group was a delayed intervention group. The primary outcome was change in the number of annual chronic disease check-ups. Secondary outcomes were: changes in the number of annual check-ups for type 2 diabetes (DM2) and chronic obstructive pulmonary disease (COPD); changes in the number of spirometry tests, changes in the use of ICPC diagnosis coding and patient stratification; sign-up for a software program for patient overview; and reduction in number of practices with few annual chronic disease check-ups.

Results

We randomised 189 general practices: 96 practices were allocated to the intervention group and 93 to the delayed intervention group. For the primary outcome, 94 and 89 practices were analysed. Almost every outcome improved from baseline to follow-up in both allocation groups. At follow-up there was no difference between allocation groups for the primary outcome (p = 0.1639). However, some secondary outcomes favoured the intervention: a higher reported use of ICPC diagnosis coding for DM2 and COPD (p = 0.0050, p = 0.0243 respectively), stratification for COPD (p = 0.0185) and a faster initial sign-up rate for the software program.

Conclusion

The mixed results from this study indicate that a semi-tailored facilitator-based intervention of relatively low intensity is unlikely to add substantially to the implementation of disease management programmes for DM2 and COPD in a context marked by important concurrent initiatives (including financial incentives and mandatory registry participation) aimed at moving all practices towards changes in chronic care.

Trial registration

ClinicalTrials.gov: NCT01297075

Consequences of a lack of standardization of continuing education terminology: the case of practice facilitation and educational outreach

Systematic reviews published in the quality improvement and continuing education literature have noted that the lack of standardized terminology for categorizing and describing various interventions in published studies is a major obstacle to drawing conclusions about their effectiveness. A case in point is practice facilitation and educational outreach. Although they are 2 long-standing interventions with some common characteristics, researchers studying 1 intervention may be unfamiliar with the other given the relatively separate literatures that have developed around both sets of terms. A comparison of articles included in recent systematic reviews of practice facilitation and educational outreach revealed a small but significant overlap of articles, journals, key words, and noncorresponding authors, but no overlap of corresponding authors. Based on these findings, the authors join the call for the creation of an intervention taxonomy and its application to these and other continuing education interventions.

Systematic review and meta-analysis of practice facilitation within primary care settings

PURPOSE

This study was a systematic review with a quantitative synthesis of the literature examining the overall effect size of practice facilitation and possible moderating factors. The primary outcome was the change in evidence-based practice behavior calculated as a standardized mean difference.

METHODS

In this systematic review, we searched 4 electronic databases and the reference lists of published literature reviews to find practice facilitation studies that identified evidence-based guideline implementation within primary care practices as the outcome. We included randomized and nonrandomized controlled trials and prospective cohort studies published from 1966 to December 2010 in English language only peer-reviewed journals. Reviews of each study were conducted and assessed for quality; data were abstracted, and standardized mean difference estimates and 95% confidence intervals (CIs) were calculated using a random-effects model. Publication bias, influence, subgroup, and meta-regression analyses were also conducted.

RESULTS

Twenty-three studies contributed to the analysis for a total of 1,398 participating practices: 697 practice facilitation intervention and 701 control group practices. The degree of variability between studies was consistent with what would be expected to occur by chance alone (I2 = 20%). An overall effect size of 0.56 (95% CI, 0.43-0.68) favored practice facilitation (z = 8.76; P <.001), and publication bias was evident. Primary care practices are 2.76 (95% CI, 2.18-3.43) times more likely to adopt evidence-based guidelines through practice facilitation. Meta-regression analysis indicated that tailoring (P = .05), the intensity of the intervention (P = .03), and the number of intervention practices per facilitator (P = .004) modified evidence-based guideline adoption.

CONCLUSION

Practice facilitation has a moderately robust effect on evidence-based guideline adoption within primary care. Implementation fidelity factors, such as tailoring, the number of practices per facilitator, and the intensity of the intervention, have important resource implications.

Carrier screening in preconception consultation in primary care

Discussing carrier screening during preconception consultation in primary care has a number of advantages in terms of promoting autonomy and enabling the greatest range of reproductive choices. For those with a family history of an inherited condition, this ought to be a routine discussion; however, this can be expanded to include the wider population, especially for those conditions for which carrier frequencies are considered relatively common. There is published literature from around the world regarding experiences with carrier screening in primary care for cystic fibrosis, haemoglobinopathies, fragile X syndrome, Tay-Sachs disease and spinal muscular atrophy, although many of these have tended to focus on consultations during rather than before pregnancy. Overall, these studies reveal that population carrier screening is well received by the participants with apparent minimal psychosocial harms; however, challenges exist in terms of approaches to ensure couples receive adequate information to make personally relevant decisions and for ongoing health professional engagement.

