scholarly journals Comparing models of delivery for cancer genetics services among patients receiving primary care who meet criteria for genetic evaluation in two healthcare systems: BRIDGE randomized controlled trial

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Kimberly A. Kaphingst ◽  
Wendy Kohlmann ◽  
Rachelle Lorenz Chambers ◽  
Melody S. Goodman ◽  
Richard Bradshaw ◽  
...  
Keyword(s):  
Primary Care ◽  
Genetic Counseling ◽  
Cancer Susceptibility ◽  
Cancer Genetics ◽  
Controlled Trial ◽  
Standard Of Care ◽  
Healthcare Systems ◽  
Genetic Services ◽  
Inherited Cancer ◽  
Services Delivery

Abstract Background Advances in genetics and sequencing technologies are enabling the identification of more individuals with inherited cancer susceptibility who could benefit from tailored screening and prevention recommendations. While cancer family history information is used in primary care settings to identify unaffected patients who could benefit from a cancer genetics evaluation, this information is underutilized. System-level population health management strategies are needed to assist health care systems in identifying patients who may benefit from genetic services. In addition, because of the limited number of trained genetics specialists and increasing patient volume, the development of innovative and sustainable approaches to delivering cancer genetic services is essential. Methods We are conducting a randomized controlled trial, entitled Broadening the Reach, Impact, and Delivery of Genetic Services (BRIDGE), to address these needs. The trial is comparing uptake of genetic counseling, uptake of genetic testing, and patient adherence to management recommendations for automated, patient-directed versus enhanced standard of care cancer genetics services delivery models. An algorithm-based system that utilizes structured cancer family history data available in the electronic health record (EHR) is used to identify unaffected patients who receive primary care at the study sites and meet current guidelines for cancer genetic testing. We are enrolling eligible patients at two healthcare systems (University of Utah Health and New York University Langone Health) through outreach to a randomly selected sample of 2780 eligible patients in the two sites, with 1:1 randomization to the genetic services delivery arms within sites. Study outcomes are assessed through genetics clinic records, EHR, and two follow-up questionnaires at 4 weeks and 12 months after last genetic counseling contactpre-test genetic counseling. Discussion BRIDGE is being conducted in two healthcare systems with different clinical structures and patient populations. Innovative aspects of the trial include a randomized comparison of a chatbot-based genetic services delivery model to standard of care, as well as identification of at-risk individuals through a sustainable EHR-based system. The findings from the BRIDGE trial will advance the state of the science in identification of unaffected patients with inherited cancer susceptibility and delivery of genetic services to those patients. Trial registration BRIDGE is registered as NCT03985852. The trial was registered on June 6, 2019 at clinicaltrials.gov.

Downstream Revenue Generated by a Cancer Genetic Counselor

2021 ◽  
pp. OP.20.00464 ◽  
Author(s):  
Caitlin B. Mauer ◽  
Brian D. Reys ◽  
Reece E. Hall ◽  
Connor L. Campbell ◽  
Sara M. Pirzadeh-Miller
Keyword(s):  
Genetic Counseling ◽  
Cancer Genetics ◽  
Healthcare Systems ◽  
Pathogenic Variant ◽  
Full Time ◽  
Cancer Genetic ◽  
Pathogenic Variants ◽  
Cancer Susceptibility Genes ◽  
Relative Value ◽  
Management Recommendations

