Randomised controlled trial of a brief intervention targeting predominantly non-verbal communication in general practice consultations

Background

The impact of changing non-verbal consultation behaviours is unknown.

Aim

To assess brief physician training on improving predominantly non-verbal communication.

Design and setting

Cluster randomised parallel group trial among adults aged ≥16 years attending general practices close to the study coordinating centres in Southampton.

Method

Sixteen GPs were randomised to no training, or training consisting of a brief presentation of behaviours identified from a prior study (acronym KEPe Warm: demonstrating Knowledge of the patient; Encouraging [back-channelling by saying ‘hmm’, for example]; Physically engaging [touch, gestures, slight lean]; Warm-up: cool/professional initially, warming up, avoiding distancing or non-verbal cut-offs at the end of the consultation); and encouragement to reflect on videos of their consultation. Outcomes were the Medical Interview Satisfaction Scale (MISS) mean item score (1–7) and patients’ perceptions of other domains of communication.

Results

Intervention participants scored higher MISS overall (0.23, 95% confidence interval [CI] = 0.06 to 0.41), with the largest changes in the distress–relief and perceived relationship subscales. Significant improvement occurred in perceived communication/partnership (0.29, 95% CI = 0.09 to 0.49) and health promotion (0.26, 95% CI = 0.05 to 0.46). Non-significant improvements occurred in perceptions of a personal relationship, a positive approach, and understanding the effects of the illness on life.

Conclusion

Brief training of GPs in predominantly non-verbal communication in the consultation and reflection on consultation videotapes improves patients’ perceptions of satisfaction, distress, a partnership approach, and health promotion.     

Appropriateness of antidepressant prescribing: an observational study in a Scottish primary-care setting

Background

Since the 1990s, Scottish community-based antidepressant prescribing has increased substantially.

Aim

To assess whether GPs prescribe antidepressants appropriately.

Design of study

Observational study of adults (aged ≥16 years) screened with the Hospital Anxiety and Depression Scale (HADS) attending a GP.

Setting

Four practices in Grampian, Scotland.

Method

Patients (n = 898) completed the HADS, and GPs independently estimated depression status. Notes were scrutinised for evidence of antidepressant use, and the appropriateness of prescribing was assessed.

Results

A total of 237 (26%) participants had HADS scores indicating ‘possible’ (15%) or ‘probable’ (11%) depression. The proportion of participants rated as depressed by their GP differed significantly by HADS depression subscale scores. Odds ratio for ‘possible’ versus ‘no’ depression was 3.54 (95% confidence interval [CI] = 2.17 to 5.76, P<0.001); and for ‘probable’ versus ‘possible’ depression was 3.59 (95% CI = 2.06 to 6.26, P<0.001). Similarly, the proportion of participants receiving antidepressants differed significantly by HADS score. Odds ratio for ‘possible’ versus ‘no’ depression was 2.79 (95% CI = 1.70 to 4.58, P<0.001); and for ‘probable’ versus ‘possible’ was 2.12 (95% CI = 1.21 to 3.70, P = 0.009). In 101 participants with ‘probable’ depression, GPs recognised 53 (52%) participants as having a clinically significant depression. Inappropriate initiation of antidepressant treatment occurred very infrequently. Prescribing to participants who were not symptomatic was accounted for by the treatment of pain, anxiety, or relapse prevention, and for ongoing treatment of previously identified depression.

Conclusion

There was little evidence of prescribing without relevant indication. Around half of patients with significant symptoms were not identified by their GP as suffering from a depressive disorder: this varied inversely with severity ratings. Rather than prescribing indiscriminately (as has been widely assumed), it is likely that GPs are initiating antidepressant treatment conservatively.     

Case finding for chronic obstructive pulmonary disease in primary care: a pilot randomised controlled trial

Background

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. However, much of the disease burden remains undiagnosed.

Aim

To compare the yield and cost effectiveness of two COPD case-finding approaches in primary care.

Design and setting

Pilot randomised controlled trial in two general practices in the West Midlands, UK.

Method

A total of 1634 ever-smokers aged 35–79 years with no history of COPD or asthma were randomised into either a ‘targeted’ or ‘opportunistic’ case-finding arm. Respiratory questionnaires were posted to patients in the ‘targeted’ arm and provided to patients in the ‘opportunistic’ arm at routine GP appointments. Those reporting at least one chronic respiratory symptom were invited for spirometry. COPD was defined as pre-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC)<0.7 and FEV1<80% of predicted. Primary outcomes were the difference in the proportion of patients diagnosed with COPD and the cost per case detected.

