Prenatal Care Indices: How Useful?
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Among the non-invasive screening methods for the identification of fetal aneuploidy, NIPT (non-invasive prenatal testing) shows the highest sensitivity and specificity in high-risk pregnancies. Due to the low false positive rate of NIPT, it is assumed that the implementation of NIPT as a primary screening method may reduce the number of invasive fetal tests and result in a similar or lowered cost in the overall detection of Down syndrome. However, most previous studies are based on theoretical economic analysis. This study aims to determine the cost effectiveness of various prenatal test strategies, including NIPT, in real clinical settings in both low risk and high risk pregnancies. In this prospective observational study, women (< 24 weeks) with singleton or twin pregnancies will be enrolled in 12 different healthcare institutions. The participants will be grouped based on the risks of fetal chromosomal abnormalities and will be counseled on the various screening or diagnostic methods, including NIPT, according to the aneuploidy risk. The final decision on screening or diagnostic methods will be made by patients after counseling. Questionnaires regarding factors affecting the decision on prenatal test will be answered by the participants and physicians. The economic analysis on final total costs will be compared according to the various prenatal test strategies. The results of present study are expected to have a significant impact on national policies in determining Korean prenatal screening test strategies and to help in developing novel and effective prenatal screening tests in the future.
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Background: Noninvasive prenatal testing (NIPT) using cell-free fetal DNA is having a significant impact on the delivery of prenatal care. Our objective was to identify how pregnant women characterize the risks and benefits of this screening test and their preferences in order to guide an informed decision-making process about its use. Methods: We conducted focus groups with women who were either pregnant or recently postpartum who received outpatient prenatal care. A moderator guide was used to elicit participants’ perspectives on noninvasive prenatal testing. Results: Despite the low chance of a false positive result, this aspect of NIPT was a key determinant in participants’ decision making about the screening test. Participants discussed how many of the drawbacks and considerations associated with prenatal screening would remain intact regardless of the accuracy of a new approach to assess fetal health. Conclusions: NIPT affects how women think about risk not only in regard to prenatal genetic screening but also broadly in the context of pregnancy. The unique and appealing aspects of NIPT do not simplify women's decision-making processes or reduce the support they need to make choices that align with their needs and preferences.
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To use a decision-analytic model to assess a comprehensive set of outcomes of prenatal genetic testing strategies among women of varying ages.We assessed outcomes of six testing strategies incorporating diagnostic testing with chromosomal microarray, multiple marker screening, cell-free DNA screening, and nuchal translucency screening alone, in combination, or in sequence. Clinical outcomes included prenatal detection or birth of a neonate with a significant chromosomal abnormality and diagnostic procedures performed. Other outcomes included maternal quality-adjusted life-years and costs. Sensitivity analyses were conducted to examine the robustness of the findings.At all ages assessed, screening strategies starting with multiple marker screening offered the highest detection rate when all chromosomal abnormalities were considered. Incorporating cell-free DNA as an optional secondary screen decreased the number of diagnostic procedures, but also decreased the number of abnormalities diagnosed prenatally, resulting in a similar number of procedures per case diagnosed at age 30 years; the option of secondary cell-free DNA screening becomes more favorable at older ages. Multiple marker screening with optional follow-up diagnostic testing was the most effective (highest quality-adjusted life-years) and least expensive strategy at ages 20-38 years. At age 40 years or older, cell-free DNA screening was optimal with an incremental cost-effectiveness ratio of $73,154 per quality-adjusted life-year.When considering all detectable chromosome problems as well as patient preferences and baseline risks, multiple marker screening with the option of diagnostic testing for screen-positive results is the optimal strategy for most women. At age 40 years and older, cell-free DNA as a primary screen becomes optimal and is cost-effective.II.
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Studies indicating that prenatal care has minimal impact sparked additional work to assess whether this is a correct conclusion or a statistical artifact. Recent work highlights the importance of including medical diagnoses as regression variables, developing inclusive measures for health outcomes, and using providergenerated measures of prenatal care utilization. We explore these issues using administrative data provided by a tertiary care hospital and a prenatal care clinic. This data includes provider-generated utilization data, coded medical diagnoses, and variable direct costs for delivery-episode hospital care. Because all patients in this dataset obtained care from one set of providers in one urban area, the data set also minimizes heterogeneity due to variations in provider practice patterns and community services. We find that prenatal care exerts a significant beneficial impact on infant outcomes, and variable direct cost provides an inclusive outcomes measure when appropriate exogenous control variables are available. Estimated per-visit cost savings range from zero for patients with no diagnoses, to $10 for patients with one diagnosis, and $22 for patients with multiple diagnoses. The differences among these per-visit savings are significant, suggesting suboptimal allocation of clinic resources. Prenatal care utilization does not, however, increase with the number of diagnoses.
