We described the time required for genetic counseling services for GS in the context of preconception carrier testing and showed that it can be a substantial time commitment, particularly for visit preparation. Factors that increased the time needed for genetic counseling were the participant (or partner) was pregnant at the time of the visit, an increased number of results, and lack of familiarity by the genetic counselors with some of the results. Several previous studies have looked at aspects of time required for genetics services related to GS in other contexts (Arora et al.
2016; Sukenik-Halevy et al.
2016; Williams et al.
2014). However, these studies are substantially different in design and context such that none of these previous reports are easily comparable to the work reported here so direct comparisons are not possible. Williams et al. (
2014) described time for pre-test work ups in a neurodevelopmental clinic, but do not provide data on time for the results disclosure process. The other two studies (Arora et al.
2016; Sukenik-Halevy et al.
2016) report on retrospective surveys and provide estimates for genetics practice in general rather than specific contexts, such as preconception care. In addition, one of these studies does not clearly break out estimates of genetic counseling time from that of other genetics providers (Arora et al.
2016).
It is also interesting to view our results in relation to current clinical genetic counseling practice. The 2016 report from the National Society of Genetic Counselors on Work Environments in Genetic Counseling (National Society of Genetic Counselors (NSGC)
2016), for example, provides estimates of time spent in various activities for currently practicing genetic counselors. Results from a survey that included over 2000 practicing genetic counselors found that 72% of respondents spend less than 30 min on preparation for disclosing results, 50% spent less than 30 min face-to-face with patient, and 60% less than 30 min on follow-up. The results of our study suggest that times for preconception results disclosure in the context of GS are somewhat longer, with over 50% of cases taking more than 30 min for both preparation and results disclosure visit times, and over 40% on the higher end of the distribution of total time, with total results disclosure times over 90 min. In addition, respondents to the NSGC survey did not separately report on time spent with patients in different subspecialties of genetics as the report considers genetics practice as a whole. This definition would include time with patients who were undergoing diagnosis of genetic conditions such as cystic fibrosis as well as persons receiving preconception carrier testing. It is also important to note that the NSGC survey required self-report of genetic counseling practice in general (e.g., for the “typical” case) compared to our prospective collection of data on specific cases in a specific context.
Our work adds to the existing research by highlighting the importance of examining preparation time when multiple results are discussed. This may be one of the main areas that is meaningfully different for GS compared to typical clinical genetic practice. In addition, our work suggests the importance of looking at specific contexts (e.g., cancer, pediatrics/adult, preconception/prenatal) because time for genetic counseling services likely differs with different medical contexts. Our study has the unique advantage of investigating the time costs in a healthy population and the inherent uncertainty of interpreting GS results without a disease phenotype.
Limitations
Although we conducted careful data collection, used prospective methods, and focused on a specific context—preconception screening—there are several limitations that need to be addressed. The generalizability of our findings are limited because we had a relatively small study sample, collected data in only one geographic area, and the patients were primarily well-educated Caucasian adults. Also, results were only disclosed by a small number (N = 3) of genetic counselors, and we did not include clinical providers other than genetic counselors, such as medical geneticists or OB/GYN providers. In particular, many OB providers coordinate care for patients who seek expanded carrier testing and deliver these carrier test results, and the time they spend on results disclosure may be different. The current study only included genetic counselors so does not provide time estimates for other types of clinical providers. Future studies exploring both the time needed for other clinical providers (such as OBs) to provide results disclosure and the outcomes of these disclosures could aid significantly in understanding the resources needed to provide results disclosure in the context of expanded carrier testing.
The research study limited the extent of counseling issues addressed to the results themselves and the targeted family history that was obtained (downstream care was referred to the clinical genetics department). Additional common preconception/prenatal counseling issues, such as advanced maternal age, specific family history concerns, or potential teratogen exposure, were not addressed during the course of the results disclosure visit. Thus, the real-world genetic counselor session for GS results disclosure would likely be more time-consuming. We also may have underestimated the time costs because we used a guided list of conditions (Himes et al.
2017) that involved gene-condition associations that were clearly established prior to testing and counseling. Variants of uncertain significance were not reported per study protocol, dramatically reducing the number of results disclosed. Our participants were able to select from five general categories of carrier results, yielding a smaller number of interrogated genes for some participants.
We used self-report of time by the individuals conducting the work, which may lead to bias if reporters are not adequately trained, or if they are motivated to misrepresent data in a way that is desirable for clinic managers or leaders. We have mitigated these risks by providing training and using a log to record times as soon as possible after activities occurred. While alternative approaches include using external observers or computerized systems using time stamps to collect data (Lopetegui et al.
2014), external observers are expensive and would likely have required activity sampling that may not be representative of the distribution of activities under study. Similarly, computerized systems are more useful for medical services where machines or technology are integral, such as dialysis, but less accurate for activities that primarily involve human communication such as genetic counseling. Despite these limitations, this research points to some important considerations for the adoption of GS or even greatly expanded carrier screening into mainstream genetics practice and for future research studies.