Results

Twenty-six per cent (212/815) in the ‘targeted’ and 13.6% (111/819) in the ‘opportunistic’ arm responded to the questionnaire and 78.3% (166/212) and 73.0% (81/111), respectively, reported symptoms; 1.2% (10/815) and 0.7% (6/819) of patients in the ‘targeted’ and ‘opportunistic’ arms were diagnosed with COPD (difference in proportions = 0.5% [95% confidence interval {CI} = –0.5% to 3.08%]). Over a 12-month period, the ‘opportunistic’ case-finding yield could be improved to 1.95% (95% CI = 1.0% to 2.9%). The cost-per case detected was £424.56 in the ‘targeted’ and £242.20 in the ‘opportunistic’ arm.

Conclusion

Opportunistic case finding may be more effective and cost effective than targeting patients with a postal questionnaire alone. A larger randomised controlled trial with adequate sample size is required to test this.     

Identification of UK sickness certification rates,standardised for age and sex

Background

There is growing interest in tackling the perceived ‘sick note’ culture in the UK.

Aim

The aim of this paper was to report the rates of sickness certification in a UK population, using sick certification rates as a precursor to addressing fitness for work.

Method

Electronic records from all 14 practices included in the Keele GP Research Network were reviewed; all sickness certification records from 2005 were retrieved and corresponding consultation records were examined. Participants were 148 176 patients registered during 2005, including 6398 patients who received at least one sickness certificate during the same year.

Results

The rate of sickness certification was 101.67 certificates per 1000 person years (95% confidence interval [CI] = 100.13 to 103.21). This rate was significantly higher in women, at 109.76 certificates per 1000 person years (95% CI = 107.550 to 112.02), compared to men who had a rate of 93.68 certificates per 1000 person years (95% CI = 91.59 to 95.78; P<0.001). The rate of sickness certification was greatest for mental health conditions, followed closely by musculoskeletal conditions.

Conclusion

On average, one in 10 patients will receive a sickness certificate each year, with the highest rates occurring around 50 years of age, in women. Mental health and musculoskeletal conditions were associated with the highest rates of certification. These results provide important information to underpin the national ‘Fit for Work’ scheme, by providing targets for intervention and a benchmark against which the impact of public health initiatives to reduce certified sickness absence due to health conditions can be evaluated and monitored.     

Predicting prolonged duration of fever in children: a cohort study in primary care

Background

Fever in children in primary care is commonly caused by benign infections, but often worries parents. Information about the duration of fever and its predictors may help in reassuring parents, leading to diminished consultation of health care.

Aim

To determine which signs and symptoms predict a prolonged duration of fever in febrile children in primary care and evaluate whether C-reactive protein (CRP) measurement has an additive predictive value for these symptoms.

Design and setting

A prospective cohort study at a GPs’ cooperative (GPC) out-of-hours service.

Method

Children (aged 3 months to 6 years) presenting with fever as stated by the parents were included. Exclusion criteria were no communication in Dutch possible, previous enrolment in the study within 2 weeks, referral to the hospital directly after visiting the GPC, or no informed consent. The main outcome measure was prolonged duration of fever (>3 days) after initial contact.

Results

Four-hundred and eighty children were analysed, and the overall risk of prolonged duration was 13% (63/480). Multivariate analysis combined model of patient history and physical examination showed that ‘sore throat’ (OR 2.8; 95% CI = 1.30 to 6.01) and ‘lymph nodes palpable’ (OR 1.87; 95% CI = 1.01 to 3.49) are predictive for prolonged duration of fever. The discriminative value of the model was low (AUC 0.64). CRP had no additive value in the prediction of prolonged duration of fever (OR 1.00; 95% CI = 0.99 to 1.01).

Conclusion

The derived prediction model indicates that only a few signs and symptoms are related to prolonged duration of fever. CRP has no additional value in this model. Overall, because the discriminative value of the model was low, the duration of fever cannot be accurately predicted.     

Touch in primary care consultations: qualitative investigation of doctors’ and patients’ perceptions

Background

Good communication skills are integral to successful doctor–patient relationships. Communication may be verbal or non-verbal, and touch is a significant component, which has received little attention in the primary care literature. Touch may be procedural (part of a clinical task) or expressive (contact unrelated to a procedure/examination).