Hematopoietic stem cell engraftment by early-stage in utero transplantation in a mouse model

A novel intrauterine transplantation (IUT) approach was developed to improve the efficiency of engraftment of hematopoietic stem cells (HSCs). HSCs with a green fluorescent protein (GFP) reporter gene were transplanted in utero on days 12.5, 13.5 and 14.5 post coitum (p.c.). The degree of chimerism of donor cells in recipient newborn mice was examined using fluorescent microscopy, polymerase chain reaction (PCR), fluorescence-activated cell sorting (FACS), and fluorescence in situ hybridization (FISH) analyses. Microscopic examination revealed the presence of green fluorescent signal in the peripheral blood of the chimeric mice. The highest survival rate (47%) as well as the highest chimerism rate (73%) were achieved by our new approach in the newborn mice that were subjected to in utero transplantation (IUT) on day 12.5 p.c. (E12.5) compared to the conventional IUT method. FACS analysis indicated that 1.55+/-1.10% of peripheral blood cells from the newborn mice were GFP-positive donor cells. FISH showed that cells containing the donor-specific GFP sequence were present in the bone marrow (BM) of the chimeric mice. Thus, the efficiency of chimera production with this new method of IUT was significantly improved over the existing IUT techniques and instruments.

Parents' experiences of universal screening for haemoglobin disorders: implications for practice in a new genetics era

BACKGROUND

England is the only country in the world that currently has universal population screening for haemoglobin disorders through linked antenatal and newborn screening. Little is known about the acceptability of such screening.

AIM

To explore parents' experiences of, and attitudes towards, new universal genetic screening for haemoglobin disorders.

DESIGN OF STUDY

Narrative interview study.

SETTING

Primary and community care settings across England.

METHOD

Narrative interviews were undertaken with a maximum variation sample of 39 people who had experienced gene-carrier identification through antenatal and newborn screening for sickle cell, thalassaemia, and other haemoglobin variants within the previous 2 years.

RESULTS

Most parents were unaware screening had occurred or had given it little consideration and so were surprised or shocked by results. However, they were glad to learn of their carrier status, reproductive genetic risk, or their newborn's carrier status. Participants emphasised that antenatal screening should happen as early as possible. Many would rather have known their carrier status before pregnancy or before entering a relationship. Although most were satisfied with the information they received, significant misunderstandings remained. There were culturally diverse attitudes towards prenatal diagnosis and termination. These procedures were acceptable to some parents with strong religious beliefs, including Christians and Muslims.

CONCLUSION

Parents support screening for haemoglobin disorders but need to be better informed and better prepared for results and what they mean. Sensitivity to patient diversity in attitudes and choices is also required. Universal screening for genetic reproductive risk will increasingly involve generalists, particularly in primary care, presenting opportunities for screening before or earlier in pregnancy, which is likely to be welcomed by patients.

The impact of genetic outreach education and support to primary care on practitioner's confidence and competence in dealing with familial cancers

AIMS

To determine the level of competence and confidence in general practice in relation to the management of familial cancers and to determine the impact of providing genetic educational outreach on confidence and competence.

METHODS

Confidence and competence in dealing with familial cancers was measured using a postal questionnaire sent to all general practitioners and practice nurses in 4 geographical areas in central England. In 2 areas, genetic educational outreach was provided to 10 randomly selected practices and a matched analysis of questionnaire responses before and after intervention was done to determine the impact of the intervention.

RESULTS

Respondents were more confident in dealing with patient queries around familial breast cancer risk than those around bowel cancer. This was inconsistent with the ability to correctly assign familial risk, with 48% incorrectly assigning a high-risk categorisation to a low-risk breast cancer scenario. Respondents who had taken part in the intervention reported more confidence in dealing with issues related to the management of patient queries around bowel cancer. Following intervention, participants were more likely to report feeling confident in knowing the relevant family history to collect (72.4% of respondents from participating practices compared to 56.1% from non-participating practices; OR 2.39, p = 0.02, 95% CI 1.14-5.00) and in making a basic assessment of risk (72.4% compared to 38.9%; OR 3.65, p = 0.01, 95% CI 1.38-9.61).

CONCLUSIONS

Providing genetic educational outreach has a positive impact upon how confident primary care staff feel in dealing with patient queries over familial cancers, particularly in relation to bowel cancer. Further research is needed to explore the impact of providing this service on other relevant outcomes such as appropriateness of referrals to genetic services.