QUESTION ASKED: How much downstream revenue do cancer genetic counselors (GCs) generate when they identify patients with hereditary breast and ovarian cancer (HBOC) ( BRCA1/BRCA2) and Lynch syndrome (LS) pathogenic variants? SUMMARY ANSWER: Over a 10-year period, the downstream revenue generated from cancer GCs’ identification of patients with HBOC and LS was $32.79 million in US dollars (USD) (mean/year = $3.25 million USD and mean/patient = $77,000 USD). One full-time GC would generate $1.49-$1.86 million USD in revenue per year ($1.26-$1.58 million USD for HBOC-positive patients and $227-$284,000 USD for LS-positive patients per year). WHAT WE DID: Expected reimbursement and work relative value units (wRVUs) were collected from all hospital and ambulatory or outpatient encounters for patients with HBOC or LS identified in the Cancer Genetics clinic. Total revenue was calculated for each patient after they met with a GC; patients were stratified into categories of affected or unaffected status and new or established patients in the hospital system. WHAT WE FOUND: The downstream revenue generated from 425 patients with HBOC or LS mutations totaled $32,798,000 USD and 73,957 work relative value units after their cancer genetics appointments. Patients unaffected with cancer (n = 176) generated $8,453,000 USD, whereas naïve patients (n = 96), defined as those whose first visit to the institution was for a genetic counseling consultation, generated $5,933,000 USD. BIAS, CONFOUNDING FACTOR(S): This study solely focuses on revenue generated from patients with HBOC or LS. However, with the advent of next-generation sequencing panels, many pathogenic variants are being identified in other genes, resulting in enhanced management recommendations. Therefore, the revenue brought in by a GC likely surpasses the data provided here. Additionally, these data focus strictly on downstream revenue generated from patients receiving follow-up care at our institution. Patient adherence to compliance of management recommendations can affect the overall amount of revenue generated. REAL-LIFE IMPLICATIONS: To our knowledge, this is the first study to describe the amount of revenue generated for an institution downstream of the identification of pathogenic variant carriers in cancer susceptibility genes by a GC. These data will aid healthcare systems and oncology practices in determining if there is standalone fiscal value to the downstream effect of genetic counseling services or if services need to be supplemented through other avenues. By identifying clinic demographics and volumes, test uptake rate, and positive pathogenic variant rate, cancer GCs and healthcare systems or oncology practices can determine the expected revenue generated from HBOC and LS pathogenic variant carriers at their own institution to justify positions and growth of their genetic counseling departments ( Fig. 1 ).

Outcomes of Treatment for Hepatitis C in Primary Care, Compared to Hospital-based Care: A Randomized, Controlled Trial in People Who Inject Drugs

2019 ◽  
Vol 70 (9) ◽  
pp. 1900-1906 ◽  
Author(s):  
Amanda J Wade ◽  
Joseph S Doyle ◽  
Edward Gane ◽  
Catherine Stedman ◽  
Bridget Draper ◽  
...  
Keyword(s):  
Primary Care ◽  
Hepatitis C ◽  
People Who Inject Drugs ◽  
Controlled Trial ◽  
Standard Of Care ◽  
Virologic Response ◽  
World Health ◽  
Specialist Care ◽  
Treatment Uptake ◽  
Historical Controls

Abstract Background To achieve the World Health Organization hepatitis C virus (HCV) elimination targets, it is essential to increase access to direct-acting antivirals (DAAs), especially among people who inject drugs (PWID). We aimed to determine the effectiveness of providing DAAs in primary care, compared with hospital-based specialist care. Methods We randomized PWID with HCV attending primary care sites in Australia or New Zealand to receive DAAs at their primary care site or local hospital (standard of care [SOC]). The primary outcome was to determine whether people treated in primary care had a noninferior rate of sustained virologic response at Week 12 (SVR12), compared to historical controls (consistent with DAA trials at the time of the study design); secondary outcomes included comparisons of treatment initiation, SVR12 rates, and the care cascade by study arm. Results We recruited 140 participants and randomized 136: 70 to the primary care arm and 66 to the SOC arm. The SVR12 rate (100%, 95% confidence interval [CI] 87.7–100) of people treated in primary care was noninferior when compared to historical controls (85% assumed). An intention-to-treat analysis revealed that the proportion of participants commencing treatment in the primary care arm (75%, 43/57) was significantly higher than in the SOC arm (34%, 18/53; P < .001; relative risk [RR] 2.48, 95% CI 1.54–3.95), and the proportion of participants with SVR12 was significantly higher in the primary care arm, compared to in the SOC arm (49% [28/57] and 30% [16/53], respectively; P = .043; RR 1.63, 95% CI 1.0–2.65). Conclusions Providing HCV treatment in primary care increases treatment uptake and cure rates. Approaches that increase treatment uptake among PWID will accelerate elimination strategies. Clinical Trials Registration NCT02555475.