Aim

To explore GPs’ and patients’ experiences of using touch in consultations.

Design and setting

Qualitative study in urban and semi-rural areas of north-west England.

Method

Participating GPs recruited registered patients with whom they felt they had an ongoing relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.

Results

All participants described the importance of verbal and non-verbal communication in developing relationships. Expressive touch was suggested to improve communication quality by most GPs and all patients. GPs reported a lower threshold for using touch with older patients or those who were bereaved, and with patients of the same sex as themselves. All patient responders felt touch on the hand or forearm was appropriate. GPs described limits to using touch, with some responders rarely using anything other than procedural touch. In contrast, most patient responders believed expressive touch was acceptable, especially in situations of distress. All GP responders feared misinterpretation in their use of touch, but patients were keen that these concerns should not prevent doctors using expressive touch in consultations.

Conclusion

Expressive touch improves interactions between GPs and patients. Increased educational emphasis on the conscious use of expressive touch would enhance clinical communication and, hence, perhaps patient wellbeing and care.     

Doctors record higher blood pressures than nurses: systematic review and meta-analysis

Background

The magnitude of the ‘white coat effect’, the alerting rise in blood pressure, is greater for doctors than nurses. This could bias interpretation of studies on nurse-led care in hypertension, and risks overestimating or overtreating high blood pressure by doctors in clinical practice.

Aim

To quantify differences between blood pressure measurements made by doctors and nurses.

Design and setting

Systematic review and meta-analysis using searches of MEDLINE, CENTRAL, CINAHL, Embase, journal collections, and conference abstracts.

Method

Studies in adults reporting mean blood pressures measured by doctors and nurses at the same visit were selected, and mean blood pressures extracted, by two reviewers. Study risk of bias was assessed using modified Cochrane criteria. Outcomes were pooled across studies using random effects meta-analysis.

Results

In total, 15 studies (11 hypertensive; four mixed hypertensive and normotensive populations) were included from 1899 unique citations. Compared with doctors’ measurements, nurse-measured blood pressures were lower (weighted mean differences: systolic −7.0 [95% confidence interval {CI} = −4.7 to −9.2] mmHg, diastolic −3.8 [95% CI = −2.2 to −5.4] mmHg). For studies at low risk of bias, differences were lower: systolic −4.6 (95% CI = −1.9 to −7.3) mmHg; diastolic −1.7 (95% CI = −0.1 to −3.2) mmHg. White coat hypertension was diagnosed more frequently based on doctors’ than on nurses’ readings: relative risk 1.6 (95% CI =1.2 to 2.1).

Conclusions

The white coat effect is smaller for blood pressure measurements made by nurses than by doctors. This systematic difference has implications for hypertension diagnosis and management. Caution is required in pooling data from studies using both nurse- and doctor-measured blood pressures.     

Diagnosing headache in primary care: a qualitative study of GPs’ approaches

Background

Headache is one of the most common symptoms in primary care. Most headaches are due to primary headaches and many headache sufferers do not receive a specific diagnosis. There is still a gap in research on how GPs diagnose and treat patients with headache.

Aim

To identify GPs’ diagnostic approaches in patients presenting with headache.

Design and setting

Qualitative study with 15 GPs in urban and rural practices.

Method

Interviews (20–40 minutes) were conducted using a semi-structured interview guideline. GPs described their individual diagnostic strategies by means of patients presenting with headache that they had prospectively identified during the previous 4 weeks. Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters.

Results

Regarding GPs’ general diagnostic approach to patients with headache, four broad themes emerged during the interviews: ‘knowing the patient and their background’, ‘first impression during consultation’, ‘intuition and personal experience’ and ‘application of the test of time’. Four further themes were identified regarding the management of diagnostic uncertainty: ‘identification of red flags’, ‘use of the familiarity heuristic’, ‘therapeutic trial’, and ‘triggers for patient referral’.

Conclusion

GPs apply different strategies in the early diagnostic phase when managing patients with headache. Identification of potential adverse outcomes accompanied by other strategies for handling uncertainty seem to be more important than an exact diagnosis. Established guidelines do not play a role in the diagnostic workup.     

Patients’ assessments of the continuity of primary care in Finland: a 15-year follow-up questionnaire survey

Background

Continuity of care is an essential aspect of quality in general practice. This study is the first systematic follow-up of Finnish primary care patients’ assessments with regard to personal continuity of care.