Educational outreach visits: effects on professional practice and health care outcomes

BACKGROUND

Educational outreach visits (EOVs) have been identified as an intervention that may improve the practice of healthcare professionals. This type of face-to-face visit has been referred to as university-based educational detailing, academic detailing, and educational visiting.

OBJECTIVES

To assess the effects of EOVs on health professional practice or patient outcomes.

SEARCH STRATEGY

For this update, we searched the Cochrane EPOC register to March 2007. In the original review, we searched multiple bibliographic databases including MEDLINE and CINAHL.

SELECTION CRITERIA

Randomised trials of EOVs that reported an objective measure of professional performance or healthcare outcomes. An EOV was defined as a personal visit by a trained person to healthcare professionals in their own settings.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. We used bubble plots and box plots to visually inspect the data. We conducted both quantitative and qualitative analyses. We used meta-regression to examine potential sources of heterogeneity determined a priori. We hypothesised eight factors to explain variation across effect estimates. In our primary visual and statistical analyses, we included only studies with dichotomous outcomes, with baseline data and with low or moderate risk of bias, in which the intervention included an EOV and was compared to no intervention.

MAIN RESULTS

We included 69 studies involving more than 15,000 health professionals. Twenty-eight studies (34 comparisons) contributed to the calculation of the median and interquartile range for the main comparison. The median adjusted risk difference (RD) in compliance with desired practice was 5.6% (interquartile range 3.0% to 9.0%). The adjusted RDs were highly consistent for prescribing (median 4.8%, interquartile range 3.0% to 6.5% for 17 comparisons), but varied for other types of professional performance (median 6.0%, interquartile range 3.6% to 16.0% for 17 comparisons). Meta-regression was limited by the large number of potential explanatory factors (eight) with only 31 comparisons, and did not provide any compelling explanations for the observed variation in adjusted RDs. There were 18 comparisons with continuous outcomes, with a median adjusted relative improvement of 21% (interquartile range 11% to 41%). There were eight trials (12 comparisons) in which the intervention included an EOV and was compared to another type of intervention, usually audit and feedback. Interventions that included EOVs appeared to be slightly superior to audit and feedback. Only six studies evaluated different types of visits in head-to-head comparisons. When individual visits were compared to group visits (three trials), the results were mixed.

AUTHORS' CONCLUSIONS

EOVs alone or when combined with other interventions have effects on prescribing that are relatively consistent and small, but potentially important. Their effects on other types of professional performance vary from small to modest improvements, and it is not possible from this review to explain that variation.

Genetics Support to Primary Care Practitioners—A Demonstration Project

Primary care practitioners need to be supported by specialist genetics services to enable them to cope effectively with the expanding relevance of genetics to their patients. Genetic counselors could be effective in such a role. This exploratory project set out to improve the Primary-Tertiary interface through piloting such a service to general practice for 1 year. Tailored genetic educational outreach was delivered by a genetic counselor to ten randomly selected general practices in central England for 12 months. A range of services were provided to the practices these included facilitated genetic update sessions, a responsive advice service and referral guidelines. The service was evaluated through pre and post intervention questionnaires and via seven semi-structured interviews. This article presents a description of the development and delivery of this service and also reports on the experiences of a sample of the participants. Participants reported positive attitudes to the service and said that they had gained knowledge and confidence, as well as recognized limitations and gaps in their current knowledge. The consistent link with a specialist genetics service provided by a genetic counselor had a positive impact during the project and participants have continued to utilize the genetic counselor for advice and support with genetic patient issues since the project was completed. This is the first example of this model of service provision. Further research, utilizing a larger sample and other measures of behavioral change needs to be carried out to assess whether this model should be adopted on a wider basis.

Microcytosis, iron deficiency and thalassaemia in a multi-ethnic community: a pilot study

The high prevalence of microcytosis (defined here as mean cell haemoglobin<27 pg) with no other abnormality is a principal cause of confusion in screening for haemoglobin disorders. Here we report the results of a small pilot study aiming to resolve this confusion by routinely proceeding to plasma ferritin and HPLC assay, using the original sequestrene blood sample, when microcytosis is detected. Participants comprised a random sample of 1,302 people referred for a full blood count by their General Practitioner (GP) to the laboratory of a North London district general hospital serving a multi-ethnic inner-city population. Ethnicity was established by questionnaire. In North Europeans, microcytosis was present in 3% of males (half were iron-deficient) and 11% of females (most were iron-deficient). Among ethnic minorities, microcytosis was present in 35% of males (one tenth were iron-deficient), and 45% of females (less than half were iron-deficient): an exclusion diagnosis of "probable alpha thalassaemia" could be made in the remainder. We conclude that when microcytosis is present, routine further analysis of the original sequestrene sample by plasma ferritin assay and haemoglobinopathy screening could lead to a more efficient and cost-effective laboratory service for primary care and maternity services.