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Noninvasive prenatal testing (NIPT) will change the delivery of prenatal care for all women, including those considered low risk for fetal chromosomal abnormalities. This study investigated pregnant women's attitudes, informational needs, and decision-making preferences with respect to current and future applications of NIPT.A survey instrument was used to identify aspects of the decision-making process for NIPT among low-risk and high-risk populations.Both low-risk and high-risk women (n = 334) expressed interest in incorporating NIPT as a screening test into their prenatal care. Information specific to NIPT's detection rate (86%), indications (77%), and performance in comparison with conventional screens and diagnostic tests (63%) were identified as lead factors when considering its use. The future availability of NIPT as a diagnostic test increased women's willingness to undergo testing for fetal aneuploidy, cancer susceptibility, and childhood-onset and adult-onset diseases. Despite its noninvasive aspects, participants expressed the need for a formal informed consent process (71%) to take place before testing.This study demonstrates that NIPT will introduce new challenges for pregnant women and their health care practitioners who will be charged with supporting informed decision making about its use. It is critical that obstetric professionals are prepared to facilitate a patient-centered decision-making process as its clinical application rapidly changes.
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The objectives of this review include the conceptualization of the health-related quality of life effects of prenatal diagnosis and a brief summary of evidence on the short- and long-term effects of prenatal diagnosis on the health-related quality of life effects associated with chorionic villi sampling and genetic amniocentesis and the identification of important unresolved issues. Although this is not a systematic review, it is an update of published research on the utility approach to assessing the health-related quality of life in prenatal diagnosis. It is based on a search of publications by investigators known to be active in the area and a hand search of selected specialized journals. Important health states associated with prenatal diagnosis include both process (undergoing testing) and outcome. Empirical studies providing preference scores for health states associated with prenatal diagnosis highlight the importance of long-term outcomes relative to process. On average with respect to process, chorionic villi sampling is less burdensome than genetic amniocentesis. On average with respect to infrequent but potentially important outcomes as health states associated with diagnostic inaccuracy, genetic amniocentesis is less burdensome than chorionic villi sampling. Almost all of the existing evidence on the health-related quality of life effects of prenatal diagnosis reports on the experience of the women undergoing prenatal diagnosis. The preferences of partners have not been assessed. Furthermore, few studies have investigated subsequent reproductive behavior. Finally, there is considerable scope for the use of preference elicitation techniques in helping couples to decide on whether or not to undergo prenatal diagnosis and if they do, help them to choose the modality that best suites their preferences.
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Abstract Prenatal genetic screening should be an informed, autonomous patient choice. Extrinsic factors which influence patient decision‐making threaten the ethical basis of prenatal genetic screening. Prior research in the area of medical decision‐making has identified that labeling may have unanticipated effects on patient perceptions and decision‐making processes. This Internet‐administered study explored the impact of option labeling on the noninvasive prenatal screening (NIPS) selections of US adults. A total of 1,062 participants were recruited through Amazon Mechanical Turk (MTurk) and randomly assigned to one of three possible label sets reflecting provider‐derived and industry‐derived option labels used in prenatal screening. Multinomial logistic regression analysis showed option labeling had a statistically significant impact on the NIPS selections of study participants ( p = .0288). Outcomes of the Satisfaction with Decision Scale (SWD) indicated option labels did not play a role in participant satisfaction with screening selection. The results of this study indicate a need for further evaluation of the impact NIPS option labeling has on patient screening decisions in real‐world clinical interactions. Clinical providers and testing laboratories offering NIPS should give careful consideration to the option labels used with prenatal screening so as to minimize influence on patient screening selection and decision‐making processes.
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OBJECTIVE To analyze the willingness to accept prenatal screening for Down’s syndrome after the knowledge of prenatal screening for Down’s syndrome was educated. METHODS 1 416 women were investigated. Epidata2.0 and SPSS11.5 software were used to do data analysis. RESULTS 91.2% of our sample will accept the prenatal screening for Down’s syndrome. The main influencing factors of prenatal screening for Down’s syndrome utilization are health service information, economic condition. CONCLUSIONS To enhance prenatal screening for Down’s syndrome service utilization, measures such as improving prenatal screening propaganda, strengthening the prenatal screening service management should be introduced.
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