Aim

To ascertain whether patient-reported longitudinal personal continuity of care is related to patient characteristics and their consultation experiences, and how this had changed over the study period.

Design and setting

A 15-year follow-up questionnaire survey that took place at Tampere University Hospital catchment area, Finland.

Method

The survey was conducted among patients attending health centres in the Tampere University Hospital catchment area from 1998 until 2013. From a sample of 363 464 patients, a total of 157 549 responded. The responses of patients who had visited a doctor during the survey weeks (n = 97 468) were analysed. Continuity of care was assessed by asking the question: ‘When visiting the health centre, do you usually see the same doctor?’; patients could answer ‘yes’ or ‘no’.

Results

Approximately half of the responders had met the same doctor when visiting the healthcare centre. Personal continuity of care decreased by 15 percentage points (from 66% to 51%) during the study years. The sense of continuity was linked to several patients’ experiences of the consultation. The most prominent factor contributing to the sense of continuity of care was having a doctor who was specifically appointed (odds ratio 7.28, 95% confidence interval = 6.65 to 7.96).

Conclusion

Continuity of care was proven to enhance the experienced quality of primary care. Patients felt that continuity of care was best realised when they could consult a doctor who had been specifically appointed to them. Despite efforts of the authorities, over the past 15 years patient-reported continuity of care has declined in Finland.     

What happens when doctors are patients? Qualitative study of GPs

Background

Current evidence about the experiences of doctors who are unwell is limited to poor quality data.

Aim

To investigate GPs'' experiences of significant illness, and how this affects their own subsequent practice.

Design of study

Qualitative study using interpretative phenomenological analysis to conduct and analyse semi-structured interviews with GPs who have experienced significant illness.

Setting

Two primary care trusts in the West of England.

Method

A total of 17 GPs were recruited to take part in semi-structured interviews which were conducted and analysed using interpretative phenomenological analysis

Results

Four main categories emerged from the data. The category, ‘Who cares when doctors are ill?’ embodies the tension between perceptions of medicine as a ‘caring profession’ and as a ‘system’. ‘Being a doctor–patient’ covers the role ambiguity experienced by doctors who experience significant illness. The category ‘Treating doctor–patients’ reveals the fragility of negotiating shared medical care. ‘Impact on practice’ highlights ways in which personal illness can inform GPs'' understanding of being a patient and their own consultation style.

Conclusion

Challenging the culture of immunity to illness among GPs may require interventions at both individual and organisational levels. Training and development of doctors should include opportunities to consider personal health issues as well as how to cope with role ambiguity when being a patient and when treating doctor–patients. Guidelines about being and treating doctor–patients need to be developed, and GPs need easy access to an occupational health service.     

Patients' perceptions of GP non-verbal communication: a qualitative study

Background

During doctor–patient interactions, many messages are transmitted without words, through non-verbal communication.

Aim

To elucidate the types of non-verbal behaviours perceived by patients interacting with family GPs and to determine which cues are perceived most frequently.

Design of study

In-depth interviews with patients of family GPs.

Setting

Nine family practices in different regions of Poland.

Method

At each practice site, interviews were performed with four patients who were scheduled consecutively to see their family doctor.

Results

Twenty-four of 36 studied patients spontaneously perceived non-verbal behaviours of the family GP during patient–doctor encounters. They reported a total of 48 non-verbal cues. The most frequent features were tone of voice, eye contact, and facial expressions. Less frequent were examination room characteristics, touch, interpersonal distance, GP clothing, gestures, and posture.

Conclusion

Non-verbal communication is an important factor by which patients spontaneously describe and evaluate their interactions with a GP. Family GPs should be trained to better understand and monitor their own non-verbal behaviours towards patients.     

Chest pain for coronary heart disease in general practice: clinical judgement and a clinical decision rule

Background

The Marburg Heart Score (MHS) is a simple, valid, and robust clinical decision rule assisting GPs in ruling out coronary heart disease (CHD) in patients presenting with chest pain.

Aim

To investigate whether using the rule adds to the GP’s clinical judgement.

Design and setting

A comparative diagnostic accuracy study was conducted using data from 832 consecutive patients with chest pain in general practice.

Method

Three diagnostic strategies were defined using the MHS: diagnosis based solely on the MHS; using the MHS as a triage test; and GP’s clinical judgement aided by the MHS. Their accuracy was compared with the GPs’ unaided clinical judgement.

