Why patients do not attend for their appointments at a genetics clinic

Assessing the prevalence of unmet need for genetic counseling in Canada and exploring associations with sociodemographic factors

Understanding the prevalence and distribution of unmet need for genetic counseling (GC) can help inform health human resource planning. It is known that not all patients who could benefit from GC are currently accessing it, however, the prevalence of unmet need in Canada is unknown. Using a cross-sectional design, we surveyed 1160 Canadians to estimate the prevalence and distribution of unmet need for GC. The survey included measures of unmet need (NSGC Pathways Tool), personal utility (PrU), capability (ICECAP-A), distrust in healthcare (Revised Health Care System Distrust Scale) and demographic variables. A market research company (Leger Opinion Panel) was used for recruitment. We used descriptive statistics to estimate prevalence and multivariable regression to explore factors associated with unmet need. We found that 39% of respondents (457/1160) had unmet need for GC and 68% of this unmet need was unperceived. In the multivariable regression analysis, unmet need for GC was more likely in individuals who: had a mental health condition, were younger ( ≤ 45 yo), reported higher personal utility, and lower levels of capability (all p < 0.05 in multivariable analysis). There is a high prevalence of unmet need for GC in Canada and individuals experiencing other challenges to accessing healthcare may also be more likely to have unmet need for GC.

Factors Affecting Engagement in Screening Clinics; Exploring the Experiences of Patients with Rare Endocrine Gene Disorders

The aim was to explore the patient experience of those attending screening appointments for rare endocrine syndromes. Obtaining insights into the factors that potentially enhanced or detracted from attendance and engagement with the clinics could assist in developing strategies to promote patient engagement. A qualitative approach using semi-structured interviews was employed to understand individuals' perceptions and experience of the screening clinics. Twelve interviews were conducted with patients (age 10-66 years, purposive sampling). Four main themes were identified: (1) Perception at a distance, (2) Seeing my future self (3) The body and person in clinic and (4) The patient or doctor, who knows best? These highlighted several areas which could be used to inform approaches to promote enhanced patient engagement: the importance of careful management of projections of self, balancing information overload and honesty, interpersonal relationships and humanisation of care and assisting with the early navigation for the non-expert individual.

Predictors of Patient Return to a Tertiary Neurofibromatosis Subspecialty Clinic

OBJECTIVE

To evaluate sociodemographic and medical predictors of patient return to a neurofibromatosis subspecialty clinic.

STUDY DESIGN

Data were collected from the Washington University Neurofibromatosis Clinical Program electronic medical records. A total of 713 subjects with initial visits to the Washington University Neurofibromatosis Clinical Program between July 1, 2005 and December 18, 2020 were included. Variables collected included sex, race, ethnicity, age, date of first visit, place of residence, diagnosis, insurance payer, physician recommendation for return, and subject return. Return rates for each demographic group were calculated. Bivariate analyses were performed to inform variable inclusion in the model, and a binary logistic regression model was calculated to predict subject return.

RESULTS

The overall return rate was 76%. The binary logistic regression model was statistically significant (χ²₉ = 131.094; P < .001) and showed that subjects who self-identified as Black and/or African American, presented with or received a diagnosis of café-au-lait macules at their initial visit, were from a rural area, were older, or who lived farther from the Washington University Neurofibromatosis Clinical Program were less likely to return to clinic.

CONCLUSIONS

These findings support the implementation of tailored communication and monitoring interventions to improve the care for children with neurofibromatosis type 1.

