A cancer genetics toolkit improves access to genetic services through documentation and use of the family history by primary-care clinicians

Abstract

Purpose:We developed, implemented, and evaluated a multicomponent cancer genetics toolkit designed to improve recognition and appropriate referral of individuals at risk for hereditary cancer syndromes. Methods:We evaluated toolkit implementation in the women's clinics at a large Veterans Administration medical center using mixed methods, including pre-post semistructured interviews, clinician surveys, and chart reviews, and during implementation, monthly tracking of genetic consultation requests and use of a reminder in the electronic health record. We randomly sampled 10% of progress notes 6 months before (n = 139) and 18 months during implementation (n = 677). Results:The toolkit increased cancer family history documentation by almost 10% (26.6% pre-and 36.3% postimplementation). The reminder was a key component of the toolkit; when used, it was associated with a twofold increase in cancer family history documentation (odds ratio = 2.09; 95% confidence interval: 1.39-3.15), and the history was more complete. Patients whose clinicians completed the reminder were twice as likely to be referred for genetic consultation (4.1-9.6%, P < 0.0001). Conclusion:A multicomponent approach to the systematic collection and use of family history by primary-care clinicians increased access to genetic services.

Primary care providers’ cancer genetic testing-related knowledge, attitudes, and communication behaviors: A systematic review and research agenda

“…40 One study evaluated an intervention designed to influence PCPs' genetic testing knowledge and clinical behaviors. 52 Scheuner and colleagues used a mixed-method study design and medical record abstraction to evaluate the feasibility and effectiveness of a multicomponent cancer genetics toolkit in the context of women's primary care clinics at a Veterans Administration medical center. Among seven primary care physicians, nurse practitioners, and physician assistants, toolkit use improved knowledge about cancer genetics [mean total correct responses increased from 59% (range: 26%-77%) pre-implementation to 73% (range: 52%-90%) postimplementation].…”

“…33,34,[41][42][43][44][45]51,52,55,56 Of these, five studies examined PCPs' views about ethical, legal, or social implications of testing. 33,41,43,44,55 These studies noted varying beliefs about the effect of genetic testing on patients' anxiety.…”

“…31,33,34,39,41,45,52,54,57 Of these, four studies provided descriptive information about PCPs' experiences discussing genetic risk and testing (2 relying on surveys in the breast cancer context 41,45 and 1 using mixed-methods in the prostate cancer context 33 ). The other used a novel study design featuring standardized patients to evaluate communication behaviors among 86 providers and found that in only 21% and 3% of encounters did providers express opinions suggesting that patients at high maternal or paternal breast cancer risk, respectively, were candidates for genetic testing.…”

“…31,52,57 For instance, as noted, Scheuner and colleagues evaluated a multicomponent cancer genetics toolkit targeted at providers that improved their discussion and documentation of cancer family history and appropriate patient referrals for genetic consultation. 52 Another study evaluated an educational intervention among 121 primary care physicians and found that some communication behaviors improved (e.g., 78% of intervention physicians explored genetic counseling benefits with a standardized patient versus 61% of controls); however, the intervention did not lead to significant differences in the offering of a genetic counseling referral or recommending of genetic testing. 31 …”

Assessing multilevel determinants of adoption and implementation of genomic medicine: an organizational mixed-methods approach

“…As a result, a multicomponent toolkit was developed; it included patient-, provider-and organizational-level interventions designed to facilitate family history risk assessment by primary-care clinicians and referral of patients with appropriate indications for genetic consultation. 38 Panel members and stakeholders representing differing viewpoints of the organizational hierarchy consulted on the design and implementation of this toolkit, helping to successfully tailor its implementation to local organizational conditions.…”