The highs and lows of my political career

Lewis Draper, MB

Journal de l'Association médicale canadienne 1996; 154 : 702-704

Dr. Lewis Draper represented the New Democratic Party in the provincial riding of Assiniboia-Gravelbourg, Sask., from 1991 to 1995.

Résumé

Le Dr Lewis Draper a représenté une circonscription rurale de la Saskatchewan à l'Assemblée législative de la province de 1991 à 1995. Dans cet article, il présente quelques réflexions sur les hauts et les bas de sa carrière politique.
| JAMC le 1er mars 1996 (vol 154, no 5) |
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sont de plus en plus populaires dans le monde. Comme d'autres pays, le Canada a mis en ¦uvre des réformes afin de tirer le maximum des enveloppes budgétaires dont nous disposons pour les soins de santé. Dans cet article, Susan MacPhee analyse des stratégies communes de réforme des soins de santé.
| JAMC le 1er mars 1996 (vol 154, no 5) |
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icirc;tra le 1er avril, on se demandera si un système privé parallèle est une option valable que le Canada devrait envisager. En août dernier, le Conseil général a décidé à l'unanimité que l'AMC devrait provoquer un débat national sur l'opportunité de mettre en place un système d'assurance privée de tous les services médicaux.
| JAMC le 1er mars 1996 (vol 154, no 5) |
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about the future of health care, chances are that someone will tell you a story about a pig -- the health care pig. It goes like this.

A farmer had a barnyard full of animals, but felt particular fondness for one pig. This pig was brilliant: it had squealed for help when the farmer was trapped under his tractor, it had pulled a toddler out of a pond, it had alerted neighbours when their farmhouse caught fire. After hearing about the lifesaving heroics, a traveller asked to see the pig. He was surprised to discover that the animal was missing a leg.

"What happened?" he asked.

The farmer shrugged. "A fine pig like that," he said, "you don't butcher all at once."

The health care pig story is a favourite among medicare defenders in Alberta, which has seen larger cuts to its health care budget than any other province and the most aggressive attempts to develop a private health care system. Government critics argue that the public health care system is being slowly butchered, just like the pig. First one leg, then the next . . . and before we know it, the whole animal will be gone.

Nothing, of course, is that simple. Defenders of our publicly funded health care system know that medicare, unlike a pig, is in a constant state of change and flux. Still, the size of our health care pig has been shrinking for several years: the proportion of Canada's gross national product (GNP) spent on health care dropped from its high of 10.1% in 1992-93 to approximately 9% the next fiscal year. "The status quo is not sustainable," Alberta pediatric cardiologist Dr. Ruth Collins-Nakai argued during last August's CMA annual meeting. "We are left with a choice. We can either change or modify the current system or we can . . . adopt new principles."

Collins-Nakai is a firm believer in a health care system that is largely publicly funded and under close government regulation because "there is ample evidence to support the concept of a single payer system being the most effective."

She and other medicare defenders argue that it is still possible to provide all the health care Canadians need within the current publicly funded system, but radical change must be made in order to sustain it. We must reshape the pig without butchering it.

What changes will guarantee continued sustainability? Identifying the right initiatives will not be easy. "It's a living laboratory out there," says Carole Clemenhagen, president of the Canadian Healthcare Association. "We can't yet see what we've achieved." As well, different provinces are reforming health care in different ways: there are wide variations in cost-cutting strategies and new delivery mechanisms.

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Squeeze the hospitals

One process yielding significant cost reductions is captured in one buzzword -- re-engineering. Usually this refers to hospitals, which are the biggest consumers of health care dollars. The Ontario government has pledged to close or merge 30 hospitals within the next couple of years, while Saskatchewan has already closed the same number of rural hospitals.