Digital health-enabled genomics: Opportunities and challenges

Digital health solutions, with apps, virtual care, and electronic medical records, are gaining momentum across all medical disciplines, and their adoption has been accelerated, in part, by the COVID-19 pandemic. Personal wearables, sensors, and mobile technologies are increasingly being used to identify health risks and assist in diagnosis, treatment, and monitoring of health and disease. Genomics is a vanguard of digital healthcare as we witness a convergence of the fields of genomic and digital medicine. Spurred by the acute need to increase health literacy, empower patients' preference-sensitive decisions, or integrate vast amounts of complex genomic data into the clinical workflow, there has been an emergence of digital support tools in genomics-enabled care. We present three use cases that demonstrate the application of these converging technologies: digital genomics decision support tools, conversational chatbots to scale the genetic counseling process, and the digital delivery of comprehensive genetic services. These digital solutions are important to facilitate patient-centered care delivery, improve patient outcomes, and increase healthcare efficiencies in genomic medicine. Yet the development of these innovative digital genomic technologies also reveals strategic challenges that need to be addressed before genomic digital health can be broadly adopted. Alongside key evidentiary gaps in clinical and cost-effectiveness, there is a paucity of clinical guidelines, policy, and regulatory frameworks that incorporate digital health. We propose a research agenda, guided by learning healthcare systems, to realize the vision of digital health-enabled genomics to ensure its sustainable and equitable deployment in clinical care.

A qualitative study showing that a telecare tool can have benefits before and during the initial hearing assessment appointment

Objective: To examine patient and audiologist experiences and perspectives of using a patient-centred telecare tool, the Ida Institute's Why Improve My Hearing? (WIMH) Tool, before and during the initial hearing assessment appointment.Design: A qualitative study comprising individual semi-structured interviews using a maximum variation sampling strategy. The data were analysed using an established thematic analysis technique.Study sample: Fifteen participants, including ten patients (i.e. adults with hearing loss) and five audiologists, were recruited from Adult Audiology Services within the United Kingdom's publicly-funded National Health Service (NHS).Results: Three themes described the impact of using the WIMH Tool. Theme 1 (i.e. enhanced preparation before the appointment): the Tool helps patients to better understand and accept their hearing difficulties in advance of their first appointment. Theme 2 (i.e. enriched discussion during the appointment): the tool can enhance patient-centred communication, as well as the efficiency of the appointment. Theme 3 (i.e. varied impact on outcomes following the appointment): the Tool can improve patient motivation, readiness, and involvement in decision-making, though it may have limited impact on additional outcomes, such as adherence.Conclusion: The WIMH Tool can be successfully implemented in audiological practice, resulting in benefits before and during the initial hearing assessment appointment.

Dying to see you? Deaths on a clinical genetics waiting list in the Republic of Ireland; what are the consequences?

Attempts to put a value on a clinical genetic consultation are challenging as outcome measures are not easily quantified. One technique is to consider the negative consequences to a referred patient who is never seen. In order to estimate possible negative effects and by default the value of a genetics consultation; we sought to identify the consequences both to the proband, who died awaiting appointment, and their relatives. We audited 45 referrals to our service who died on our waiting list since 2008. Of these, 39/45 were new referrals, and the remainder, 6/45, died awaiting a follow up appointment. Relatives from 14/45 (31%) families have been counselled since the proband's death. We estimated a minimal total of 207 living first degree relatives to 45 probands. The majority (30/45) were referred for cancer risk estimation (1 predictive, 29 diagnostic), 11 developmental delay/dysmorphology referrals, 3 cardiac genetic referrals, (2 predictive testing, 1 segregation analysis) and 1 a referral for early onset dementia. The deaths of 17/45 cases were judged by us as having potentially significantly impacted the health of 76 first-degree relatives; 13/45 have potentially moderately impacted the health of 57 first-degree relatives; 12/45 posed a minimal impact to their relatives; and in 3/45 cases families were fully counselled. For each proband, significantly or moderately negatively impacted (n = 30), they have a minimum of 4.4 first-degree relatives, range 1-11, total = 133.