A meta-analysis of continuing medical education effectiveness

INTRODUCTION

We undertook a meta-analysis of the Continuing Medical Education (CME) outcome literature to examine the effect of moderator variables on physician knowledge, performance, and patient outcomes.

METHODS

A literature search of MEDLINE and ERIC was conducted for randomized controlled trials and experimental design studies of CME outcomes in which physicians were a major group. CME moderator variables included the types of intervention, the types and number of participants, time, and the number of intervention sessions held over time.

RESULTS

Thirty-one studies met the eligibility criteria, generating 61 interventions. The overall sample-size weighted effect size for all 61 interventions was r = 0.28 (0.18). The analysis of CME moderator variables showed that active and mixed methods had medium effect sizes (r = 0.33 [0.33], r = 0.33 [0.26], respectively), and passive methods had a small effect size (r = 0.20 [0.16], confidence interval 0.15, 0.26). There was a positive correlation between the effect size and the length of the interventions (r = 0.33) and between multiple interventions over time (r = 0.36). There was a negative correlation between the effect size and programs that involved multiple disciplines (r = -0.18) and the number of participants (r = -0.13). The correlation between the effect size and the length of time for outcome assessment was negative (r = -0.31).

DISCUSSION

The meta-analysis suggests that the effect size of CME on physician knowledge is a medium one; however, the effect size is small for physician performance and patient outcome. The examination of moderator variables shows there is a larger effect size when the interventions are interactive, use multiple methods, and are designed for a small group of physicians from a single discipline.

Informed patient consent to participation in cluster randomized trials: an empirical exploration of trials in primary care

Cluster randomized trials are increasingly common. Obtaining informed patient consent to participation in these trials raises practical challenges and ethical issues. The aims of this paper were to 1) develop a typology of interventions employed in cluster randomized trials in primary care; 2) assess whether the likelihood of seeking individual consent to participation varies by intervension type; 3) assess whether this likelihood has increased over time; 4) assess evidence for under reporting of consent procedures; 5) articulate reasons for not obtaining consent; and 6) make recommendations for future trial investigators. We collected data on trial interventions and consent procedures from reports of 152 recently published trials, and 47 unpublished trials. We develop a typology of interventions based on reasons for adopting a clustered design. We examine proportions seeking individual consent to participation among trials involving different types of intervention, in different periods, and among published and unpublished trials. Two-thirds of the trials had multifaceted interventions. Trials involving different types of intervention had different propensities to seek consent, largely because of practical obstacles to obtaining consent. Obtaining consent can compromise internal validity. More recent trials are no more likely to obtain consent than past trials. There was no evidence of under-reporting of consent procedures in publications. In conclusion, future trial investigators should consider both practical reasons and scientific arguments for not obtaining individual patient consent for all interventions in their trials. Where feasible, they should allow patients to opt out of the trial. Lay individuals should represent trial participants as part of the process of cluster consent to participation, and lay individuals could also be involved in considering ethical issues during trial planning. A more public debate may clarify the general acceptability of not obtaining consent in certain situations.

'Rakter dosh'--corrupting blood: The challenges of preventing thalassemia in Bengal, India

Thalassemia is an inherited blood disorder that has been receiving increasing attention in India. However, prevention of thalassemia in India continues to be difficult despite efforts of public health professionals and the government. Using West Bengal as a case study, this paper attempts to unravel some of the barriers to the prevention campaign and the consequent under utilization of the program. Lack of access, low awareness, low-risk perception and poverty are all important proximate constraints; however, one of the greatest barriers to the program is rooted in cultural notions of blood, marriage, identity, personhood and kinship in Bengali society. Blood is so deeply valued in the Bengali kinship system that this genetic mutation is perceived to be corrupting the blood (rakter dosh). Being a thalassemia carrier (i.e., having thalassemia minor) renders an individual unfit as a suitable marriage partner because of beliefs related to purity of blood, its association with the continuity of the lineage, and subsequent transmission of desirable traits to future generations. The risk of non-marriage affects women disproportionately, and parents are not inclined to test their daughters because of the possibility of not being able to marry them off to eligible suitors. The stigma associated with having thalassemia minor (TMI) is a deterrent to the disclosure of thalassemia status as well as to testing. Using anthropological theories and ethnographic methods, this paper focuses on the gendered process by which the diagnosis of a thalassemia carrier 'spoils' identities, thereby creating a disjuncture between the goals of the prevention program and people's need for social conformity, and ultimately between medical desirability and social desirability. The paper also suggests policies for enhancing the utilization of the program. Finally the conclusions from this study have potential applications for public health prevention programs that confront problems of stigma in program acceptability.

