Disparities in Genetic Testing for Neurologic Disorders

Genetic counseling for adult-onset neurogenetic conditions in Hispanic/Latine communities: A qualitative study of barriers and facilitators from Hispanic/Latine genetic counselors' perspectives

Hispanic/Latine (H/Le) individuals, despite being at higher risk for certain adult-onset neurological conditions (AONCs) compared to non-Hispanic white individuals, experience delays in accessing neurologic health services and are significantly underrepresented in clinical research for conditions such as Alzheimer's disease and Parkinson's disease. While existing studies have highlighted barriers to genetic health services for H/Le groups, there is limited research on their experiences with adult-onset conditions beyond cancer. This study aimed to explore the perspectives of H/Le genetic counselors on factors that influence adult neurogenetic counseling (NGC) access for H/Le individuals, and suggestions for expanding access as subject matter experts of both genetic counseling and their respective communities. Using a constructivist paradigm, semi-structured interviews were conducted with six H/Le genetic counselors who have counseled H/Le patients on non-cancer adult-onset conditions, followed by iterative coding of interview transcripts. Codes were grouped into six overarching themes: (1) Participants described familial and personal reasons for pursuing evaluation for AONCs; (2) Barriers to pursuing evaluations for AONCs include limited health literacy, family communication patterns, cultural beliefs, and systemic factors; (3) H/Le patients experience challenges communicating with healthcare providers due to language or cultural expectations; (4) Healthcare providers have limited knowledge about genetics and genetic counseling; (5) Finances influenced access to adult NGC for H/Le communities; and (6) Suggested strategies to increase access to adult NGC. The clinical implications addressed in this study may contribute to ongoing efforts toward improving neurologic health outcomes for H/Le adults.

Disparities in the utilization of genetic testing for non-acquired infantile epileptic spasms syndrome in a single healthcare center in North Carolina

OBJECTIVE

To investigate disparities in the utilization of genetic sequencing among children with Infantile Epileptic Spasms Syndrome (IESS), a severe early-onset epilepsy where timely diagnosis and treatment are crucial for improving neurodevelopmental outcomes, previous studies have highlighted disparities in the evaluation and management of IESS. Genetic sequencing has emerged as a crucial tool in diagnosing unexplained epilepsies, offering precise etiological insights that can guide management. Despite guidelines recommending genetic sequencing for all unexplained epilepsies, little is known about how demographic and clinical factors influence the utilization of genetic sequencing in children with IESS.

METHODS

Retrospective cross-sectional cohort study, of 121 children diagnosed with IESS (2015-2020) within a single healthcare system. The primary outcome was the association between the utilization of genetic sequencing and demographic factors (race, ethnicity, language, rurality, and insurance status). Secondary outcomes included the utilization of genetic sequencing and its association with healthcare providers or clinical characteristics.

RESULTS

Genetic sequencing was performed in 64% (n = 74) of the patients with IESS. Race was significantly associated with the utilization of genetic sequencing, with non-Hispanic Black/African American children having significantly lower odds of undergoing genetic testing (OR = 0.19, 95% CI = 0.04-0.74, p = 0.02). No significant associations were found between language, rurality, or insurance status and the utilization of genetic sequencing. Notably, a low number of patients were from small towns and rural areas (7%). Clinical measures of seizure severity, including the presence of additional seizure types (p = 0.039) and the use of interventions in addition to standard IESS treatments (p = 0.01), were associated with higher rates of genetic sequencing.

SIGNIFICANCE

Non-Hispanic Black/African American children with IESS were less likely to undergo genetic sequencing. These findings underscore the need for evidence-based solutions addressing genetic sequencing utilization that may disproportionately impact children with IESS from medically underserved groups.

PLAIN LANGUAGE SUMMARY

This study looked at how genetic testing is used in children with Infantile Epileptic Spasms Syndrome (IESS), a serious type of epilepsy. The results showed that Black/African American children were much less likely to receive genetic testing compared to children of other racial groups, even though this testing is important for diagnosing and treating IESS. The study also found that only 7% of children in the study came from small towns or rural areas, suggesting that children in these areas may not have the same access to healthcare. These findings show the need for more research to understand and address gaps in genetic testing for children with IESS.

Association of Social Determinants of Health With Genetic Test Request and Completion Rates in Children With Neurologic Disorders

BACKGROUND AND OBJECTIVES

Genetic testing is critical for optimal diagnosis and management of pediatric neurology patients, but access is challenging. We investigated whether social determinants of health (SDOH) were associated with genetic testing among pediatric neurology patients in a retrospective observational study.

METHODS

Electronic health record data were extracted from pediatric outpatients (0-18 years) evaluated at a single tertiary care institution between July 2018 and January 2020. Genetic testing requests, insurance denials, and test completion rates were compared among non-Hispanic single-racial or multiracial Black (Black) vs non-Hispanic single-racial White (White) patients. SDOH and clinical variables including ethnoracial identity, insurance type, Area Deprivation Index, rural urban commuting area, sex, age, diagnoses, and number of neurology visits were evaluated to identify associations with chromosomal microarray (CMA), multigene panel (MGP), and exome/genome sequencing (ES/GS) test completion.

RESULTS

Of 11,371 patients (mean age 9.25 years; 46.1% female), 554 (4.9%) completed ≥1 genetic test in the study interval, with White patients nearly twice as likely to have completed ≥1 genetic test compared with Black patients (aOR 1.88, 95% CI 1.41-2.51). Outpatient pediatric neurology was the most common specialty through which testing was completed. Neurology provider request rates for genetic testing did not differ by patient ethnoracial identity, but insurance denial rates after neurology request were lower for White vs Black patients (relative rate ratio [RR] 0.44, 95% CI 0.27-0.73), and those with public insurance were less likely to complete genetic testing after it was requested through neurology (aOR 0.59, 95% CI 0.35-0.97). However, when considering individual genetic test types completed through any specialty, insurance type was significantly associated only with MGP completion (public vs private OR 0.56, 95% CI 0.40-0.77), not CMA or ES/GS.