Associations of sociodemographic and clinical factors with gastrointestinal cancer risk assessment appointment completion

Cancer risk assessment services are important for patient care; effective use requires appropriate provider referral, accurate scheduling processes, and completed attendance at booked appointments. Sociodemographic and clinical factors associated with gastrointestinal cancer (GIC)-specific risk assessment appointments remain unstudied; therefore, we aimed to identify factors associated with appointment completion in a GIC risk assessment program at a tertiary academic center. Retrospective chart review was conducted on all patients scheduled for an appointment in the Gastrointestinal Cancer Risk Evaluation Program (GI-CREP) between January 2016 and December 2017. Data collected included demographic and clinical factors. Chi-square and Wilcoxon's rank-sum tests compared variables among patients based on the study outcome of whether a GI-CREP appointment was completed; marginal standardization was used to predict the standardized percentage of patients that had appointment completion. A total of 676 patients had a scheduled GI-CREP appointment; 32 individuals were excluded due to incomplete information or scheduling error, resulting in 644 patients available for final analysis. Our study population was predominantly female (61%), White (77%), and married (64%), had private healthcare insurance (76%), and lacked a personal history of cancer (60%). Referrals internal to the healthcare system were most common (77%), with gastroenterologists as the most frequent referring provider (42%). Seventy-five percent of scheduled individuals had appointment completion, while 25% of individuals did not. Independent predictors for an incomplete GI-CREP appointment included Medicaid insurance (OR 2.45, 95% CI 1.21-4.28, p = .01), self-identified Black race (OR 1.97, 95% CI: 1.20-3.25, p = .008), and personal history of cancer (OR 1.60, 95% CI 1.11-2.31, p = .01). These data highlight existing disparities in GIC risk assessment appointment completion associated with race, health insurance coverage, and medical status. Further studies of these areas are necessary to ensure equitable access to important GIC risk assessment services.

Addition of an online, validated family history questionnaire to the Dutch FIT-based screening programme did not improve its diagnostic yield

Background

Faecal immunochemical testing (FIT) is suboptimal in detecting advanced neoplasia (AN). To increase the sensitivity and yield of a FIT-based screening programme, FIT could be combined with risk factors for AN. We evaluated the incremental yield of adding a family history questionnaire (FHQ) on colorectal cancer (CRC) and Lynch syndrome-associated tumours to the Dutch FIT-based screening programme.

Methods

Six thousand screen-naive individuals, aged 59–75 years, were invited to complete a FIT (FOB-Gold, cut-off 47 µg Hb/g faeces) and a validated online FHQ. Participants with a positive FIT and/or positive FHQ, confirmed after genetic counselling, were referred for colonoscopy. Yield of detecting AN per 1000 invitees for the combined strategy was compared with the FIT-only strategy.

Results

Of the 5979 invitees, 1952 (32.6%) completed the FIT only, 2379 (39.8%) completed both the FIT and FHQ and 95 (1.6%) completed the FHQ only. Addition of the FHQ to FIT-based screening resulted in one extra case of AN detected after 16 additional colonoscopies, resulting in a yield of 19.6 (95% CI, 16.4–23.5) for the combined strategy versus 19.5 (95% CI, 16.3–23.3) for the FIT-only strategy (p = 1.0).

Conclusions

The addition of an FHQ to one round of FIT screening did not increase the detection of AN compared with FIT only (ClinicalTrials.gov NCT02698462).

Hearing aid review appointment: clients' reasons for attendance and non-attendance

Objective: To investigate hearing aid owners' decisions to attend or not to attend an annual hearing aid review (HAR) appointment. To investigate the possible factors associated with appointment attendance, including age, gender, transportation, travel time, and hearing aid outcomes.Design: A prospective cohort study. Potential participants were notified of their annual HAR appointment in the usual process employed by their clinic. Two months later, potential participants were identified as those who had attended and those who had not attended an appointment.Study sample: One hundred and twenty adult hearing aid users ranging in age from 26 to 100 (M = 74, SD = 11) years recruited from a single hearing clinic in Perth, Western Australia.Results: Factors found to be significantly associated with attendance at an annual HAR appointment included hearing aid funding source (government subsidised), participants valuing the importance and benefit of the appointment, and superior hearing aid outcomes.Conclusions: Within a controlled practice setting, appointment attendance is influenced by some factors modifiable by the clinician, including providing better education about the process and purpose of the HAR appointment. The value of the HAR appointment was emphasised by the positive association between better hearing aid outcomes HAR appointment attendance.