Tony Dagnone, president and chief executive officer of the London, Ont., Health Sciences Centre, formerly University/Victoria Hospital, recently managed the second largest voluntary merger of teaching hospitals in Canada. He helped restructure two competing institutions into one hospital, with common management, governance and an integrated medical staff. His goal: cut $40 million from a combined operating budget of $400 million. He is still on track to meet this goal, but today is less certain, given the Ontario government's recent economic statement, that he will be able to divert the savings to meet unmet needs in the community.

Part of Dagnone's success has been tighter management, achieved through the kind of "delayering" strategies common in North American corporations. But clinicians have also played an important role. One physician-driven initiative has been the development of sophisticated "clinical-pathway" models. For instance, everything that happens to a heart-transplant patient between day 1 and day 30 has been tracked to see how the sequencing of tests and procedures can be improved. "We have been able to reduce length of stay, and the patient feels more in control of his or her own recovery," he says.

Dagnone argues that savings from improvements like these increase the viability of publicly financed hospitals. "I can compete with the Americans when it comes to cost and outcome of procedures, although they still manage lower length-of-stay figures than we do."

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Focus on effective care

Both Clemenhagen and Dagnone point out that hospital closures and rapid downsizing of the institutional sector are not enough in themselves to secure the future of medicare. "I'm worried that the emphasis on re-engineering and structural reforms is raising false hope that this is all we need to do," says Clemenhagen. "The changes were necessary, but the key to the future is building an ability to understand health care. What works? What are we doing to our patients? How effective are we?"

The London Health Sciences Centre is unusual in that projects such as clinical pathways identify interventions that can be eliminated because they have no proven clinical value. Clemenhagen points out that when it comes to both quality improvement and resource allocation, "many institutions are not implementing what we know. There is still rigid, control-oriented management when we need a much faster, more business-oriented approach."

Most hospitals are not using evidence-based decision making, even though guidelines have developed since the 1980s. There is also a wealth of medical information available on the Internet, but many physicians and other providers remain computer illiterate and unaware of software packages that would keep them up to date.

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Exploit new information technology

Part of the reason for foot dragging is a shortage of financial officers and entrepreneurial administrators in the health care system. Employers must invest in information technology that will enable providers to do more with less. Toronto's Hospital for Sick Children, for instance, now has a telelink with Thunder Bay, Ont., that allows videoconferencing and the transfer of images, links that expand health care services in underserviced region at minimal cost.

Moreover, squeezing the hospital sector only attacks one aspect of the problem. Andrew Vaz, national director of health care consulting at Ernst & Young, says "we must rethink the relationship of the parts to the whole system. We must ensure that both the institution and the doctors within it, for example, are aligned in the same direction."

The way physicians are paid is one element in this rethinking. Collins-Nakai argues that alternate payment methods should be adopted more widely because "not everyone wants the same thing."

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Use least-cost alternatives

Until now, health care professionals have focused on ensuring the highest standards within their own professions. Now they must focus on delivery and come together across professional boundaries. Many hospitals are developing "multiskilled workers" who cross job-description boundaries. Thanks to good relations with its unions, the London Health Sciences Centre has pioneered looser job definitions for hospital employees. "It means that a housekeeper is no longer just a housekeeper," explains Dagnone. "She can take on some of the responsibilities, for example, of the nursing assistants." This saves money and also means that the patient doesn't have to deal with as many strangers. Similarly, nurses are now doing tasks that used to be performed by physicians, and nursing assistants are taking over some of the nurses' responsibilities. Each "task bumping" represents a saving.

Quebec has already bumped much of its health care out of hospitals and into the community. Its CLSCs, or community service centres, provide a coordinated array of health and social services provided by physicians, nurses, social workers, occupational therapists, physiotherapists, counsellors and community workers. Family health care, inoculation services, health-promotion programs, home care and psychologic counselling are all on the menu. Moreover, the services are performed by the lowest-cost provider qualified for the job. In the Notre-Dame-de-Grace CLSC in Montreal, for example, there are only six physicians among the 150 staff members.