Results

Sensitivity and specificity of the GPs’ unaided clinical judgement was 82.9% (95% confidence interval [CI] = 72.4 to 89.9) and 61.0% (95% CI = 56.7 to 65.2), respectively. In comparison, the sensitivity of the MHS was higher (difference 8.5%, 95% CI = −2.4 to 19.6) and the specificity was similar (difference −0.4%, 95% CI = −5.3 to 4.5); the sensitivity of the triage was similar (difference −1.5%, 95% CI = −9.8 to 7.0) and the specificity was higher (difference 11.6%, 95% CI = 7.8 to 15.4); and both the sensitivity and specificity of the aided clinical judgement were higher (difference 8.0%, 95% CI = −6.9 to 23.0 and 5.8%, 95% CI = −1.6 to 13.2, respectively).

Conclusion

Using the Marburg Heart Score for initial triage can improve the clinical diagnosis of CHD in general practice.     

Exploring the impact of patient views on ‘appropriate’ use of services and help seeking: a mixed method study

Background

There are commonly-held views relating to what constitutes appropriate and inappropriate use of finite NHS resources. However, very little is known about how and why such views have an impact on consultation patterns.

Aim

To quantify the prevalence of opinion on whether people use health services unnecessarily within primary care and accident and emergency (A&E) in order to examine the impact of these views on help-seeking behaviour.

Design of study

A mixed method study utilising cross-sectional questionnaire survey and semi-structured interviews.

Setting

A primary care practice in South West England, UK.

Method

Responders to the questionnaire survey were drawn from a random sample of individuals, stratified by sex, selected from one practice in the UK (n = 911). The qualitative sample (n = 22) were purposefully selected from the same general practice.

Results

The quantitative data suggest that the majority of people believe individuals utilise either GP or A&E services inappropriately (65.6%; 95% confidence interval [CI] = 62.4 to 68.7). However, strong views relating to this inappropriate healthcare use were not associated with reported seeking of immediate care (odds ratio [OR] = 0.98, 95% CI = 0.66 to 1.46 for ‘lump’ vignette). Responders tend to consider other people as time wasters, but not themselves. Individuals'' generally describe clear rationales for help seeking, even for seemingly trivial symptoms and anxiety level was strongly predictive of health-seeking behaviour (OR = 2.88; 95% CI = 1.98 to 4.19 for lump vignette).

Conclusion

Perceptions that individuals'' use health services inappropriately are unlikely to explain differences in help-seeking behaviours. The findings suggest that people do not take the decision to consult health services lightly and rationalise why their behaviour is not time wasting.     

GPs’ responses to adolescents presenting with psychological difficulties: a conceptual model of fixers,future planners,and collaborators

Background

Psychological difficulties are common in adolescents yet are not often addressed by GPs. Anxiety and uncertainty about professional practice, with a reluctance to medicalise distress, have been found among GPs. GP involvement in this clinical area has been shown to be influenced by how GPs respond to the challenges of the clinical consultation, how they view young people and their perception of their health needs, and a GP’s knowledge framework.

Aim

To explore the relationship between the above three influences to develop an overarching conceptual model.

Design and setting

Qualitative study based in 18 practices in the north east of England. The practices recruited included rural, urban, and mixed populations of patients predominantly living in socioeconomically disadvantaged communities.

Method

Theoretical sampling was used to guide recruitment of GP participants continuing until theoretical saturation was reached. Data were analysed using the constant comparative method of grounded theory and situational analysis.

Results

In total 19 GPs were recruited: 10 were female, the age range was 29–59 years, with a modal range of 40–49 years. Three levels of analysis were undertaken. This study presents the final stage of analysis. GP ‘enactment of role’ was found to be the key to explaining the relationship between the three influencing factors. Three role archetypes were supported by the data: ‘fixers’, ‘future planners’, and ‘collaborators’.

Conclusion

The role of GPs in managing adolescent psychological difficulties is unclear. Policy advocates a direct role but this is unsupported by education and service delivery. GPs adopt their own position along a continuum, resulting in different educational needs. Better preparation for GPs is required with exploration of new, more collaborative models of care for troubled adolescents.     

Effectiveness of general practice-based health checks: a systematic review and meta-analysis

Background

A recent review concluded that general health checks fail to reduce mortality in adults.

Aim

This review focuses on general practice-based health checks and their effects on both surrogate and final outcomes.

Design and setting

Systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials.

