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Sickle cell screening based in primary care 'is more efficient'

By Lilian Anekwe

Current arrangements for sickle cell antenatal screening are failing to screen women in time and would be more efficient if they were based in primary care, suggests a Department of Health funded evaluation.

An NHS Health Technology Assessment study found basing universal antenatal screening for sickle cell anaemia and thalassaemia (SCT) in primary care would lead to a huge increase in the numbers of women being screened, but would require significant additional resources.

The HTA looked at three screening strategies in nearly 1,700 women at 25 practices in two London PCTs – Newham and Lambeth. Women were allocated to parallel screening - with both parents screened for SCT in primary care - sequential screening in primary care with fathers only tested if the mother was identified as a carrier, and screening in secondary care.

NICE guidance recommends SCT screening should be offered before 10 weeks so the primary outcome was the proportion of women screened through each of the different strategies before this key watershed.

Three per cent of women were offered screens before 10 weeks in secondary care, much lower than the 47% offered in primary care with parallel testing and 48% in primary care with sequential testing.

The percentage of screens conducted also supported basing SCT screening in primary care. Two per cent of women were screened before 10 weeks in secondary care, compared with 24% in primary care with parallel testing and 28% in primary care with sequential testing.

But the predicted average total cost per pregnancy of offering antenatal SCT screening was higher in primary care, at £18.50 for parallel testing, and £16.40 for sequential testing, compared with £13 in standard care.

Professor Theresa Marteau, the study's lead researcher and professor of health psychology at King's College London, concluded: ‘Offering antenatal SCT screening as part of pregnancy-confirmation consultations significantly increased the proportion of women screened before 10 weeks, but additional resources may be required to implement this.'

She said: ‘In the current system many women do not even have their first visit with a midwife until 12 weeks or later. This is much too late. Our work shows that the majority of women do visit their GP early to confirm the pregnancy and this provides an opportunity to offer the SCT test immediately'.

Dr Allison Streetly, director of the NHS Sickle Cell and Thalassaemia screening programme, told Pulse the Department of Health was keen to ramp up the role of primary care in SCT screening to deal with ‘service failures'.

‘Current arrangements are struggling to deliver. It's the system that fails women. Primary care can contribute to supporting the process. There's a big window before maternity care services kick in after twelve weeks, but we know many women will see their GP before then. This work shows the important role of primary care helping to close that gap.'

Health Technol Assess. 2010 Apr;(20):1-160.

Sickle cell screening based in primary care 'is more efficient' NICE guidance on screening for haemoglobinopathies

• Screening for sickle cell diseases and thalassaemias should be offered to all women as early as possible in pregnancy (ideally by 10 weeks to allow women the option of a non-invasive procedure which can be offered up to 12 weeks)

• Pre-conception counselling (supportive listening, advice-giving and information) and carrier testing should be available to all women who are identified as being at higher risk of haemoglobinopathies, using the Family Origin Questionnaire from the NHS Antenatal and Newborn Screening Programme.

Source: Antenatal care: Routine care for the healthy pregnant woman. NICE, March 2008

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