All Quebec residents have had access to CLSCs since 1988. Visits to a centre cost the system less than visits to physicians or a hospital emergency room, but there is a still cheaper alternative. CLSC users can now call a 24-hour information line and talk to a nurse. This avoids unnecessary, and expensive, consultations about the common cold or normal childhood illnesses.

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Restrict the definition of "medically necessary"

Almost one-third of Canada's health care spending already takes place in the private sector and the proportion is growing all the time, since medicare covers only items considered "medically necessary." This has always excluded dental care and most drug costs; today, governments are busy pushing additional items off their lists of insured procedures. In 1994, Ontario delisted the reversal of vasectomies and tubal ligations, most in-vitro fertilization and routine circumcisions, as well as the removal of tattoos and spider veins. In Alberta, routine eye examinations for those aged 19 to 64 are no longer considered medically necessary.

But there is no national definition of what medically necessary means. Andrew Vaz expects public debate on this issue to accelerate as ad hoc definitions narrow across the country. "Expenditures of millions of dollars are affected by where the line is drawn," he observes. "Clinicians and consumers need to participate in the discussion about what is in and what is out." The debate should not focus exclusively on fiscal pressures, he adds, but should cover arguments about personal responsibility for health and society's obligation to the poor.

Neither the federal government nor the CMA is anxious to start dictating a list, since such a top-down approach might push us too close to the American system of health care micromanagement, with its attendant encroachment on clinicians' judgement. "But the menu of insured services right now is too big and bloated," argues Dagnone. "The tax base cannot sustain it. We must identify core medical services, then see if private health insurance companies will cover the balance."

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Look for additional revenue sources

Vaz argues that the growth of the private sector is inevitable. "It's not just an affordability issue," he says, "it's also a market issue. There are tremendous market opportunities." Consumers want choice, and are willing to invest in their health and health care. Public-sector institutions might investigate the opportunities for generating extra revenue without compromising their primary mission.

How? Some of today's social and health care programs won't be available tomorrow, suggests Clemenhagen, who speculates that home-care services such as visiting nurses or meals on wheels may not be universally available. Entrepreneurial hospital administrators could then contract with a private company to offer home care on a pay-as-you-go basis without infringing the Canada Health Act. A patient who comes in for a hip replacement will be given a choice of different kinds of after care, with the level of service depending on how much she wants to pay. This means that tomorrow's hospitals will be dealing with multiple payers, and also points to tremendous opportunities for private health insurance to cover the growing market for nonessential services. "We'll see more market forces within the public system," continues Clemenhagen. "Internal markets could be the route needed to preserve our public framework."

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Political will

The efficiency and effectiveness of Canada's publicly funded health care system could be improved enormously by taking steps such as these. Most provinces -- Saskatchewan and New Brunswick are the best examples -- have already made their health care systems more efficient. They have weathered noisy protests from citizens who have lost services they had become accustomed to, and they have not unduly compromised the quality of their care. "The levers in the single-payer model have served us well in the push for cost reductions," Clemenhagen notes. "Compare Canada with the United States, where they have no controls over their hospital budgets, capital expenditures or number of physicians in practice and now spend more than 15% of their GNP on health care."

But new directions taken in the field are not enough to preserve our publicly funded system. "Without a change of policy direction by governments," comments Dr. Jack Armstrong, the CMA president, "we cannot maintain universality."

Armstrong, a Winnipeg pediatrician, acknowledges that recent cuts have made the system more efficient, but the quality of care is now being affected by continued chopping. "If we go on like this, our system will start to look like Solzhenitsyn's Cancer Ward."

What both Armstrong and Clemenhagen seek is a predictable, meaningful level of federal funding. Last November HEAL (the Health Action Lobby, an umbrella group representing health care organizations, including the CMA) told a Commons committee that Ottawa should permanently earmark a portion of federal transfers to the provinces exclusively for health care. Clemenhagen says this would ensure "that Ottawa has the moral and practical authority to expect compliance with the Canada Health Act." Without it, she argues, Ottawa will lose its clout and control. Every province will take the message that there are no national standards, and the publicly funded system will dissolve.