Practice Implications
Although preconception carrier testing by GS is not currently clinically available in some communities, expanded carrier testing panels have been increasing in size. The possibility of incorporating secondary findings into preconception carrier testing will likely increase demands on the clinical providers providing results disclosure. Thus, our results may help health systems plan how to provide genetic counseling services as GS becomes part of standard practice. Our study’s results indicate that if GS becomes the standard of care, many more patients will need preconception genetic counseling services and providers will need to allocate more time to deliver these services. While current professional guidelines recommend preconception carrier screening related to only very few conditions (e.g., cystic fibrosis), the results of our study indicate that many more individuals will have a preconception result with GS, which will also require increased genetic counseling services to help interpret the meaning of that result for their reproductive planning. We found that 78% of study participants are carriers of at least one condition. Thus, even if the number of patients who want preconception carrier testing remains the same (e.g., the number of tests ordered does not increase), expansion of GS to the standard of care would likely substantially increase genetic counseling time. Given that the current genetic counseling work force is relatively small, the growing demand for genetic counseling in laboratory settings as well as clinical settings suggests that we will need substantially more genetic counseling providers if GS becomes the standard of care. This will be critical to address prior to implementation given the time it takes for a person to be trained as a genetic counseling is substantial (
Bureau of Labor Statistics (BLS)), and thus, there likely may be a shortage of genetic counseling in clinical settings.
Given the likely shortage of genetic counseling services as use of GS expands throughout medical care contexts, experts have suggested alternative methods for providing genetic counseling in the context of GS. For example, OB/GYN providers often provide genetics results for carrier status for commonly tested conditions such as cystic fibrosis, and some experts have discussed the possibility of such providers disclosing results for GS (Rothwell et al.
2016). A recent ACOG committee opinion on expanded carrier testing recommended referring patients to genetic counseling only when both partners are carrier of the same condition (ACOG
2017). Although this strategy would reduce the genetic counselors’ time demands, the implications for the primary OB providers could potentially be significant as they would be tasked in learning about potentially thousands of conditions and addressing issues about the possibility for the change in interpretation of results over time. In a recent survey of OB/GYNs (Bayefsky et al.
2016), respondents expressed both practical and ethical concerns regarding prenatal GS, but it is unclear if these same concerns would apply to a preconception setting. Results of our qualitative data echo these concerns. Genetic counselors discussed the complex process of preparing for GS results disclosure, describing the need to do extensive research on many results, the need to integrate multiple results, and the importance of having time to put all these factors together prior to the results disclosure visit. As GS becomes more familiar to providers, and additional educational material is developed; however, it may become more realistic for medical staff other than genetic counselors to provide GS results.
Another possible approach to reducing the time required to conduct results disclosure is to complete the visits remotely (Cohen et al.
2013; Tabor et al.
2017; Yu et al.
2013). This includes providing traditional genetic counseling over the phone or by video (Cohen et al.
2013), as well as providing disclosure of GS results through a self-guided management approach (Tabor et al.
2017; Yu et al.
2013). Telephone genetic counseling might mitigate some time needed for GS results disclosure as travel and wait times might decrease, but telephonic genetic counseling is still dependent on the time of genetic counselors. In contrast, self-guided methods might decrease the need for genetic counseling time. For example, My46 is a web tool (Tabor et al.
2017) that guides patients through preferences for what results they want disclosed, educational material regarding results, and helping patients to assess the meaning of the results. While self-guided models hold promise for more efficient results disclosure in some contexts, they have yet to be fully tested in different GS contexts or with a wide range of populations. In addition, they may raise some ethical concerns for some types of results. For example, recent research focusing on carrier testing indicates that patients were highly satisfied with genetic counseling, that genetic counseling improved patients’ understanding of preconception results, and that counseling influenced participant’s reproductive decisions (Rothwell et al.
2016). In contrast, such methods may be more convenient for patients and may become more acceptable over time as both providers and patients become more comfortable with GS.
Our results also suggest several other practical ways which could improve genetic counseling for GS results disclosure in the preconception context. Centralized collection of information on less common results and high-quality patient education materials could reduce the research time needed by practicing genetic counselors and other providers. Another option that could reduce genetic counseling time would be simultaneous testing of both reproductive partners. While this parallel testing would likely increase laboratory testing costs, it would likely reduce genetic counseling time if only at-risk couples are referred for genetic counseling. This approach is not recommended in a recent ACOG committee opinion (
2017 ibid.). Another alternative is to limit the scope of the carrier testing through GS in order to maximize clinical utility, and reduce patient stress and clinician time (Stevens et al.
2017). Finally, protocols could be developed to allow primary care providers to provide part of the results of GS disclosure process in low-risk situations such that genetic counseling services would only provide care for more complex or high-risk situations. This is done routinely in OB/GYN clinics for results for single gene testing for common conditions such as cystic fibrosis and Tay Sachs. Such protocols for GS results disclosure, however, do not exist at this point and they would need to be developed and tested prior to adoption in clinical genetics care.
Research Recommendations
Future research assessing the time providers, including non-genetics providers, require to provide genetic counseling in the context of GS could greatly aid in planning for expansion of GS into preconception care and other areas of medical care. Results of our study suggest that it is important to study time use in specific contexts as general studies may mask important differences in time needed for genetic counseling in different GS contexts. In addition, our results suggest that prospectively collecting data on the amount of time dedicated to these efforts will provide much more accurate results. In addition to aiding in planning for expansion of GS, studying time costs could aid in understanding broad workforce and reimbursement issues (e.g., number of genetic counselors needed) or the cost of a genetic counseling visit in the context of GS. Time studies could also identify tasks that have a high time cost that could be targeted for new interventions, such as development of web-based patient educational materials, or new methods for results disclosure. It would also be very valuable to study how patient understanding of results, satisfaction with results disclosure, and downstream actions following disclosure vary depending on who provides results disclosure and how much time is spent on it. Finally, as public and private insurers grapple with whether or not to include GS in insurance coverage, it is critical to look beyond the laboratory costs of providing GS and ensure that estimates account for genetic counseling and other OB providers’ services, potential prenatal and preimplantation testing, and other downstream activities. Developing accurate and fair health care policies will depend on strong estimates of all the costs of providing GS, and time studies could aid in accurate understanding of what is needed for quality genetic counseling services in the context of GS.