GPs' opinions of their role in prenatal genetic services: a cross-sectional survey

BACKGROUND

In the UK about 4.5% of the population carry cystic fibrosis, whilst in the inner city areas an even higher proportion carry one of the haemoglobin disorders such as thalassaemia. Couples who both carry the same recessive disorder have a 1 in 4 risk of an affected child in every pregnancy.

OBJECTIVES

To assess GPs' confidence in their ability to provide initial prenatal advice for couples carrying common autosomal recessive disorders (either the cystic fibrosis or thalassaemia gene), and their opinions of different approaches for referral to prenatal diagnostic services for such at-risk couples.

METHODS

A cross-sectional postal survey of all 644 GPs in 388 general practices in Nottinghamshire. Practices were randomly allocated to receive either the cystic fibrosis or the thalassaemia scenario survey. The survey questions predominantly used six-point Likert scales to assess confidence and opinions of prenatal services.

RESULTS

The questionnaire was returned by 62% (397) of GPs. Only 23% (91) were confident in providing prenatal advice to the at-risk carrier couples. GPs were more confident about advising cystic fibrosis carriers than thalassaemia carriers (P = 0.01). The least popular approach to prenatal service provision was direct referral to prenatal services after counselling with 52% (194) scoring this as useful, whilst 60.5% (233) of GPs scored referral to the obstetric services with the prenatal diagnosis organised by the obstetrician as useful.

CONCLUSIONS

GPs perceive that they lack the confidence to provide basic prenatal genetic advice to women at risk of the commonest recessive disorders, with particularly low confidence where the couple both carry thalassaemia. A significant knowledge gap was demonstrated by the poor awareness of the importance of rapid referral to prenatal diagnostic services.

Impact of a national beta-thalassemia carrier screening program on the birth rate of thalassemia major

BACKGROUND

In Taiwan, the prevalence of beta-thalassemia trait is at least 1.1%. The Taiwan government initiated a National Screening Program in 1993. Herein we examine the differences before and after the initiation of this program.

PROCEDURE

Data consisting of the total number of patients and the birth prevalence beta-thalassemia major were collected. Ninety-one patients with transfusion-dependent thalassemia treated in our hospitals were included for analysis. DNA analysis was performed for 86 patients.

RESULTS

In Taiwan 361 patients exist. The birth prevalence of per 100,000 births was 5.6% in 1994 and declined to 1.21 in 2002. Fourteen patients were born after the program's initiation. DNA analysis of them revealed a new mutation (IVS-1-5 (G-C)), which was introduced through an inter-racial marriage. Otherwise, the remainder was the common beta-thalassemia mutations found in Taiwan.

CONCLUSIONS

Despite how successful the National Screening Program is, a few doctors still failed to detect parents at risk. In addition, we are concerned about the emerging problem of the increase of interracial marriages where parents may not have appropriate screening. Hence, postgraduate education programs for physicians, health education for the general population, and timely screening of inter-racial marriage should become a priority.

Collecting genetic information in primary care: evaluating a new family history tool

BACKGROUND

The family history is a time-honoured method for identifying genetic predisposition. In specialist practice the standard approach is to draw up a family tree based on a genetic pedigree interview, but this is too time-consuming and focused on single gene disorders to be applicable in primary care.

OBJECTIVES

To assess the ability of a brief self-administered Family History Questionnaire (FHQ), given to patients when they register with a GP, to identify genetic risk.

METHODS

A comparative study. Informants completed an FHQ at registration, and later participated in a genetic pedigree interview. Two clinical geneticists independently scored results obtained with each instrument. Discrepancies were agreed by consensus. The genetic risks identified by the two instruments were compared.

RESULTS

326 new registrants completed the FHQ, and 121 also completed the genetic interview. 24% of FHQs and 36% of genetic interviews resulted in a score 'higher than population risk'. There was 77% agreement in the scores obtained with the two instruments, with a moderate kappa of 0.52. (95% CI 0.40-0.64). There was 90% agreement in the scores for a family history of premature coronary heart disease (Kappa 0.67; 95% CI 0.49 to 0.85). The instruments were equally effective in identifying ethnicity-related risk of common recessive disorders.

CONCLUSIONS

The FHQ identified most informants with genetic risks that are appropriately addressed in primary care-those with a family history of premature coronary heart disease, those warranting specialist referral, and those who might appropriately be offered carrier testing. However, it was less effective in identifying those with a possible Mendelian disorder for whom more information was required.