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

2013 ◽  
Vol 16 (1) ◽  
pp. 60-69 ◽  
Author(s):  
Maren T. Scheuner ◽  
Alison B. Hamilton ◽  
Jane Peredo ◽  
Taylor J. Sale ◽  
Colletta Austin ◽  
...  
Keyword(s):  
Primary Care ◽  
Family History ◽  
Cancer Genetics ◽  
Genetic Services ◽  
The Family ◽  
Access To Genetic Services ◽  
Primary Care Clinicians

Effect of Routine Assessment of Specific Psychosocial Problems on Personalized Communication, Counselors' Awareness, and Distress Levels in Cancer Genetic Counseling Practice: A Randomized Controlled Trial

2014 ◽  
Vol 32 (27) ◽  
pp. 2998-3004 ◽  
Author(s):  
Willem Eijzenga ◽  
Neil K. Aaronson ◽  
Daniela E.E. Hahn ◽  
Grace N. Sidharta ◽  
Lizet E. van der Kolk ◽  
...  
Keyword(s):  
Genetic Counseling ◽  
Cancer Genetics ◽  
Controlled Trial ◽  
Intervention Group ◽  
Psychosocial Problems ◽  
Genetic Counselors ◽  
Cancer Genetic Counseling ◽  
Control Group ◽  
Counseling Session ◽  
Routine Assessment

Purpose This study evaluated the efficacy of a cancer genetics–specific questionnaire in facilitating communication about, awareness of, and management of psychosocial problems, as well as in lowering distress levels. Methods Individuals referred to genetic counseling for cancer at two family cancer clinics in the Netherlands were randomly assigned to an intervention or a control group. All participants completed the psychosocial questionnaire before counseling. In the intervention group, the counselors received the results of this questionnaire before the counseling session. All sessions were audiotaped for content analysis. Primary outcomes were the frequency with which psychosocial problems were discussed, the genetic counselors' awareness of these problems, and their management. Secondary outcomes included cancer worries and psychological distress, duration and dynamics of the counseling, and satisfaction. Results The frequency with which psychosocial problems were discussed with 246 participating counselees was significantly higher in the intervention group (n = 127) than in the control group (n = 119; P = .004), as was the counselors' awareness of psychosocial problems regarding hereditary predisposition (P < .001), living with cancer (P = .01), and general emotions (P < .001). Counselors initiated more discussion of psychosocial problems in the intervention group (P < .001), without affecting the length of the counseling session. No significant differences were found on management (P = .19). The intervention group reported significantly lower levels of cancer worries (P = .005) and distress (P = .02) after counseling. Conclusion The routine assessment of psychosocial problems by questionnaire facilitates genetic counselors' recognition and discussion of their clients' psychosocial problems and reduces clients' distress levels.

Test of InheRET, an online tool to facilitate NCCN Guideline compliant referrals for cancer genetic counseling.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 1530-1530
Author(s):  
Lynn McCain ◽  
Kara J. Milliron ◽  
Amanda Cook ◽  
Lee Schroeder ◽  
James Arthurs ◽  
...  
Keyword(s):  
Primary Care ◽  
Genetic Counseling ◽  
Family History ◽  
Cancer Genetics ◽  
Ease Of Use ◽  
Cancer Genetic Counseling ◽  
Cancer Genetic ◽  
Increased Risk ◽  
The Family ◽  
The Impact

1530 Background: Identifying the ~60 million unaffected persons in the US at risk for inherited cancers has the potential to reduce their cancer risk by up to 95%. However, most of these individuals are not identified currently because of multifactorial deficits in the 3-generation pedigree collection in clinical settings. Methods: Here we evaluated the impact InheRET, an online family history gathering and risk assessment reporting tool, has on facilitating National Comprehensive Cancer Network (NCCN) Guideline-compliant referrals for cancer genetic counseling/genetic evaluation by decreasing and/or removing the barriers of 1) in-clinic 3-generation family history collection, and 2) interpretation of the family and personal history in light of current NCCN Guidelines. Patients enrolled from primary care and specialty clinics completed the family health history from a web-enabled devices using InheRET Inherited Risk Evaluation Tool. Results: Of 255 enrolled patients, 78.4% completed the history form and, of these, 86.5% completed the feedback survey. 39.2% of primary care and 79.9% of specialty cancer genetics patients were found to be at increased risk. Patients with ≤ HS education ranked InheRET at 4.7/5.0 for Understandability and 3.33/5.0 for Ease of Use. Following the addition of clarifying directions, they ranked InheRET at 5.0 and 4.0, respectively. Pts. <60 ranked InheRET between 3.5 and 3.8 on Ease of Use, while those 60-69 and 70+ ranked it 3.0 and 2.7, respectively, potentially reflective of lower technical skills. Age did not impact Understandability. In the cancer genetics clinic, 86% of pts. completed the online survey, in ~ 1 week, compared to paper forms, which required reminders, and >4 weeks to obtain. Conclusions: In this pilot, InheRET accelerated appropriate referrals and efficient utilization of genetic counseling services; improvements to navigation are being implemented prior to dissemination.

