Practices and perceptions of long-term follow-up among state newborn screening programs

Defining the Minimal Long-Term Follow-Up Data Elements for Newborn Screening

Newborn screening (NBS) is hailed as a public health success, but little is known about the long-term outcomes following a positive newborn screen. There has been difficulty gathering long-term follow-up (LTFU) data consistently, reliably, and with minimal effort. Six programs developed and tested a core set of minimal LTFU data elements. After an iterative data collection process and the development of a data collection tool, the group agreed on the minimal LTFU data elements. The denominator captured all infants with an NBS diagnosis, accounting for children who moved or died prior to the follow-up year. They also agreed on three LTFU outcomes: if the child was still alive, had contact with a specialist, and received appropriate care specific to their diagnosis within the year. The six programs representing NBS public health programs, clinical providers, and research programs provided data across multiple NBS disorders. In 2022, 83.8% (563/672) of the children identified by the LTFU programs were alive and living in the jurisdiction; of those, 92.0% (518/563) saw a specialist, and 87.7% (494/563) received appropriate care. The core LTFU data elements can be applied as a foundation to address the impact of early diagnosis by NBS within and across jurisdictions.

Newborn screening data management: proposing a framework for Iran

Introduction

Different countries use a variety of methods to manage the newborn screening data. In this study, we aimed to compare the experiences of the selected countries to propose a framework for managing the newborn screening data in Iran.

Methods

In this comparative study, data were collected using electronic databases and the official website of the Department of Health in America, England and Australia. Data related to the process of newborn screening in Iran were collected using an open-ended questionnaire and reviewing the published documents.

Results

In this study, a framework for newborn screening data management was proposed which consisted of six main areas, namely; objectives, involved organisations, data elements, data collection processes, data classification systems and the methods of controlling data quality.

Conclusion

The framework suggested in this study can help to re-organise the process of newborn screening with more focus on data management. These data can be used in conducting research and setting strategies for improving the quality of child health in the country.

Follow-up status during the first 5 years of life for metabolic disorders on the federal Recommended Uniform Screening Panel

PURPOSE

To investigate the 5-year follow-up status for newborns diagnosed with metabolic disorders designated as "primary disorders" on the federal Recommended Uniform Screening Panel (RUSP).

METHODS

Follow-up status and demographic characteristics are described for 426 newborns diagnosed with one of 20 primary metabolic disorders on the RUSP between 2005 and 2009. Newborn screening program data were linked to birth certificate data. Follow-up status is described for each year through age 5 and by disorder type. Maternal characteristics of those who stayed in active care were compared with those who did not.

RESULTS

Of 426 diagnosed newborns, by the end of 5 years of follow-up 55.2% stayed in active care, 20.4% became lost to follow-up, 8.7% moved out of state, 6.3% were determined to require no further follow-up, 4.7% refused follow-up, and 4.7% died. Among the initial group of disorders with more than 10 diagnosed cases, phenylketonuria (90%) had the highest percentage of patients still in active care after 5 years. Patients in active care had similar characteristics to patients not in active care when maternal age, race/ethnicity, completed education years, and expected source of payment for delivery were compared.

CONCLUSION

Staying in active care may associate with disorder type but not maternal characteristics.

Newborn Screening Programs and Sickle Cell Disease: A Public Health Services and Systems Approach

INTRODUCTION

Despite universal newborn screening (NBS), children in the U.S. continue to experience morbidity and mortality from sickle cell disease and related causes. Recognizing that assessments of public health services and systems can improve public health system performance and ultimately health outcomes, this study examined variations in NBS program activities for sickle cell disease.

METHODS

A mixed methods study included (1) a 2009 survey of NBS programs based on ten essential public health services (N=39 states with ten or more sickle cell births over a 3-year period) and (2) key informant interviews in 2011 with 13 states that had sufficient Phase 1 survey scores, black births, and variability in state legislation and geography. Key informants were from 13 NBS programs, 22 sickle cell treatment centers, and ten advocacy organizations. Analyses were conducted in 2009-2014.

RESULTS

Considerable variability exists across states in program activities and roles. More programs reported activities oriented to care of individuals-ensuring access to services, coordination, and provider education; fewer reported planning and analysis activities oriented to statewide policy development and system change. Numbers of activities were not related to the number of affected births. In-depth interviews identified opportunities to enhance activities that support statewide comprehensive systems of care.

CONCLUSIONS

NBS programs perform important public health roles that complement and enhance clinical services. Nationwide efforts are needed to enable NBS programs to strengthen population-based functions that are essential to ensuring quality of care for the entire population of children and families affected by sickle cell disease.