Antenatal screening for haemoglobinopathies in primary care: a whole system participatory action research project

BACKGROUND

The usual system for antenatal screening for haemoglobinopathies permits termination only late in the second trimester of pregnancy.

AIM

To evaluate a system where pregnant women are screened in general practice, and to develop a model of care pathway or whole system research able to bring into view unexpected effects of health service innovation.

DESIGN OF STUDY

A whole system participatory action research approach was used. Six purposefully chosen general practices screened women who attended with a new pregnancy. Data of gestational age of screening were compared with two control groups. Qualitative data were gathered through workshops, interviews and feedback to the project steering group. At facilitated annual workshops participants from all parts of the care pathway produced a consensus about the meaning of the data as a whole.

SETTING

Six general practices in north London.

METHOD

A whole system participatory action research approach allowed stakeholders from throughout the care pathway to pilot the innovation and reflect on the meaning and significance of quantitative and qualitative data.

RESULTS

The gestational age of screening in general practice was 4.1 weeks earlier (95% confidence interval (CI) = 3.41 to 4.68) than in hospital clinics (P<0.001), and 2.9 weeks earlier (95% CI = 2.07 to 3.65) than in community midwife clinics (P <0.001). However, only 35% of pregnant women in the study were screened in the practices. Changes required throughout the whole care pathway make wider implementation more difficult than at first realised. The cost within general practice is greater than initially appreciated owing to a perceived need to provide counselling about other issues at the same time. Practitioners considered that other ways of early screening should be explored, including preconceptual screening. The research approach was able to bring into view unexpected effects of the innovation, but health workers were unfamiliar with the participatory processes.

CONCLUSION

Antenatal screening for haemoglobinopathies in general practice lowers the gestational age at which an at-risk pregnancy can be identified. However, widespread implementation of such screening may be too difficult.

In utero transplantation of human hematopoetic stem cells into fetal goats under B-type ultrasonographic scan: an experimental model for the study of potential prenatal therapy

OBJECTIVE

Using fetal goats as animal models, to establish the methodology of in utero transplantation of human hematopoeitic stem cell (HSC) under B-scan ultrasonographic guidance for prenatal therapy.

STUDY DESIGN

Human HSC were directly injected into the peritoneal cavities of the recipient fetal goats at 45-55 days of gestation (term: 145 days) under the guidance of B-type ultrasound scan. After birth, the peripheral blood was collected for fluorescence assisted cell sorting (FACS), quantitative real-time PCR and fluorescence in situ hybridization (FISH) to detect and analyze the presence of human cells in the recipients.

RESULTS

The 32 recipients were born alive except one miscarriage. To test for the presence of human-goat chimeras, cells from 13 randomly selected transplanted goats were collected. FACS analyses showed the presence of human cells in all the transplanted goats tested. The average proportion of CD34+ cells and GPA+(glycophorin A) cells in the peripheral blood were 1.34 +/- 1.10% and 2.80 +/- 2.10%, respectively. No CD34+ or GPA+ cells were found in the non-transplanted goats tested. The results of the quantitative real-time PCR in three engraftment goats were 1.2 x 10(4), 2.9 x 10(4), and 3.2 x 10(4) copies of human GPA DNA per mug of genomic DNA. FISH experiments showed that cells containing human specific alpha-satellite DNA sequence were present in the peripheral blood of the transplanted goats.

CONCLUSIONS

The method described herein is safe and reliable, with low miscarriage risk and high chimerism rate. This approach may provide a promising animal model for potential prenatal treatment.

Timeline: Raising the profile of genetics in primary care

Primary care practitioners recognize that genetics is relevant to their daily practice, for example, for detecting and managing the risk of multifactorial disorders and genetic reproductive risks, and, in future, for targeted drug therapy. However, they lack confidence in their ability to apply genetic approaches. In fact, genetics is already ingrained in current practice, and the development of appropriate guidelines and web-based information resources will help practitioners to make personalized genetic risk assessment a part of holistic, patient-oriented primary health care.

Population genetic screening programmes: principles, techniques, practices, and policies