Method

Relevant data were extracted from randomised trials comparing the health outcomes of general practice-based health checks versus usual care in middle-aged populations.

Results

Six trials were included. The end-point differences between the intervention and control arms in total cholesterol (TC), systolic and diastolic blood pressure (SBP, DBP), and body mass index (BMI) were −0.13 mmol/l (95% confidence interval [CI] = −0.19 to −0.07), −3.65 mmHg (95% CI = −6.50 to −0.81), −1.79 mmHg (95% CI = −2.93 to −0.64), and −0.45 kg/m² (95% CI = −0.66 to −0.24), respectively. The odds of a patient remaining at ‘high risk’ with elevated TC, SBP, DBP, BMI or continuing smoking were 0.63 (95% CI = 0.50 to 0.79), 0.59 (95% CI = 0.28 to 1.23), 0.63 (95% CI = 0.53 to 0.74), 0.89 (95% CI = 0.81 to 0.98), and 0.91 (95% CI = 0.82 to 1.02), respectively. There was little evidence of a difference in total mortality (OR 1.03, 95% CI = 0.90 to 1.18). Higher CVD mortality was observed in the intervention group (OR 1.30, 95% CI = 1.02 to 1.66).

Conclusion

General practice-based health checks are associated with statistically significant, albeit clinically small, improvements in surrogate outcome control, especially among high-risk patients. Most studies were not originally designed to assess mortality.     

Quality deviations in cancer diagnosis: prevalence and time to diagnosis in general practice

Background

High quality in every phase of cancer diagnosis is important to optimise the prognosis for the patient. General practice plays an important role in this phase.

Aim

The aim was to describe the prevalence and the types of quality deviations (QDs) that arise during the diagnostic pathway in general practice as assessed by GPs and to analyse the association between these QDs, the cancer type, and the GP’s interpretation of presenting symptoms as well as the influence on the diagnostic interval.

Design and setting

A Danish retrospective cohort study based on questionnaire data from 1466 GPs on 5711 incident patients with cancer identified in the Danish National Patient Registry (response rate = 71.4%). The GP was involved in diagnosing in 4036 cases.

Method

Predefined QDs were prompted with the possibility for free text. QD prevalence was estimated as was the association between QDs and diagnosis, the GP’s symptom interpretation, and time to diagnosis.

Results

QDs were present for 30.4% (95% confidence interval [CI] = 29.0 to 31.9) of cancer patients. The most prevalent QD was ‘retrospectively, one or more of my clinical decisions were less optimal’. QDs were most prevalent among patients with vague symptoms (24.1% for alarm symptoms versus 39.5% for vague symptoms [P<0.001]). QD presence implied a 41-day (95% CI = 38.4 to 43.6) longer median diagnostic interval.

Conclusion

GPs noted at least one QD, which often involved clinical decisions, for one-third of all cancer patients. QDs were more likely among patients with vague symptoms and increased the diagnostic interval considerably.     

Screening for sickle cell and thalassaemia in primary care: a cost-effectiveness study

Background

Haemoglobinopathies, including sickle cell disease and thalassaemia (SCT), are inherited disorders of haemoglobin. Antenatal screening for SCT rarely occurs before 10 weeks of pregnancy.

Aim

To explore the cost-effectiveness of offering SCT screening in a primary care setting, during the pregnancy confirmation visit.

Design and setting

A model-based cost-effectiveness analysis of inner-city areas with a high proportion of residents from ethnic minority groups.

Method

Comparison was made of three SCT screening approaches: ‘primary care parallel’ (primary care screening with test offered to mother and father together); ‘primary care sequential (primary care screening with test offered to the mother and then the father only if the mother is a carrier); and ‘midwife care’ (sequential screening at the first midwife consultation). The model was populated with data from the SHIFT (Screening for Haemoglobinopathies In First Trimester) trial and other sources.

Results

Compared to midwife care, primary care sequential had a higher NHS cost of £34 000 per 10 000 pregnancies (95% confidence interval [CI] = £15 000 to £51 000) and an increase of 2623 women screened (95% CI: 1359 to 4495), giving a cost per additional woman screened by 10 weeks of £13. Primary care parallel was dominated by primary care sequential, with both higher costs and fewer women screened.

Conclusion

The policy judgement is whether an earlier opportunity for informed reproductive choice has a value of at least £13. Further work is required to understand the value attached to earlier informed reproductive choices.