Will the federal government strengthen its commitment to the public system? Armstrong is not optimistic, because the CMA's discussions with the departments of health and finance have suggested that their only priority is fiscal restraint. And if the government took the step urged by HEAL, it would be abandoning its commitment to the other provincial programs that are partially financed by federal transfers: welfare and postsecondary education. In January, Finance Minister Paul Martin explicitly rejected the HEAL suggestion. "There is no doubt about the absolute necessity of ensuring that medicare is protected," he said. "But I also think there are other responsibilities out there as well."

Public opinion polls have a strong impact on political will. "I have seen a very acute shift of opinion within the past 8 years on how sacred health care really is," Vaz remarks. "Both Ralph Klein and Mike Harris are making much deeper cuts than they promised in their election campaigns, and by and large they are getting away with it."

If Canadians' attachment to medicare continues to loosen, it is unlikely that Ottawa will go out of its way to save it.

| CMAJ March 1, 1996 (vol 154, no 5) |
ason why some of the participants had not used them. Checklists and inset boxes tended to be the parts most often read. Text was described as "too wordy." Recommendations included more tables, algorithms, bulleted points and white space, less text, larger type and plainer language.

Practicality

Practical guidance was required in some areas, particularly legal and ethical issues. For example, what constitutes informed consent? What are the codes most often used to identify a patient (e.g., a patient's birth date or billing number)? What is a physician's responsibility regarding notification of an HIV-positive patient's sexual or drug-using partner(s)?

Other areas requiring clarification included the definition of the "window period" between exposure to HIV and seroconversion, how best to tell a patient about a positive test result, new issues such as rapid HIV testing, and specific issues concerning counselling of people from different cultural backgrounds and living situations (e.g., ethnic communities, street people).

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Discussion

The focus groups provided detailed, credible and consistent information about the face and content validity of the CMA's HIV counselling guidelines. The guidelines are relevant, particularly to practising physicians with no specific expertise in HIV/AIDS care who are required to test patients for HIV infection and counsel them. To improve clarity, various changes to format and text were recommended. Practical guidance was felt to be needed mostly in legal and ethical areas.

The main limitation of the study is its generalizability. Women were overrepresented and rural physicians underrepresented in the focus groups. This bias may have been due in part because of the nonrandom sampling method used in some of the cities and because the focus groups were held in urban centres only. The inclusion of a survey or interviews in the evaluation design might have helped to reach a broader range of physicians (e.g., those in rural areas) and to assess patients' reactions. However, although some evaluators agree with combining qualitative and quantitative approaches,[33] others are strictly opposed to this.[34]

There are several strengths of the study. An in-depth understanding of the issues was achieved through substantial interaction among the physicians in the focus groups. Innovative ideas surfaced and were tested in a dynamic forum. The participants felt comfortable in sharing practice dilemmas with their peers and in expressing their discomforts about HIV testing and counselling. Finally, the information was gathered quickly (over 5 months), which greatly facilitated the revision of the guidelines. The third edition of the HIV counselling guidelines was published by the CMA in May 1995.[35]

In conclusion, results from this study suggest that qualitative evaluations of CPGs can be useful, particularly at the inception stage of guidelines development, when an in-depth scope of coverage and dynamic group interaction are valuable in identifying improvements. In addition to the involvement of health care providers, consideration should be given to patient participation and the combining of qualitative and quantitative evaluation methods.