This paper examines the professional and scientific views on the principles, techniques, practices, and policies that impact on the population genetic screening programmes in Europe. This paper focuses on the issues surrounding potential screening programmes, which require further discussion before their introduction. It aims to increase, among the health-care professions and health policy-makers, awareness of the potential screening programmes as an issue of increasing concern to public health. The methods comprised primarily the review of the existing professional guidelines, regulatory frameworks and other documents related to population genetic screening programmes in Europe. Then, the questions that need debate, in regard to different types of genetic screening before and after birth, were examined. Screening for conditions such as cystic fibrosis, Duchenne muscular dystrophy, familial hypercholesterolemia, fragile X syndrome, hemochromatosis, and cancer susceptibility was discussed. Special issues related to genetic screening were also examined, such as informed consent, family aspects, commercialization, the players on the scene and monitoring genetic screening programmes. Afterwards, these questions were debated by 51 experts from 15 European countries during an international workshop organized by the European Society of Human Genetics Public and Professional Policy Committee in Amsterdam, The Netherlands, 19-20, November, 1999. Arguments for and against starting screening programmes have been put forward. It has been questioned whether genetic screening differs from other types of screening and testing in terms of ethical issues. The general impression on the future of genetic screening is that one wants to 'proceed with caution', with more active impetus from the side of patients' organizations and more reluctance from the policy-makers. The latter try to obviate the potential problems about the abortion and eugenics issues that might be perceived as a greater problem than it is in reality. However, it seems important to maintain a balance between a 'professional duty of care' and 'personal autonomy'.

Comparison of activities and attitudes of general practitioners concerning genetic counseling over a 10-year time-span

The aim of this study was to investigate whether the activities and attitudes of general practitioners (GPs) concerning genetic counseling have changed between 1989 and 1999. In 1989 a random sample of 124 GPs in The Netherlands was selected. Of these GPs, 98 were contacted again in 1999 and 71 completed the questionnaire. The study showed an increase in the percentage of GPs who provided genetic counseling when a risk factor for having a child with a congenital disorder was present and known. In both 1989 and 1999, the GPs seldom used a recommended combination of oral and written information, and only data that was available in the databases on the risk indicator 'use of medication' increased over the years. GPs are still supporters of a directive method of counseling, and seem to believe that the main goal of genetic counseling is to prevent hereditary and congenital disorders. Although, between 1989 and 1999 more GPs provided genetic counseling when a risk indicator was present and known or referred to a clinical geneticist, only limited improvement was found in the activities of GPs to attempt to collect these data.

Genetics education for primary-care providers

In an era of growing knowledge about genetics and health, primary-care physicians will have increasing responsibility for evaluating genetic risk and using genetic tests. Although most have little knowledge of genetics, their expertise in the prudent use of technology is relevant to the task. Successful educational programmes will need to forge partnerships between primary care and genetics.

A randomised controlled trial of the effect of educational outreach by community pharmacists on prescribing in UK general practice

BACKGROUND

Educational outreach visits are commonly used to promote changes in prescribing in family practice. However, the effectiveness of outreach visits has not been evaluated across a range of settings.

AIM

To estimate the effectiveness of educational outreach visits on United Kingdom (UK) general practice prescribing and to examine the extent to which practice characteristics influenced outcome.

DESIGN OF STUDY

Randomised controlled trial.

SETTING

General practices in 12 health authorities in England.

METHOD

Educational outreach visits were made to practices that received two of four guidelines. Each practice provided data on treatment of patients for all four guidelines for both pre and post-intervention periods. The primary outcome is average effect across all four guidelines. Secondary analyses examined the predictive effect of practice and guideline characteristics.

RESULTS

Seventy per cent of practices approached agreed to take part in the intervention. Overall, educational outreach was associated with a significant improvement in prescribing practice (odds ratio [OR] = 1.24 [95% CI = 1.07 to 1.42]), a 5.2% (95% CI = 1.7% to 8.7%) increase in the number of patients treated within the guideline recommendations. Smaller practices (two or fewer full-time equivalent practitioners) responded much more favourably to educational outreach than larger practices. Smaller practices improved their performance in line with the guidelines by 13.5% (95% CI = 6% to 20.9%) attributable to outreach, while larger practices improved by only 1.4% (95% CI = -2.4% to 5.3%, P-value for interaction <0.001).

CONCLUSION

In large practices, educational outreach alone is unlikely to achieve worthwhile change. There is good evidence to support the use of educational outreach visits in small practices.

Informed choice in genetic screening for thalassaemia during pregnancy: audit from a national confidential inquiry

OBJECTIVE

National audit of informed choice in antenatal screening for thalassaemia.

DESIGN

Audit from the UK Confidential Enquiry into Counselling for Genetic Disorders.

SETTING

Thalassaemia module of the UK Confidential Enquiry into Counselling for Genetic Disorders.

SUBJECTS

138 of 156 couples who had had a pregnancy affected by a major beta thalassaemia from 1990 to 1994.

MAIN OUTCOME MEASURES

How and when genetic risk was identified for each couple, and whether and when prenatal diagnosis was offered.

