Offering a choice between NIPT and invasive PND in prenatal genetic counseling: the impact of clinician characteristics on patients’ test uptake

Abstract

Testing options for pregnant women at increased risk of common aneuploidies are non-invasive prenatal testing (NIPT) and invasive prenatal diagnosis (PND). Clinicians are challenged to comprehensively discuss the complex information in a patient-centered and non-directive manner, to allow for patients' informed decision-making. This study explored the information-centeredness, patient-centeredness, and level of non-directivity of different clinicians and examined group differences between their patients. First, semi-structured interviews with four senior obstetricians and one senior nurse were held regarding their information provision, their adaptation of a patient-centered attitude, and their practice of nondirectivity. Interviews were transcribed verbatim and rated by four independent researchers. Secondly, 181 pregnant women were included in the study, of whom 82% opted for NIPT and 18% chose PND. Between clinicians, we assessed the distribution of choice ratios, patients' impression of clinicians' test preferences, and patients' knowledge scores. The results indicate that clinicians do not differ in their information-centeredness, but do differ in their patient-centeredness and their level of non-directivity. Significant differences in patients' NIPT/PND ratios were observed between clinicians, with the largest difference being 35 vs. 4% opting for invasive PND. Between 9 and 22% of the patients had an impression of their clinician's preference and chose in accordance with this preference. Patients' overall knowledge scores did not differ across clinicians. In conclusion, the differences in NIPT/PND ratios between clinicians indicate that clinicians' differing counseling approaches affect the choices their patients make. The interviews indicate a possible framing effect which may unintentionally steer the decision-making process.

Decision-making factors in prenatal testing: A systematic review

“…The studies examined show that non-invasive prenatal screening is the most chosen procedure when the sample includes women with low risk pregnancy or both low and high-risk pregnancy ( Bangsgaard and Tabor, 2013 ; Chan et al, 2014 ; Chen et al, 2018 ; Dahl et al, 2011a , 2011b ; Farrell et al, 2014 ; Fumagalli et al, 2018 ; Gil et al, 2015 ; Lo et al, 2019 ; Lund et al, 2018 ; Miltoft et al, 2018 ; Sahlin et al, 2016 ; Seven et al, 2017 ; van Schendel et al, 2015 ; Verweij et al, 2013 ). In studies with samples composed only of high-risk women, this trend is confirmed in favor of NIPT compared to invasive diagnosis ( Cheng et al, 2018, 2019 ; Lo et al, 2017 ; Schlaikjær-Hartwing et al, 2019 ; Seror et al, 2019 ; van der Steen et al, 2019 ; van Schendel et al, 2016 ; Watanabe et al, 2017 ). The couples’ preference for the use of the NIPT as a first-tier screen therefore clearly emerges.…”

“…Pre-test counseling characterized by clinicians’ patient-centeredness communication and non-directiveness, has been found to influence the test uptake ( van der Steen et al, 2019 ). For example, talking about the risk of miscarriage for an invasive procedure using words like “negligible” or “extremely small” encourages taking this test.…”

A Randomized Controlled Trial on the Influence of Prenatal Counseling on the Attitudes and Preferences Toward Invasive Prenatal Testing Among Women in Their First Trimester of Pregnancy (INVASIVE)

“…In Netherlands, where conventional Down syndrome screening had a low uptake (46%), a study showed that the introduction of cfDNA testing might allow couples to decide about prenatal testing based mostly on their will to test or not, rather than largely based on fear of miscarriage risk or the uncertainty of results ( Van Schendel et al, 2014 ). In another Dutch study, interviews performed in clinicians and pregnant women showed significant differences in cfDNA/invasive testing ratios after a high-risk result between women and clinicians, with the largest difference being 35 vs. 4% opting for invasive testing ( Van Der Steen et al, 2019 ). In an international study comparing the preferences on prenatal testing between women and health professionals, demonstrate that women assign a relatively higher value to test safety and having comprehensive information, while health professionals place more emphasis on accuracy and early testing than women do.…”

The factors affecting amniocentesis decision by pregnant women in the risk group and the influence of consultant

“…Since the rates of false negative results in terms of Down syndrome in particular are low, it has a potential to decrease the necessity of invasive procedure considerably. [10,11] Sentimental values, beliefs, cultural characteristics and customs are also significant for the invasive procedure decision of families. This is a matter affecting all clinicians in modern medicine practices in the world.…”