A C TA Obstetricia et Gynecologica
AOGS S H O R T RE S E A R CH RE P OR T
Decision making in prenatal screening: money matters E. JOANNE VERWEIJ1, DIEDERIK VEERSEMA2, EVA PAJKRT3 & MONIQUE C. HAAK1 1
Department of Obstetrics, Leiden University Medical Center, Leiden, 2Department of Obstetric Ultrasound, Synergos, Eindhoven, and 3Department of Obstetrics, Academic Medical Center, Amsterdam, the Netherlands
Key words Prenatal screening, reimbursement, Down syndrome, trisomy 21, informed decision making Correspondence E. Joanne Verweij, Department of Obstetrics, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands. E-mail: [email protected] Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. Please cite this article as: Verweij EJ, Veersema D, Pajkrt E, Haak MC. Decision making in prenatal screening: money matters. Acta Obstet Gynecol Scand 2015; 94: 212– 214.
Abstract The aim of this study is to determine the influence of withdrawal of reimbursement on the uptake of the first-trimester combined test. Until January 2007 the combined test was offered to all pregnant women in a designated geographical area as a pilot study before the introduction of the national screening program in the Netherlands, to test the logistic procedures. In January 2007 the insurance companies suddenly stopped paying for the combined test with respect to women aged ≤35 years by decision of the government. In 2006 the combined test was performed in 4616 women compared with 3459 who had the combined test in 2007, a reduction of 25% (95% CI 23.8–26.3%, p < 0.001). A decline was observed in the uptake of the combined test in women aged ≤35 years (p < 0.001) as opposed to an increase in uptake in women aged ≥36 years (p < 0.001). The financial impact on the uptake of the first-trimester combined test should not be underestimated.
Received: 19 May 2014 Accepted: 23 September 2014 DOI: 10.1111/aogs.12518
Introduction Prenatal screening aims to detect women at high risk for fetal trisomy and other structural anomalies in a population of normal pregnancies. One of the available screening methods is the first-trimester combined test, consisting of maternal serum screening and nuchal translucency measurement. This test identifies women at risk for trisomies 21 (T21, Down syndrome), 18 and 13. The serum test is normally performed between 9+0 weeks and 13+6 weeks of gestation and the nuchal translucency assessment between 11+0 and 13+6 weeks of gestation. In the Netherlands the antenatal screening program was designed to provide information to every pregnant woman so that she will be able to make an informed choice. If the risk assessment shows a high risk for fetal trisomy or if fetal anomalies are detected, invasive testing
212
is offered. Parity, fertility history, family history for chromosomal anomalies, education level, ethnicity and religion are acknowledged to attribute to women’s choices for prenatal screening (1). The main reasons for undergoing prenatal tests are reassurance and the desire to have knowledge about the health of the fetus (2,3). The decision to decline these tests may be related to personal views on pregnancy termination and the fear for iatrogenic pregnancy loss (2,3). This study was performed in a fully covered healthcare insurance system, which provides equal health care to every citizen. With the introduction of the national prenatal screening program in 2007, the government decided that the 20-week anomaly scans should be reimbursed by the insurance companies for all pregnant women. In contrast, the combined test (price €154) would be reimbursed only for women aged 36 years or older. Although
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 212–214
Prenatal screening: money matters
E.J. Verweij et al.
younger women (≤35 years) are informed about the combined test, they have to take the personal costs into account when deciding whether or not to undergo firsttrimester screening. However, invasive prenatal diagnosis, such as amniocentesis and chorionic villous sampling, is subsequently reimbursed to all women with an increased risk, whether based on maternal age or on the combined test results. In countries like Denmark, which offers prenatal screening without costs, the uptake is more than 90% (4), compared with the Netherlands where the uptake is around 25%. Very little is published about the influence of personal costs in the decision to undergo first-trimester screening. The aim of this study was to determine the influence of personal costs on the uptake of the combined test.
Material and methods In the period from the first of January 2004 to the end of December 2006 the combined test and 20-week anomaly scan were performed without personal costs in a regional ultrasound center (Diagnostic center Diagnostiek voor U, Eindhoven, the Netherlands). The center covers a specific geographical area and serves hospitals and several community midwifery practices. During this period the tests were performed within a pilot study framework in this selected region before the start of a national screening program (http://www.rivm.nl/Onderwerpen/D/Downscreening), to test the logistic procedures and quality aspects. Counseling concerning the combined test and 20 weeks scan was done at about 9–12 weeks of gestation at the booking visits by both midwives and doctors. With the introduction of the program in 2007, the insurance companies suddenly stopped paying for the combined test with respect to women ≤35 years of age in this region, as decided by the Ministry of Health. Counseling did not change, except that all Dutch women ≤35 years old were informed about the costs of the test and that they had to pay for the test themselves. We assessed the influence of the stopping of reimbursement by studying the difference in uptake of the combined test 12 months before and 12 months after January 2007. The monthly number of 20-week anomaly scans performed in the same ultrasound center, free of cost and independent of age, was used as a reference to rule out demographic changes. Data entry and analysis were performed using PASW version 18 (IBM Corp., Armonk, NY, USA). Differences between the two periods were analyzed using the chi-squared tests for the categorical variables and Student’s t-tests were used for the continuous variables. A p-value
AOGS S H O R T RE S E A R CH RE P OR T
Decision making in prenatal screening: money matters E. JOANNE VERWEIJ1, DIEDERIK VEERSEMA2, EVA PAJKRT3 & MONIQUE C. HAAK1 1
Department of Obstetrics, Leiden University Medical Center, Leiden, 2Department of Obstetric Ultrasound, Synergos, Eindhoven, and 3Department of Obstetrics, Academic Medical Center, Amsterdam, the Netherlands
Key words Prenatal screening, reimbursement, Down syndrome, trisomy 21, informed decision making Correspondence E. Joanne Verweij, Department of Obstetrics, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands. E-mail: [email protected] Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. Please cite this article as: Verweij EJ, Veersema D, Pajkrt E, Haak MC. Decision making in prenatal screening: money matters. Acta Obstet Gynecol Scand 2015; 94: 212– 214.