Mothers' Perceived Barriers to and Recommendations for Health Care Appointment Keeping for Children Who Have Cerebral Palsy

Children with cerebral palsy (CP) require ongoing rehabilitation services to address complex health care needs. Attendance at appointments ensures continuity of care and improves health and well-being. The study's aim was to gain insight into mothers' perspectives of the factors associated with nonattendance. A qualitative descriptive design was conducted to identify barriers and recommendations for appointment keeping. Semi-structured interviews were conducted with 15 mothers of children with CP. Data underwent inductive qualitative analysis. Mothers provided rich context regarding barriers confronted for appointment keeping-transportation and travel, competing priorities for the child and family, and health services. Mothers' recommendations for improving the experience of attending appointments included virtual care services, transportation support, multimethod scheduling and appointment reminders, extended service hours, and increased awareness among staff of family barriers to attendance. The results inform services/policy strategies to facilitate appointment keeping, thereby promoting access to ongoing rehabilitation services for children with CP.

Impact of Appointment Waiting Time on Attendance Rates at a Clinical Cancer Genetics Service

The increase in demand for clinical cancer genetics services has impacted the ability to provide services timeously. Given limited resources, this often results in extended appointment waiting times. Over the last 3 years, the Cancer Genetics Service at the National Cancer Centre Singapore has continued to experience a steady increase in demand for its service. Nevertheless, significant no-show rates have been reported. This study sought to determine whether an association exists between appointment waiting times and attendance rates. Data was gathered for all participants meeting inclusion criteria. Attendance rates and appointment waiting times were calculated. The relationship between mean waiting times for those who did and did not attend their scheduled appointments was evaluated using Welch's t test and linear regression model. The results showed a significant difference in mean appointment waiting times between patients who did and did not attend (32.66 versus 43.50 days respectively; p < 0.0001). Furthermore, patients who waited for longer than 37 days were significantly less likely to attend. No-show rates increased as the waiting time increased, at a rate of 19.60% per 20 days and 21.40% per 30 days. In conclusion, appointment waiting time is a significant predictor for patient attendance. Strategies to ensure patients receive an appointment within the necessary timeframe at the desired setting are important to ensure that individuals at increased cancer risk attend their appointments in order to manage their cancer risks effectively.

Success of referral to genetic counseling after positive lynch syndrome screening test

PURPOSE

Lynch syndrome (LS) is a hereditary condition that increases one's risk of developing colorectal, endometrial, and other extracolonic cancers. MD Anderson Cancer Center at Cooper implemented a reflex screening protocol for DNA mismatch repair (dMMR) deficiency. Those with findings suspicious for LS were referred for genetic counseling (GC). Our goal was to assess compliance with GC and factors associated with successful follow-up.

METHODS

Immunohistochemistry (IHC) for the MMR proteins MSH2, MLH1, MSH6, and PMS2 was performed on all colorectal tumor resections from patients ≤70 years old and all stage II cancers. Tumors with loss of MLH1/PMS2 were subsequently tested for BRAF mutation or MLH1 promoter methylation to identify tumors with likely epigenetic inactivation of MLH1. Patients with loss of MLH1/PMS2 without BRAF mutations or with absence of MLH1 promoter methylation and those with loss of MSH2/MSH6 were referred to GC. Compliance with GC was assessed.

RESULTS

Between March 2014 and August 2016, 203 tumors were tested by IHC. Fifteen (7.4%) patients had abnormal MMR protein expression patterns in the absence of BRAF mutation or MLH1 promoter methylation suggestive of possible LS. GC compliance was 35.7% overall and 85.7% in those with family history of LS-associated cancers.

CONCLUSIONS

Overall, GC compliance was relatively low in our study. Interestingly, patients with a strong family history of LS-associated neoplasms were more likely to pursue GC. In the future, assessing and addressing barriers to seeking GC will provide opportunities to improve patient care through increased identification of patients with cancer predisposition syndromes.

What Predicts the Use of Genetic Counseling Services After the Birth of a Child with Down Syndrome?