Long-term follow-up of children with confirmed newborn screening disorders using record linkage

BACKGROUND

Long-term follow-up of children identified through newborn screening is a critical process of data collection and analysis for advancing the public health understanding of the health outcomes and service uptake of the affected children. This article describes first steps toward the long-term follow-up of newborn screening children with confirmed disorders through records linkage using population-based administrative data.

METHODS

The study cohort consisted of children born in 2006-2007 with confirmed disorders identified through newborn screening. Deterministic data linkage methods were used for record matching.

RESULTS

The cohort was followed up to 2 years after birth by matching to data sources including vital records, hospital discharges, the Congenital Malformations Registry, and Early Intervention to monitor service utilization, comorbidities, and mortality of the affected children. Of 1215 children with confirmed conditions identified through newborn screening, 25 deaths (2.1%) were identified, 86.1% used hospital (in- or outpatient) services, 36.1% were enrolled in the Congenital Malformations Registry, and 19.9% used the services of the Early Intervention program during the 2-year follow-up period.

CONCLUSIONS

Long-term follow-up of children with disorders identified through newborn screening can be initiated by using existing administrative data. This method is an inexpensive, cost-effective. and efficient approach for periodical assessment of services utilization, the efficiency of service delivery, and health outcomes for affected individuals.

Improving follow-up to newborn hearing screening: a learning-collaborative experience

Although approximately 95% of US newborns are now screened for hearing loss at birth, more than half of those who do not pass the screen lack a documented diagnosis. In an effort to improve the quality of the follow-up process, teams from 8 states participated in a breakthrough-series learning collaborative. Teams were trained in the Model for Improvement, a quality-improvement approach that entails setting clear aims, tracking results, identifying proven or promising change strategies, and the use of small-scale, rapid-cycle plan-do-study-act tests of these changes. Parents acted as equal partners with professionals in guiding system improvement. Teams identified promising change strategies including ensuring the correct identification of the primary care provider before discharge from the birthing hospital; obtaining a second contact number for each family before discharge; "scripting" the message given to families when an infant does not pass the initial screening test; and using a "roadmap for families" as a joint communication tool between parents and professionals to demonstrate each family's location on the "diagnostic journey." A learning-collaborative approach to quality improvement can be applied at a state-system level. Participants reported that the collaborative experience allowed them to move beyond a focus on improving their own service to improving connections between services and viewing themselves as part of a larger system of care. Ongoing quality-improvement efforts will require refinement of measures used to assess improvement, development of valid indicators of system performance, and an active role for families at all levels of system improvement.

Quality assurance in medical and public health genetics services: a systematic review

As genetic services grow in scope, issues of quality assessment in genetic services are emerging. These efforts are well developed for molecular and cytogenetic testing and laboratories, and newborn screening programs, but assessing quality in clinical services has lagged, perhaps owing to the small work force and the recent evolution from a few large training programs to multiple training sites. We surveyed the English language, peer-reviewed literature to summarize the knowledge-base of quality assessment of genetics services, organized into the tripartite categories of the Donabedian model of "structure," "process," and "outcome." MEDLINE searches from 1990 to July 2008, yielded 2,143 articles that addressed both "medical/genetic screening and counseling" and "quality indicators, control, and assurance." Of the 2,143 titles, 131 articles were extracted for in-depth analysis, and 55 were included in this review. Twenty-nine articles focused on structure, 19 on process, and seven on outcomes. Our review underscored the urgent need for a coherent model that will provide health care organizations with tools to assess, report, monitor, and improve quality. The structure, process, and outcomes domains that make up the quality framework provide a comprehensive lens through which to examine quality in medical genetics.

Ensuring the safe use of genomic medicine in children

Several clinical guidelines recommend that genetic testing in children be limited to tests with immediate clinical benefit. However, use of genome risk profiling will not likely meet this requirement, as the benefits are anticipated to be years away. Children who are at higher risk, though, will benefit the most from early initiation of treatment or interventions. The shift in benefit from immediate to long-term benefit warrants a reevaluation of the current practices of testing in children. In this commentary, the authors advocate the use of genomic risk profiling to identify children at increased risk who would benefit from early intervention, but recognize that its integration in clinical practice for this population will require a more nuanced approach to delivery and follow-up. In particular, the importance of counseling, context, consent, communication, and follow-up in the delivery of genomic risk testing to children and adolescents is highlighted.

Assuring clinical genetic services for newborns identified through U.S. newborn screening programs

PURPOSE

The study purpose was to determine whether U.S. newborn screening and/or genetics programs systematically document whether newborns and their families, identified with genetic disorders through newborn dried blood spot screening, receive clinical genetic services.

METHODS

Nineteen state genetic plans were reviewed and a 30-question survey was administered to 53 respondents, including state newborn screening program coordinators and state genetics program coordinators in 36 states and principal investigators of 5 Health Resources and Services Administration-designated regional genetic and newborn screening collaboratives.

