Miron-Shatz Talya, Rapaport Sivan R, Srebnik Naama, Hanoch Yaniv, Rabinowitz Jonina, Doniger Glen M, Levi Linda, Rolison Jonathan J, Tsafrir Avi
Center for Medical Decision Making, Ono Academic College, 104 Zahal St, Kiryat Ono, Israel.
Center for Medicine in the Public Interest, New York, NY, USA.
J Genet Couns. 2018 Feb;27(1):59-68. doi: 10.1007/s10897-017-0120-9. Epub 2017 Jun 14.
Funding policy and medico-legal climate are part of physicians' reality and might permeate clinical decisions. This study evaluates the influence of maternal age and government funding on obstetrician/gynecologist recommendation for invasive prenatal testing (i.e. amniocentesis) for Down syndrome (DS), and its association with the physician's assessment of the risk of liability for medical malpractice unless they recommend amniocentesis. Israeli physicians (N = 171) completed a questionnaire and provided amniocentesis recommendations for women at 18 weeks gestation with normal preliminary screening results, identical except aged 28 and 37. Amniocentesis recommendations were reversed for the younger ('yes' regardless of testing results: 6.4%; 'no' regardless of testing results: 31.6%) versus older woman ('yes' regardless of testing results: 40.9%; 'no' regardless of testing results: 7.0%; χ = 71.55, p < .01). About half of the physicians endorsed different recommendations per scenario; of these, 65.6% recommended amniocentesis regardless of testing results for the 37-year-old woman. Physicians routinely performing amniocentesis and those advocating for amniocentesis for all women ≥ age 35 were approximately twice as likely to vary their recommendations per scenario. Physicians who perceived risk of liability for malpractice as large were nearly one-and-a-half times more likely to vary recommendations. The results indicate physicians' recommendations are influenced by maternal age, though age is already incorporated in prenatal DS risk evaluations. The physician's assessment of the risk that they will be sued unless they recommend amniocentesis may contribute to this spurious influence.
资助政策和医疗法律环境是医生现实工作的一部分，可能会渗透到临床决策中。本研究评估了产妇年龄和政府资助对妇产科医生针对唐氏综合征（DS）进行侵入性产前检测（即羊膜穿刺术）建议的影响，以及其与医生对除非推荐羊膜穿刺术否则面临医疗事故责任风险评估之间的关联。以色列医生（N = 171）完成了一份问卷，并为妊娠18周、初步筛查结果正常、除年龄分别为28岁和37岁外其他情况相同的女性提供羊膜穿刺术建议。针对年轻女性（无论检测结果如何，“是”：6.4%；“否”：31.6%）与年长女性（无论检测结果如何，“是”：40.9%；“否”：7.0%；χ = 71.55，p <.01），羊膜穿刺术建议出现了反转。约一半的医生针对每种情况支持不同的建议；其中，65.6%的医生无论检测结果如何都建议37岁女性进行羊膜穿刺术。经常进行羊膜穿刺术的医生以及主张为所有35岁及以上女性进行羊膜穿刺术的医生，针对每种情况改变建议的可能性大约是其他医生的两倍。认为医疗事故责任风险大的医生改变建议的可能性几乎是其他医生的1.5倍。结果表明医生的建议受到产妇年龄的影响，尽管年龄已纳入产前DS风险评估中。医生对除非推荐羊膜穿刺术否则将被起诉风险的评估可能导致了这种虚假影响。