We thank the members of the expert working group (Marc Steben, MD [chair]; Catherine A. Hankins, MD [cochair]; Michael V. O'Shaughnessy, PhD; Allan D. Peterkin, MD; and Gerry Bally, MD) for their valuable insights into the use of focus groups to evaluate clinical practice guidelines; Pamela Thompson, MSc, president of INPRO Consulting, and her associates for their work on the focus groups; and, from the CMA Department of Health Care and Promotion, Anne Carter, MD, and Susan Beardall, MHSc, for their helpful reviews and suggestions, and Anita Kothari, MHSc, for performing the literature search.

Financial and staff support for this study was provided from Health Canada and the Canadian Medical Association.

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References

  1. Carter AO, Battista RN, Hodge MJ et al: Report on activities and attitudes of organizations active in the clinical practice guidelines field. CMAJ 1995; 153: 901-907
  2. A Compendium of Quality of Care Developments in Canada, Canadian Medical Association, Ottawa, 1994: vii
  3. Guidelines for Canadian Clinical Practice Guidelines, Canadian Medical Association, Ottawa, 1992: 1
  4. Woolf SH: Practice guidelines, a new reality in medicine. Arch Intern Med 1992; 152: 946-952
  5. Mittman BS, Tonesk X, Jacobson PD: Implementing clinical practice guidelines: social influence strategies and practitioner behavior changes. QRB Qual Rev Bull 1992; 18: 413-422
  6. Audet A, Greenfield S, Field M: Medical practice guidelines: current activities and future directions. Ann Intern Med 1990; 113: 709-714
  7. Lomas J, Anderson GM, Domnick-Pierre K et al: Do practice guidelines guide practice? N Engl J Med 1989; 321: 1306-1311
  8. Field MJ, Lohr KN (eds): Guidelines for Clinical Practice: from Development to Use, National Academy Press, Washington, 1992: 27
  9. Battista RN, Hodge MJ: Clinical practice guidelines: between science and art. CMAJ 1993; 148: 385-389
  10. Basinski ASH: Evaluation of clinical practice guidelines. CMAJ 1995; 153: 1575-1581
  11. Health Services Research Group: Standards, guidelines and clinical policies. CMAJ 1992; 146: 833-837
  12. Kelly JT, Toepp MC: Practice parameters: development, evaluation, dissemination, and implementation. QRB Qual Rev Bull 1992; 18: 405-409
  13. Grimshaw JM, Russell IT: Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342: 1317-1322
  14. Carter A: Total quality management and clinical guidelines. [presentation] Quality Assessment and Technology Assessment, Charlottetown, Sept 24, 1993
  15. Carter A: Guidelines for guidelines: the Canadian experience. [presentation] World Organization of National Colleges, Academies and Academic Associations of General Practitioners and Family Physicians/Societas Internationalis Medicinae Generalis Congress: Quality of Care in Family Medicine/General Practice, The Hague, the Netherlands, June 13-17, 1993
  16. Fink A: Evaluation Fundamentals: Guiding Health Programs, Research, and Policy, Sage Publications, Newbury Park, Calif, 1993: 8-10
  17. Patton MQ: Utilization-Focused Evaluation, Sage Publications, Newbury Park, Calif, 1986: 65-66
  18. Posavac EJ, Carey RG: Program Evaluation: Methods and Case Studies, 4th ed, Prentice Hall, Englewood Cliffs, NJ, 1992: 12
  19. Russell IT, Grimshaw JM: The effectiveness of referral guidelines: a review of the methods and findings of published evaluations. In Roland M, Coulter A (eds): Hospital Referrals, Oxford University Press, New York, 1992: 179-211
  20. Patton MQ: Qualitative Evaluation Methods, Sage Publications, Beverly Hills, Calif, 1980: 39-48, 98-107
  21. Patton MQ: How to Use Qualitative Methods in Evaluation, Sage Publications, Newbury Park, Calif, 1987: 9-10
  22. Guba EG, Lincoln YS: Fourth Generation Evaluation, Sage Publications, Newbury Park, Calif, 1989: 158-162
  23. Pope C, Mays N: Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ 1995; 311: 42-45
  24. Fraenkel JR, Wallen NE: How to Design and Evaluate Research in Education, McGraw-Hill Publishing, Toronto, 1990: 379-380
  25. Morgan DL: Focus Groups as Qualitative Research. Vol 16 of Sage University Paper Series on Qualitative Research Methods, Sage Publications, Newbury Park, Calif, 1988: 10
  26. Quatromoni PA, Milbauer M, Posner BM et al: Use of focus groups to explore nutrition practices and health beliefs of urban Caribbean Latinos with diabetes. Diabetes Care 1994; 17: 869-873
  27. Palm L, Windahl S: Focus groups -- some suggestions. Scand J Prim Health Care Suppl 1988; 1: 91-95
  28. Ramirez A, Sheppard J: The use of focus groups in health research. Scand J Prim Health Care Suppl 1988; 1: 81-90
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  33. Strauss A, Corbin J: Basics of Qualitative Research: Grounded Theory Procedures and Techniques, Sage Publications, Newbury Park, Calif, 1990: 17-32
  34. Leininger M: Current issues, problems, and trends to advance qualitative paradigmatic research methods for the future. Qual Health Res 1992; 2: 402
  35. Counselling Guidelines for HIV Testing, Canadian Medical Association, Ottawa, 1995
| CMAJ March 1, 1996 (vol 154, no 5) |
her 1992; 46: 544-555
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    | CMAJ March 1, 1996 (vol 154, no 5) |
    es not have DS.[128] No study has adequately addressed possible psychologic harm to women with a positive result of a screening test who do not subsequently undergo amniocentesis.