RESULTS

Survey findings indicate that none of the state newborn screening and/or state genetics programs routinely tracked patient-level data on clinical genetic services for newborns identified with all of the genetic and congenital conditions for which their programs screened. Few programs could provide information systematically on whether patients were referred for, or received, genetic counseling.

CONCLUSIONS

Systematic tracking of clinical genetic services for newborns identified by newborn screening programs is desirable and manageable. Recent national guidelines recommend tracking genetic counseling in newborn screening follow-up. The communications processes that state programs currently use to obtain follow-up reports from subspecialists could be augmented with clinical genetic service questions. Programs should be encouraged and supported in the efforts to track genetic services for the benefit of newborns and their families.

Long-term follow-up culture in state newborn screening programs

PURPOSE

Long-term follow-up is an increasing focus as newborn screening expands in the United States. The present study informs this issue by examining the role played by organizational culture in shaping the scope and substance of long-term follow-up in state newborn screening programs.

METHODS

Qualitative interviews were conducted with 38 state newborn screening programs.

RESULTS

Several key cultural norms were identified within state newborn screening programs that may undermine proactive attempts to conduct long-term follow-up. These include (a) beliefs that place direct patient care and specialist care versus a public health orientation at the center of long-term follow-up; (b) an everyday emphasis on short-term follow-up that obscures the longer-term follow-up focus; and (c) the perception that others are engaged in long-term follow-up at the state level.

CONCLUSIONS

The findings support the importance of understanding state newborn screening program culture and how that culture may shape the scope and substance of long-term follow-up in a given state, regardless of the level of staff and resources made available to conduct these activities.

Structures for clinical follow-up: newborn screening

Clinical follow-up of children identified by newborn screening is critical in ensuring that the short-term and long-term needs of the newborn infant are managed. Within the United States, one of the biggest challenges in the newborn screening programme is clinical follow-up, and there still remains wide variation in practice patterns among states on how infants are followed up. In addition, there is lack of consistency in the treatment and diagnostic protocols used by health care providers. There is growing interest in the establishment of a systematic process for follow-up and for the development of a nationwide infrastructure that will ensure that all children will be provided consistent and effective treatment in a timely manner. Within this framework of optimal diagnosis and therapy, there must also be opportunities to study the natural history of these conditions, to monitor short- and long-term health outcomes, to assist with policy decision-making, to validate the effectiveness of screening, to define the clinical spectrum of the diseases, and to provide opportunities for the advancement of novel therapeutic interventions and screening/diagnostic technologies. It will only be through the development of a structured clinical follow-up system that we will be able to make certain these newborn infants are provided the most appropriate treatment for their disease variants and allow researchers to make more rapid advances in improving the clinical management of these conditions.

Randomized comparison of phone versus in-person BRCA1/2 predisposition genetic test result disclosure counseling

PURPOSE

This study evaluated whether phone results were equivalent to in-person result disclosure for individuals undergoing BRCA1/2 predisposition genetic testing.

METHODS

A total of 111 of 136 subjects undergoing education and counseling for BRCA1/2 predisposition genetic testing agreed to randomization to phone or in-person result disclosure. Content and format for both sessions were standardized. Data from the State-Trait Anxiety Inventory and the Psychological General Well-Being index were collected at baseline and then again at 1 week and 3 months after disclosure of test results. Baseline measures were administered after the following had occurred: counseling/education session had been conducted, informed consent had been obtained, and decision to be tested had been made. Satisfaction and cost assessments were administered after the result session. At 1 week, participants were asked their preferred method of result disclosure.

RESULTS

There were no differences in anxiety and general well-being measures between 50 phone and 52 in-person results disclosure. Both groups reported similar rates of satisfaction with services. Among those with a preference, 77% preferred the notification method assigned. There was a statistically significant preference for phone results among the 23% who did not prefer the method assigned. Greater costs were associated with in-person result disclosure.

CONCLUSIONS

These data suggest that phone results are a reasonable alternative to traditional in-person BRCA1/2 genetic test disclosure without any negative psychologic outcomes or compromise in knowledge. However, further study is needed in a more clinically representative population to confirm these findings.

Quality performance of newborn screening systems: strategies for improvement

Newborn metabolic screening is a public health activity with the potential to realize significant health gains for infants affected with a range of congenital conditions. Many of these are inborn errors of metabolism. The activities required to achieve the gains are diverse and carried out by a number of organizations, by families and by many health care professionals. Laboratories have the best-developed quality strategies, which include quality assurance programmes, guidelines, protocols and standards. Two-tier testing and use of multiple markers improve sensitivity and specificity. There are international initiatives to harmonize assay materials and definitions to allow better benchmarking between programmes. Outside the laboratory, standards, education and protocols improve the quality of specimen collection, diagnosis and treatment, which together produce the health gains.