In the state of Victoria, Australia, a government funded genetic counseling service exists to meet the needs of families. An audit showed that many families do not use this service after the birth of a child with a genetic problem. To investigate this we surveyed families of children born with Down syndrome over 2 years in Victoria. Questionnaires were completed by 74 mothers, of whom only 18 had received genetic counseling between the birth and the time of the study (mean 3.5 years). Of those not receiving genetic counseling, 71% said they were not offered or had not heard of it. Mothers who had genetic counseling were younger than those who had not, and were more likely to have attended University. Those who had genetic counseling indicated less "satisfaction with care at the diagnosis" and were more likely to perceive their child as "unwell at birth" than those who were aware of genetic counseling but did not have it. Of those who did not have genetic counseling, over half were unclear about what it is, although 74% agreed with the statement "genetic counseling is most useful when planning to have another child." Of those who had heard of genetic counseling, 73% said they were not sure how it could help. Many families with children with Down syndrome are not aware of the existence or functions of genetic counseling. With greater awareness, some may still choose not to have genetic counseling, but others enunciated needs that could be met by this service if it were offered to them.

Can valid and practical risk-prediction or casemix adjustment models, including adjustment for comorbidity, be generated from English hospital administrative data (Hospital Episode Statistics)? A national observational study

Background

NHS hospitals collect a wealth of administrative data covering accident and emergency (A&E) department attendances, inpatient and day case activity, and outpatient appointments. Such data are increasingly being used to compare units and services, but adjusting for risk is difficult.

Objectives

To derive robust risk-adjustment models for various patient groups, including those admitted for heart failure (HF), acute myocardial infarction, colorectal and orthopaedic surgery, and outcomes adjusting for available patient factors such as comorbidity, using England’s Hospital Episode Statistics (HES) data. To assess if more sophisticated statistical methods based on machine learning such as artificial neural networks (ANNs) outperform traditional logistic regression (LR) for risk prediction. To update and assess for the NHS the Charlson index for comorbidity. To assess the usefulness of outpatient data for these models.

Main outcome measures

Mortality, readmission, return to theatre, outpatient non-attendance. For HF patients we considered various readmission measures such as diagnosis-specific and total within a year.

Methods

We systematically reviewed studies comparing two or more comorbidity indices. Logistic regression, ANNs, support vector machines and random forests were compared for mortality and readmission. Models were assessed using discrimination and calibration statistics. Competing risks proportional hazards regression and various count models were used for future admissions and bed-days.

Results

Our systematic review and empirical analysis suggested that for general purposes comorbidity is currently best described by the set of 30 Elixhauser comorbidities plus dementia. Model discrimination was often high for mortality and poor, or at best moderate, for other outcomes, for examplec = 0.62 for readmission andc = 0.73 for death following stroke. Calibration was often good for procedure groups but poorer for diagnosis groups, with overprediction of low risk a common cause. The machine learning methods we investigated offered little beyond LR for their greater complexity and implementation difficulties. For HF, some patient-level predictors differed by primary diagnosis of readmission but not by length of follow-up. Prior non-attendance at outpatient appointments was a useful, strong predictor of readmission. Hospital-level readmission rates for HF did not correlate with readmission rates for non-HF; hospital performance on national audit process measures largely correlated only with HF readmission rates.

Conclusions

Many practical risk-prediction or casemix adjustment models can be generated from HES data using LR, though an extra step is often required for accurate calibration. Including outpatient data in readmission models is useful. The three machine learning methods we assessed added little with these data. Readmission rates for HF patients should be divided by diagnosis on readmission when used for quality improvement.

Future work

As HES data continue to develop and improve in scope and accuracy, they can be used more, for instance A&E records. The return to theatre metric appears promising and could be extended to other index procedures and specialties. While our data did not warrant the testing of a larger number of machine learning methods, databases augmented with physiological and pathology information, for example, might benefit from methods such as boosted trees. Finally, one could apply the HF readmissions analysis to other chronic conditions.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Mobile telephone short message service reminders can reduce nonattendance in physical therapy outpatient clinics: a randomized controlled trial

OBJECTIVE

To investigate whether short message service (SMS) reminders reduce nonattendance in physical therapy outpatient clinics.