Abstract The aim of this study is to determine the influence of withdrawal of reimbursement on the uptake of the first-trimester combined test. Until January 2007 the combined test was offered to all pregnant women in a designated geographical area as a pilot study before the introduction of the national screening program in the Netherlands, to test the logistic procedures. In January 2007 the insurance companies suddenly stopped paying for the combined test with respect to women aged ≤35 years by decision of the government. In 2006 the combined test was performed in 4616 women compared with 3459 who had the combined test in 2007, a reduction of 25% (95% CI 23.8–26.3%, p < 0.001). A decline was observed in the uptake of the combined test in women aged ≤35 years (p < 0.001) as opposed to an increase in uptake in women aged ≥36 years (p < 0.001). The financial impact on the uptake of the first-trimester combined test should not be underestimated.
Received: 19 May 2014 Accepted: 23 September 2014 DOI: 10.1111/aogs.12518
Introduction Prenatal screening aims to detect women at high risk for fetal trisomy and other structural anomalies in a population of normal pregnancies. One of the available screening methods is the first-trimester combined test, consisting of maternal serum screening and nuchal translucency measurement. This test identifies women at risk for trisomies 21 (T21, Down syndrome), 18 and 13. The serum test is normally performed between 9+0 weeks and 13+6 weeks of gestation and the nuchal translucency assessment between 11+0 and 13+6 weeks of gestation. In the Netherlands the antenatal screening program was designed to provide information to every pregnant woman so that she will be able to make an informed choice. If the risk assessment shows a high risk for fetal trisomy or if fetal anomalies are detected, invasive testing
212
is offered. Parity, fertility history, family history for chromosomal anomalies, education level, ethnicity and religion are acknowledged to attribute to women’s choices for prenatal screening (1). The main reasons for undergoing prenatal tests are reassurance and the desire to have knowledge about the health of the fetus (2,3). The decision to decline these tests may be related to personal views on pregnancy termination and the fear for iatrogenic pregnancy loss (2,3). This study was performed in a fully covered healthcare insurance system, which provides equal health care to every citizen. With the introduction of the national prenatal screening program in 2007, the government decided that the 20-week anomaly scans should be reimbursed by the insurance companies for all pregnant women. In contrast, the combined test (price €154) would be reimbursed only for women aged 36 years or older. Although
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 212–214
Prenatal screening: money matters
E.J. Verweij et al.
younger women (≤35 years) are informed about the combined test, they have to take the personal costs into account when deciding whether or not to undergo firsttrimester screening. However, invasive prenatal diagnosis, such as amniocentesis and chorionic villous sampling, is subsequently reimbursed to all women with an increased risk, whether based on maternal age or on the combined test results. In countries like Denmark, which offers prenatal screening without costs, the uptake is more than 90% (4), compared with the Netherlands where the uptake is around 25%. Very little is published about the influence of personal costs in the decision to undergo first-trimester screening. The aim of this study was to determine the influence of personal costs on the uptake of the combined test.
Material and methods In the period from the first of January 2004 to the end of December 2006 the combined test and 20-week anomaly scan were performed without personal costs in a regional ultrasound center (Diagnostic center Diagnostiek voor U, Eindhoven, the Netherlands). The center covers a specific geographical area and serves hospitals and several community midwifery practices. During this period the tests were performed within a pilot study framework in this selected region before the start of a national screening program (http://www.rivm.nl/Onderwerpen/D/Downscreening), to test the logistic procedures and quality aspects. Counseling concerning the combined test and 20 weeks scan was done at about 9–12 weeks of gestation at the booking visits by both midwives and doctors. With the introduction of the program in 2007, the insurance companies suddenly stopped paying for the combined test with respect to women ≤35 years of age in this region, as decided by the Ministry of Health. Counseling did not change, except that all Dutch women ≤35 years old were informed about the costs of the test and that they had to pay for the test themselves. We assessed the influence of the stopping of reimbursement by studying the difference in uptake of the combined test 12 months before and 12 months after January 2007. The monthly number of 20-week anomaly scans performed in the same ultrasound center, free of cost and independent of age, was used as a reference to rule out demographic changes. Data entry and analysis were performed using PASW version 18 (IBM Corp., Armonk, NY, USA). Differences between the two periods were analyzed using the chi-squared tests for the categorical variables and Student’s t-tests were used for the continuous variables. A p-value