DISCUSSION

Marked ethnoracial disparities in genetic testing completion were identified despite equivalent rates of genetic testing requests by neurologists. While Black patients had higher rates of insurance denials, insurance type itself accounted for the disparity in MGP but not CMA or ES/GS completion. Other unmeasured barriers stemming from systemic racism likely affected genetic testing among Black patients.

Disparities in Genetic Testing for Inborn Errors of Immunity

BACKGROUND

Inequities in genetic testing have been documented in a range of diseases, and no-charge genetic testing programs have been proposed as a means to enhance access. However, no studies have examined disparities in genetic testing for inborn errors of immunity (IEI) and the impact of no-charge programs on testing equity.

OBJECTIVE

To examine socioeconomic, geographic, and racial disparities in the uptake of genetic testing for IEI in the United States and the impact of a no-charge sponsored program on testing equity.

METHODS

This was a retrospective cohort analysis of (1) a national claims database capturing individuals with IEI (n = 18,603), and (2) data from a clinical genetic testing laboratory capturing patients with IEI participating in a no-charge sponsored program (n = 6,681) and a non-sponsored program (n = 29,579) for IEI genetic testing.

RESULTS

Among patients with IEI captured in the claims database, those residing in areas of greater deprivation (odds ratio [OR] = 0.95; 95% CI, 0.92-0.98), rural areas (OR = 0.82; 95% CI, 0.71-0.96), and non-White neighborhoods (OR = 0.89, 95% CI 0.81-0.98) were less likely to undergo genetic testing. Participants in the sponsored IEI genetic testing program lived in areas of greater deprivation compared with the non-sponsored program (median, 46 vs 42; P < .001). However, historically excluded racial groups were underrepresented in both the sponsored and non-sponsored programs relative to disease burden.

CONCLUSIONS

We found significant disparities in genetic testing for IEI. Although eliminating the financial barriers to testing reduced socioeconomic disparities in genetic testing for IEI, racial disparities persisted. Further research is needed to address barriers to testing among underserved populations.

Survey of the Landscape of Society Practice Guidelines for Genetic Testing of Neurodevelopmental Disorders

Genetic testing of patients with neurodevelopmental disabilities (NDDs) is critical for diagnosis, medical management, and access to precision therapies. Because genetic testing approaches evolve rapidly, professional society practice guidelines serve an essential role in guiding clinical care; however, several challenges exist regarding the creation and equitable implementation of these guidelines. In this scoping review, we assessed the current state of United States professional societies' guidelines pertaining to genetic testing for unexplained global developmental delay, intellectual disability, autism spectrum disorder, and cerebral palsy. We describe several identified shortcomings and argue the need for a unified, frequently updated, and easily-accessible cross-specialty society guideline. ANN NEUROL 2024;96:900-913.

Clinical Reasoning: A 26-Year-Old Woman With Chronic Progressive Gait Dysfunction

Careful evaluation of symptom progression and radiographic findings are essential tools when approaching cases of suspected chronic myelopathies. In this case, a 26-year-old woman presented with progressive ambulatory and bladder dysfunction for 4 years. Her examination was marked by bilateral lower-extremity upper motor neuron signs and distal large-fiber sensory loss. Neurologic workup for acquired causes of this presentation was unrevealing. MRI of the brain revealed a characteristic radiologic finding. Guided genetic testing ultimately yielded the final diagnosis. In this clinical vignette, we review the approach to chronic myelopathy including consideration of genetic etiologies and pursuit of targeted gene testing. We further discuss the typical clinical and radiographic findings of a rare diagnosis.

Protocol for a type 3 hybrid implementation cluster randomized clinical trial to evaluate the effect of patient and clinician nudges to advance the use of genomic medicine across a diverse health system

BACKGROUND

Germline genetic testing is recommended for an increasing number of conditions with underlying genetic etiologies, the results of which impact medical management. However, genetic testing is underutilized in clinics due to system, clinician, and patient level barriers. Behavioral economics provides a framework to create implementation strategies, such as nudges, to address these multi-level barriers and increase the uptake of genetic testing for conditions where the results impact medical management.

METHODS

Patients meeting eligibility for germline genetic testing for a group of conditions will be identified using electronic phenotyping algorithms. A pragmatic, type 3 hybrid cluster randomization study will test nudges to patients and/or clinicians, or neither. Clinicians who receive nudges will be prompted to either refer their patient to genetics or order genetic testing themselves. We will use rapid cycle approaches informed by clinician and patient experiences, health equity, and behavioral economics to optimize these nudges before trial initiation. The primary implementation outcome is uptake of germline genetic testing for the pre-selected health conditions. Patient data collected through the electronic health record (e.g. demographics, geocoded address) will be examined as moderators of the effect of nudges.

DISCUSSION

This study will be one of the first randomized trials to examine the effects of patient- and clinician-directed nudges informed by behavioral economics on uptake of genetic testing. The pragmatic design will facilitate a large and diverse patient sample, allow for the assessment of genetic testing uptake, and provide comparison of the effect of different nudge combinations. This trial also involves optimization of patient identification, test selection, ordering, and result reporting in an electronic health record-based infrastructure to further address clinician-level barriers to utilizing genomic medicine. The findings may help determine the impact of low-cost, sustainable implementation strategies that can be integrated into health care systems to improve the use of genomic medicine.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT06377033. Registered on March 31, 2024. https://clinicaltrials.gov/study/NCT06377033?term=NCT06377033&rank=1.