DESIGN

Prospective single-blinded randomized controlled trial.

SETTING

Two physical therapy outpatient departments in metropolitan acute public hospitals.

PARTICIPANTS

Participants with an appointment in a physical therapy outpatient clinic and who provided a contact mobile telephone number were included. Participants were excluded if their appointment was scheduled for the same day on which they made the appointment.

INTERVENTION

Participants allocated to the intervention group received an SMS reminder before their next appointment; participants allocated to the control group did not receive a reminder.

MAIN OUTCOME MEASURES

The primary outcome was rate of nonattendance without cancellation. Secondary outcomes were cancellation and attendance rates and exploration of other factors associated with nonattendance.

RESULTS

Patients (N=679) were allocated to receive either an SMS reminder (n=342) or no reminder (n=337). The nonattendance rate for patients who did not receive a reminder (16%) was more than nonattendance for patients receiving the SMS reminder (11%; odds ratio, 1.61; 95% confidence interval [CI], 1.03-2.51; number needed to treat, 19; 95% CI, 9-275). There were no differences in cancellation or attendance rates between groups. Exploration of other factors found that patients who were younger with a neck and trunk musculoskeletal or a neuromuscular disorder and who were scheduled to have an initial appointment or an appointment on a Monday or Friday were significantly predictive of increased nonattendance.

CONCLUSIONS

SMS reminders can reduce nonattendance in physical therapy outpatient clinics.

The use of family history questionnaires: an examination of genetic risk estimates and genetic testing eligibility in the non-responder population

The use of mailed family history questionnaires (FHQs) has previously been established to be an effective method for obtaining family history information for the triage of patients for genetic counseling and genetic testing of hereditary breast and ovarian cancer syndrome; yet only 53% of patients complete their FHQ within 6 months from the date of mailing (Armel et al. Journal of Genetic Counseling, 18(4):366-378, 2009). Although literature exists evaluating why women may not attend genetic counseling, no data are currently available examining genetic risk or genetic testing eligibility in the population of patients not returning their FHQ (non-responders). Concern exists that if non-responders are not followed-up for the purpose of triage for genetic counseling, individuals at high-risk for a hereditary cancer syndrome may be missed. This article explores the demographics of the non-responder population to assess genetic risk estimates for mutations in the BRCA1 and BRCA2 genes and genetic testing eligibility as compared to a responder population of patients who completed a mailed FHQ. A total of 430 pedigrees were obtained, 215 from non-responders and 215 from responders. Results of this study indicate that 69% of non-responders were either unreachable by telephone (42%), declined an appointment (19%), or were previously seen in another center for a genetic counseling visit (8%). Additionally, results indicate that non-responders are less likely to be eligible for genetic testing (40%) as compared to responders (57%) (p = 0.0004). Together these data shed light on a population of patients for which limited information exists and suggest that we question how and to what extent clinics should pursue non-responders, particularly in light of global reductions in health care funding.

Inequality of use of cancer genetics services by members of breast, ovarian and colorectal cancer families in South East Scotland

Some studies have found a deficiency of male, younger and more socially deprived individuals amongst referrals to and/or attendees at cancer genetics clinics. We investigated this inequality of use of genetics services from data on 4,178 Scottish patients with a family history of breast and/or ovarian cancer (BOC) or colorectal cancer (CRC) referred from 2000--2006. Some 98% BOC and 60% CRC referrals were female. Median age of female referrals was greater in the CRC than the BOC group (45.3 vs. 38.7 years, P < 0.001). Both groups of referrals were less socially deprived than the general population (P < 0.001) and the CRC less deprived than the BOC group (P < 0.001). Some 88% patients attended the first appointment offered. Attendance was greater in the CRC group (P < 0.001) and in older patients (P < 0.001) and in the BOC group was highly significantly lower in more socially deprived patients (P < 0.001). Male relatives may feel counselling is less relevant and relatives of both sexes may delay counselling until approaching the age of onset of cancer in a relative. We suggest that medical professionals and the general public may have more knowledge about the genetics of BOC than of CRC. Thus relatives in CRC families seeking counselling are likely to be those with access to more information. The lower attendance amongst more deprived relatives in BOC families may result from poor understanding of the reason for referral. These findings confirm the need to provide male, younger and more socially deprived relatives with more helpful information on cancer genetics.