    Of women undergoing second-trimester abortion because of a fetal abnormality, 80% reported an acute grief reaction, and in some cases the grief was prolonged.[131] The grief experienced by women who have terminated a pregnancy because of genetic indications may be as intense as that felt by those who lose a fetus spontaneously.[132]

    Use of prenatal diagnosis is related to views on the acceptability of pregnancy termination and to the perceived risk of abnormality in the fetus.[133] The role played by health care professionals in shaping beliefs may be important. Although most women feel that they are autonomous in their decision making, many feel there is a risk that they will be persuaded.[134] There is some evidence that individuals' perceptions of the risk of procedures and of DS may be inconsistent.[135] Some couples may accept the risk of amniocentesis even when the chance of having a fetus with DS is very low. The perception of the nature of the disability may play a greater role in the decision than its probability of occurrence.[136-138]

    The psychologic implications of having no access to prenatal diagnosis or of giving birth to an infant with DS must be weighed against those of receiving false-positive results of screening tests, of undergoing the procedures and of making decisions concerning diagnosis and termination. No study has contrasted these benefits and harms directly. Although a randomized controlled trial of screening versus no screening, in which psychologic as well as physical outcomes were compared, would address these issues directly, the challenge of conducting such a trial may be onerous given the values and preferences involved. It remains to be shown whether decision analysis (such as that used to study the decisions concerning amniocentesis versus CVS[126]) or other approaches would clarify the balance of harms and benefits.

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    Effect of prenatal diagnosis

    Crude estimates of the reduction in live births of infants with DS as a result of prenatal diagnosis offered to women 35 years and older range from 7.3% to 20%.[139-142] The reduction in birth rates of infants with DS appears to be due, at least in part, to a disproportionately higher use of pregnancy termination, without prenatal diagnosis, among older women in certain areas.[143,144] The effect of triple-marker screening has yet not been assessed widely. Attempts have been made to gauge the economic effect of prenatal screening for and diagnosis of DS.[43,145-149] Triple-marker screening is thought to be a more cost-effective approach to prevention than amniocentesis, CVS or single-marker screening.[43,147,149] However, the complex, value-laden ethical and methodologic issues underlying economic analyses in this context are beyond the scope of these guidelines.

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    Recommendations

    The task force's recommendations, and the strength of the evidence supporting them, are summarized in Table 3.