RESULTS

Risk was detected by screening before or during the first pregnancy in 49% (68/138) of couples and by diagnosis of an affected child in 28% (38/138) of couples. Prenatal diagnosis was offered in 69% (274/400) of pregnancies, ranging from 94% (122/130) for British Cypriots to 54% (80/149) for British Pakistanis and from 90% in the south east of England to 39% in the West Midlands. Uptake of prenatal diagnosis was 80% (216/274), ranging from 98% (117/120) among British Cypriots in either the first or second trimester to 73% (35/48) among British Pakistanis in the first trimester and 39% (11/28) in the second trimester. A demonstrable service failure occurred in 28% (110/400) of pregnancies, including 110 of 126 where prenatal diagnosis was not offered and 48 of 93 that ended with an affected liveborn infant.

CONCLUSION

Although antenatal screening and counselling for haemoglobin disorders are standard practices in the United Kingdom, they are delivered inadequately and inequitably. An explicit national policy is needed, aiming to make prenatal diagnosis in the first trimester available to all couples and including ongoing national audit.

The role of the haemoglobinopathy nurse counsellor: an exploratory study

The haemoglobin disorders are among the most common genetically inherited conditions within the United Kingdom. Individuals who are fully affected have severely impaired health while carriers may be faced with difficult reproductive decisions although generally they are well. Policy makers agree that counselling for families at risk should be undertaken in primary care settings and since the early 1980s this service has been undertaken mainly by specialist haemoglobinopathy nurse counsellors. Despite a number of government reports and recommendations for best practice, problems with service provision continue to be highlighted. However, there is little documented information about the work undertaken by the counsellors or how they perceive their role. A descriptive study was therefore conducted to fill this gap. It took the form of a questionnaire survey undertaken with 26 counsellors. The results were analysed by content and used to develop an interview schedule which was employed to obtain more detailed information from staff in four centres. The counsellors suggested that most of their time was spent in client-centred activities and most clients were first seen antenatally. However, there were significant barriers which prevented optimal service provision. These included: problems of communication with other health professionals, obtaining laboratory results crucial to the early identification of couples at risk, late referral from general practitioners and poor facilities for administration, especially maintaining computer databases essential for record keeping. Developing and obtaining written information suitable for families was particularly time-consuming.

Neonatal screening for sickle cell disease

BACKGROUND

Sickle cell disease is an inherited disorder that occurs throughout the world with its highest incidence in areas of Africa where malaria is endemic. It affects up to one in 60 infants born in some areas of Africa. There are a number of potentially serious complications associated with the condition, and it is suggested that early treatment (before symptoms develop) can improve both morbidity and mortality. Screening for the condition in the neonatal period would enable early diagnosis and therefore early treatment.

OBJECTIVES

To assess whether there is evidence that neonatal screening for sickle cell disease rather than symptomatic diagnosis reduces adverse short and long term outcomes for those in whom the disease is detected, without adverse outcomes in the population screened.

SEARCH STRATEGY

We searched the Controlled Trials Register of the Cochrane Cystic Fibrosis and Genetic Disorders Group (See Group search strategy). Contact was made with experts in the field for any work as yet unpublished and reference lists of published studies were also searched. Date of the most recent search of the Group's specialised register: November 1999.

SELECTION CRITERIA

Any randomised or pseudorandomised trial, published or unpublished comparing diagnosis by screening to clinical diagnosis would have been considered eligible for inclusion.

DATA COLLECTION AND ANALYSIS

No trials of neonatal screening for sickle cell disease were found.

MAIN RESULTS

No trials of neonatal screening for sickle cell disease were found.

REVIEWER'S CONCLUSIONS

There is a lack of evidence from trials of neonatal screening for sickle cell disease. There is evidence of benefit from early treatment which is made possible by screening and there are a number of reviews and economic analyses of non-trial literature suggesting that screening is appropriate. Health care providers must therefore assess whether the information provided by these documents is relevant to their practice and situation when making decisions regarding neonatal screening for sickle cell disease. Systematic reviews of early treatments/interventions, including penicillin prophylaxis, pneumococcal vaccine and parental education should be considered.

Combined maternal and congenital myotonic dystrophy managed by a multidisciplinary team

Myotonic dystrophy is a rare autosomal dominant degenerative neuromuscular and neuroendocrine disease. Pregnancy can aggravate the maternal disease. Obstetrical complications include stillbirth, premature labor, polyhydramnion, abnormal presentation, prolonged labor, increased operative delivery, postpartum hemorrhages and anesthetic accidents. If the fetus is affected severe neonatal morbidity and mortality with arthrogryposis and mental retardation is common. We present a case where the family chose continuation of pregnancy with a known diagnosis of maternal and severe fetal myotonic dystrophy. A multidisciplinary team was used in the management of pregnancy and counseling the patient.