Parental experience of a pediatric genetic referral

OBJECTIVE

To describe the experience of parents whose child has been referred for possible genetic diagnosis.

STUDY DESIGN AND METHODS

Phenomenology was used to examine the experience of 20 sets of parents. Interviews with parents were conducted on three occasions and the transcripts were subjected to coding and thematic analysis.

RESULTS

Four themes were found: (1) impact of the child's condition on the family, (2) parental needs and motivation related to the referral, (3) psychological outcome of the referral for parents, and (4) psychosocial needs of parents in relation to the referral. Parents reported much stress, fear, and anxiety. Parents were motivated to accept the genetics referral to obtain information that could enhance the child's care or education and/or assist the parents to adjust psychologically to the child's condition, but preparatory information about the process of the clinical encounter was lacking. One of the worst stressors for parents was waiting for results. Communication with the professionals while they were waiting would have been helpful to them, as would the support to facilitate acceptance and adjustment to the situation. The impact of the child's condition on the family was powerful, altering the way in which the entire family functioned. Guilt about being the cause of the child's condition was expressed by mothers.

CLINICAL IMPLICATIONS

Professional input before, during, and after the genetic referral is needed by families to enable them to access additional information, explanations, and psychological support. Nurses should know where to refer parents for community support groups as well as for professional support.

How do Obstetric Providers Discuss Referrals for Prenatal Genetic Counseling?

To investigate referrals of pregnant women to genetic counseling, we analysed transcripts from audiotaped first prenatal visits of 104 patients (72 actual patient visits and 32 simulated patient visits) with 32 providers (obstetricians and nurse-midwives). All patients had at least one indication for referral. Only 10% of visits with actual patients included a genetic counseling referral. When genetic counseling was discussed, it was only briefly described, primarily as an information session. This study shows that the majority of pregnant women with an indication for referral for genetic counseling are not referred. In addition, obstetric providers' inadequate descriptions of prenatal genetic counseling may result in women being poorly prepared for genetic counseling sessions.

Ethics and practice: two worlds? The example of genetic counselling

The aim of this paper is to work out the relationship between ethics and practice with reference to genetic counselling. First, the most important principles with respect to genetic counselling and to counsellor-client-interaction, are explained briefly. Then, we discuss what these principles might mean, when applied to the practice of counselling. To do so, we also look at some empirical data. Finally, we draw some conclusions.

Participation rates of Ashkenazi Jews in a colon cancer community-based screening/prevention study

In a recent colon cancer risk study, genetic assessment and colonoscopy were offered to virtually all of the adult Ashkenazi Jews in an urban community. The present study was designed to examine factors influencing participation and response in the initial study and to suggest strategies for improving participation in future health promotion programs. The study comprised a random sample of three groups of individuals who had been targeted for participation in the previous study: those who had (a) agreed to participate (n = 234); (b) declined participation (n = 179); and (c) failed to respond to a mailed recruitment package (n = 128). All participants completed a brief telephone survey. Key multivariate predictors of both response and participation were individuals' perceptions of the drawbacks of participating in colon cancer screening research and the degree of decisional conflict they experienced. Response was further predicted by the influence of spouses, family history of colon cancer, past knowledge of genetic testing for colon cancer, and education level. Participation was predicted by awareness that the study was supported by the Ashkenazi Jewish community, past experience with genetic testing, individuals' perceptions of the benefits of participating, and whether or not they had children. The degree to which individuals understand the purpose and nature of genetic screening research, along with their levels of decisional conflict and other psychosocial factors, may influence the likelihood of their participation in such research. Results of this study suggest a number of possible strategies for improving participation and response rates in disease prevention and detection studies.