    There is fair evidence (grade B recommendation) to offer triple-marker screening to women under 35 years of age within a comprehensive screening and prenatal-diagnosis program including education, interpretation and follow-up. However, there is concern about the limited sensitivity of the screening test, the number of women who receive false-positive results and the number of women who receive positive results but do not subsequently undergo amniocentesis. These limitations may place a heavy burden on family physicians and obstetricians to inform fully all parents interested in screening. Screening of maternal serum markers outside of a comprehensive program is not recommended.

    Women provided with detailed information on serum-marker screening may demonstrate more knowledge of the procedure and more satisfaction with it. Relevant information about triple-marker screening may include (1) the limited sensitivity and specificity of screening, (2) the time sequence, nature and risks of prenatal diagnosis and second-trimester abortion, and (3) the psychologic implications of screening and diagnosis as well as the implications of having a child with DS.

    There is fair evidence (grade B recommendation) to offer prenatal diagnosis with CVS or amniocentesis, accompanied by information on the limitations and advantages of each procedure, to women who are 35 years of age or over, who have had a previous fetus with DS or who are carriers of chromosome 21 rearrangements. The quality of evidence concerning the balancing of all risks with benefits among these women is limited; therefore, a grade A recommendation has not been made. However, the potential benefit in reducing distress among women who are at a high risk of having a fetus with DS is clearly substantial. Although triple-marker screening has been advocated as a more efficient method of diagnosing DS among fetuses of women at a high risk (older than 35 years of age), its value as a replacement for CVS or amniocentesis in high-risk groups has not been assessed. However, some women in this age group may see triple-marker screening as an attractive alternative that provides a chance of avoiding prenatal diagnostic procedures. Accordingly, it may be offered as an alternative to prenatal diagnosis for women 35 years or older.

    There is insufficient evidence to offer testing of single maternal-serum markers (such as AFP alone) specifically for screening of DS. However, maternal serum AFP measurement may be offered to screen for neural tube defects. An abnormal AFP result, which suggests a risk of DS in the fetus, necessitates subsequent counselling and offering of prenatal diagnosis.

    Ultrasonographic screening with the use of long-bone and nuchal skinfold measurements is not currently recommended as a method of screening for DS because there is insufficient evaluation of its effectiveness, insufficient comparison with triple-marker screening and concern about the reliability and generalizability of these techniques.

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    Validation

    Several other groups have made recommendations concerning screening for and prenatal diagnosis of DS.[110,150-157] Amniocentesis and CVS have been recommended for prenatal diagnosis in high-risk groups by the US Preventive Services Task Force[152] and the Society of Obstetricians and Gynaecologists of Canada, in conjunction with the Canadian College of Medical Geneticists.[153] There have been no recommendations made concerning maternal serum triple-marker screening or ultrasonographic screening. The Cochrane Pregnancy and Childbirth Group has recently reviewed several topics in prenatal diagnosis and has made conclusions regarding amniocentesis, and transcervical and transabdominal CVS that are consistent with these recommendations.[110,154-157] The US Centers for Disease Control and Prevention have also recently published recommendations on prenatal counselling about CVS and amniocentesis that are consistent with these recommendations.[158]

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    Research questions

    These guidelines were developed and endorsed by the Canadian Task Force on the Periodic Health Examination, which is funded by the Health Services and Promotion Branch, Health Canada, and by the National Health Research and Development Program.

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    References

    1. Canadian Task Force on the Periodic Health Examination: The periodic health examination. CMAJ 1979; 121: 1193-1254
    2. Proceed with Care: Final Report of the Royal Commission on New Reproductive Technologies, Royal Commission on New Reproductive Technologies, Ottawa, 1994: 804-809
    3. Ethics and Public Policy Committee, Canadian College of Medical Geneticists: Prenatal diagnosis: the medical genetics perspective. CMAJ 1991; 144: 1129-1132
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