amchp 2005 conference newborn screening in maryland the maryland program informed consent...
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AMCHP 2005 Conference
Newborn Screening in Maryland
The Maryland ProgramInformed Consent
Informational Materials Linkage to Services
Challenges of Working with Commercial Labs
AMCHP 2005 Conference
The goal of newborn screening is to eliminate, through early identification and treatment, “screenable” disorders as a cause of morbidity and mortality and to improve the quality of life for affected individuals.
AMCHP 2005 Conference
Newborn screening is not just a laboratory service; it is a system of care including, not only testing, but also follow up, definitive diagnosis, treatment, long term management, education and evaluation----
AMCHP 2005 Conference
The goal of newborn screening follow up is to ensure that each affected infant receives the full benefit of early detection and optimal long term treatment and management.
AMCHP 2005 Conference
Follow Up
• short term follow up- assure that a definitive diagnostic work-up is done, that the infant really has the disorder and that the infant is started on appropriate treatment
• long term follow up- assure that the infant continues to receive appropriate treatment and monitors the long term outcome
AMCHP 2005 Conference
Long-term tracking of affected children provides the data for outcome evaluation and the clinical utility of screening.
AMCHP 2005 Conference
Why is Follow up Important?
• assures the benefit to the infant/ family
• collects data needed for program evaluation
• holds all program components together
AMCHP 2005 ConferenceComponents of a Follow Up
System• trained personnel• database• administrative, secretarial and computer
support• medical direction• protocols• cooperative birthing facilities• informed families• PCP –medical home• specialty consultants and providers• screening and diagnostic laboratories• effective communication
AMCHP 2005 ConferenceThe Role of the State in Newborn
Screening• Assure that all infants are offered
screening, without regard to ability to pay • Assure that all infants with results that
are not normal are followed up• Assure that all affected infants receive
appropriate treatment in the necessary time frame, without regard to ability to pay
• Assure that all affected infants receive appropriate long term care
AMCHP 2005 ConferenceHistory of Newborn Screening in
Maryland• Both health professionals and families advocate
screening• 1963 lab begins to perfect Guthrie technique• 1965 mandatory PKU screening begins• 1973 statute for Commission on Hereditary Disorders• Commission decides all genetic testing (including
newborn screening) will be voluntary and require informed consent
• 1973 MSUD, homocystinuria and tyrosinemia added • 1975 new regulations require informed consent • 1978 hypothyriodism added
AMCHP 2005 ConferenceHistory of Newborn Screening in
Maryland• 1981 galactosemia added, method changed 1987• 1984 biotinidase deficiency added• 1985 sickle cell disease added• 2000 hearing screening added• 2001 CAH added• 2003 MS.MS added• 2003 commercial lab licensed• 2005 cystic fibrosis to be added
AMCHP 2005 ConferenceUnusual Features of the Maryland
Newborn Screening Program
• Short term follow up unit established at the outset• Long term follow up unit, including nutritional management,
established at the outset • Nutritional management provided, free of charge, through
the health department from the outset• Patients linked to services – NBS is part of Genetics/CSHCN
unit• One of the earliest advisory commissions- consumer
dominated , includes medical experts and legislators • Voluntary screening with informed consent since 1975• Routine second specimen• Metabolic Centers receive State subsidies since 1981 • Hematology/ endocrine follow up also subsidized
AMCHP 2005 ConferenceAdding Disorders to the Maryland Panel
Classical criteria for selecting disorders to screen for:• Relatively “high” incidence• Treatment available • Good screening test• Low cost /cost effective
(Genetic Screening: Procedural Guidance and Recommendations.
National Academy of Sciences, 1975)
AMCHP 2005 ConferenceA “good” screening test is
:• accurate • reproducible • inexpensive • non-invasive • uses an indicator, which is sensitive and
specific• a positive test has a high positive
predictive value.
AMCHP 2005 ConferenceMS.MS and the advantages of identifying a whole cohort of
affected children• Clinical spectrum-
classical, variants• Epidemiology- birth
prevalence, gene frequency
• Genetics- inheritance pattern, mechanisms, mutational analysis
• Natural history
• Pathophysiology• Development and
evaluation of treatment
• Genetic counseling and PND
• Refinement of diagnosis and screening
One test identifies multiple disorders !
AMCHP 2005 ConferenceAdding MS.MS to the Maryland
Program• Strong advocacy by parent groups• Parents involved legislators• Metabolic geneticists excited about
opportunities for treatment and research• Discussion lab focused• Advisory Council accedes to requests for speed
of implementation• Little attention paid to adequacy of resources for
public and professional education, follow up protocols and manpower, database, funding for increased workload at metabolic centers
AMCHP 2005 ConferenceInformed Consent for Newborn
Screening in Maryland• Simple good will informed consent• Most effective when explained by health professional• Analogous to other medical testing in babies and
children• Informational booklet/ consent form is a legal
document and must be approved by the AG• Very long detailed informational booklet• Booklets provided by the State to childbirth education
groups,hospitals (floors and pre-admission packets), birthing centers, OB, pediatric and familypractice offices
AMCHP 2005 ConferenceNewborn Screening is a population based
program
• Populations are very diverse: demographically, culturally, educationally
• Not all parents want their baby screened (5 to 10 families / 70,000 / year)
• Some parents, approximately one third, don’t want to know about disorders unless there is effective treatment*
*Rebecca Kerns, MS, Master’s thesis
AMCHP 2005 Conference
Informed Consent for MS.MS
• How can you explain a large number (>30) of complex metabolic disorders without common names and with varying degrees of “treatability” to the general population?
• You can’t!• Professional education is also a major
issue
AMCHP 2005 ConferenceInformational Materials for
Obtaining Informed Consent in Maryland
• Focus groups in 2004, in collaboration with Dr Terry Davis at LSU, sponsored by MCHB Genetics Branch
• Most parents don’t feel the need for very detailed information
• Most parents don’t read the long brochure • However, if the baby has a positive test result, parents
find almost all of their questions are answered in the long booklet
• How do we get the information to parents,especially those with positive results, in the right time frame?
• Both booklets at once in the hospital?• Many parents had no idea the State was involved
in newborn screening
AMCHP 2005 ConferenceChallenges of Working with a Commercial
NBS Lab• In Maryland, the commercial lab competes with the
State public health lab on a hospital by hospital basis• Many problems stem from having more than one lab
• Families who can’t pay• Volume of samples needed for QA/QC• Financial viability of the State lab• Comparability of test results• Initial and routine second samples going to different labs• Use of lab slip to collect other data- infant hearing screening
or hepatitis B immunizations • Database integration without any new resources• HIPAA concerns of commercial lab re reporting to the
State follow up unit• Differing interpretations of what should be reported
AMCHP 2005 ConferenceThe Role of the State in Newborn
Screening• Assure that all infants are offered screening,
without regard to ability to pay • Assure that all infants with results that are not
normal are followed up• Assure that all affected infants receive
appropriate treatment in the necessary time frame, without regard to ability to pay
• Assure that all affected infants receive appropriate long term care
• Evaluate program performance