Experiences in physical activity promotion in health care settings for primary prevention in the UK

2014 ◽  
Vol 62 (2) ◽  
Keyword(s):  
Physical Activity ◽  
Primary Care ◽  
Health Professionals ◽  
Controlled Trial ◽  
Full Range ◽  
Tertiary Care ◽  
Physical Activity Promotion ◽  
Community Based ◽  
Activity Promotion ◽  
Randomised Controlled

In addition to the delivery of primary care services, recent changes to the NHS in the United Kingdom have placed increasing responsibility on GPs for the commissioning of the full range of health services from prevention through to clinical interventions and rehabilitation. Whilst historically there has always been an expectation that primary care professionals were ideally placed to provide support for prevention as well as treatment, their active engagement in the promotion of physical activity has remained largely superficial. With notable exceptions where individuals have a personal interest or commitment, the majority of health professionals tend to limit themselves to peremptory non-specific advice at best, or frequently don’t broach the subject at all. There are a number of reasons for this including increasing time pressures, a general lack of knowledge, limited evidence and concerns about litigation in the event of an adverse exercise induced event. However in the 1990s there was a surge of interest in the emerging “Exercise on Prescription” model where patients could be referred to community based exercise instructors for a structured “prescription” of exercise in community leisure centres. Despite the continuing popularity of the model there remain problems particularly in getting the active support of health professionals who generally cite the same barriers as previously identified. In an attempt to overcome some of these problems Wales established a national exercise referral scheme with an associated randomised controlled trial. The scheme evaluated well and had subsequently evolved with new developments including integration with secondary and tertiary care pathways, accredited training for exercise instructors and exit routes into alternative community based exercise opportunities.

The Evolution of Physical Activity on Prescription (FaR) in Sweden

2014 ◽  
Vol 62 (2) ◽  
Keyword(s):  
Physical Activity ◽  
Primary Care ◽  
Healthcare Professionals ◽  
Systems Approach ◽  
Ecological Model ◽  
Controlled Trial ◽  
Professional Associations ◽  
Successful Implementation ◽  
Surgeon General ◽  
Positive Effects

In 1996, the first Report of the US Surgeon General on Physical Activity and Health provided an extensive knowledge overview about the positive effects of physical activity (PA) on several health outcomes and PA recommendations. This contributed to an enhanced interest for PA in Sweden. The Swedish Professional Associations for Physical Activity (YFA) were appointed to form a Scientific Expert Group in the project “Sweden on the Move” and YFA created the idea of Physical Activity on Prescription (FaR) and the production of a handbook (FYSS) for healthcare professionals. In Swedish primary care, licensed healthcare professionals, i.e. physicians, physiotherapists and nurses, can prescribe PA if they have sufficient knowledge about the patient’s current state of health, how PA can be used for promotion, prevention and treatment and are trained in patient-centred counselling and the FaR method. The prescription is followed individually or by visiting local FaR providers. These include sport associations, patient organisations, municipal facilities, commercial providers such as gyms, sports clubs and walking clubs or other organisations with FaR educated staff such as health promoters or personal trainers. In clinical practice, the FaR method increases the level of PA in primary care patients, at 6 and at 12 months. Self-reported adherence to the prescription was 65% at 6 months, similar to the known compliance for medications. In a randomised controlled trial, FaR significantly improved body composition and reduced metabolic risk factors. It is suggested that a successful implementation of PA in healthcare depends on a combination of a systems approach (socio-ecological model) and the strengthening of individual motivation and capability. General support from policymakers, healthcare leadership and professional associations is important. To lower barriers, tools for implementation and structures for delivery must be readily available. Examples include handbooks such as FYSS, the FaR system and the use of pedometers.

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