Objectives
US Department of Veterans Affairs (VA) patients with genetics referrals are 1.5 times more likely to have multiple cancer screening and preventive procedures if they completed their genetic consultations, but only when completed under a VA traditional model staffed by a team of clinical geneticists and genetic counselors versus a VA nontraditional, centralized telehealth model staffed by genetic counselors working independently. We sought to understand the reasons for these differences in cancer screening and prevention uptake.
Methods
We reviewed randomly selected medical records of patients with cancer genetics referrals stratified by model (142 records from each model). We conducted semi-structured interviews with 15 genetics providers and 36 referring clinicians from 13 VA facilities using purposive sampling. We analyzed annotated medical records and interview transcripts using a rapid assessment process. We characterized annotations as personalized recommendations (eg, begin colonoscopy at age 30 then every 1-2 years), options (eg, consider bilateral mastectomy), and generic messages (eg, refer to guidelines or another provider).
Results
Cancer screening or prevention was documented in 80 traditional-model records (141 annotations) and 106 nontraditional-model records (143 annotations). Personalized recommendations comprised 69% (97/141) of annotations within traditional-model records and 30% (43/143) within nontraditional-model records. Generic messages comprised 17% (24/141) of annotations in traditional-model records and 51% (73/143) in nontraditional-model records. From interview data, referring clinicians expected a broad range of services from genetics providers, including management and screening recommendations, and stated their role was to follow through on recommendations made. Under the traditional model, geneticists formulated recommendations documented by genetic counselors. Under the nontraditional model, scope of practice limited how genetic counselors addressed cancer screening and prevention.
Conclusions/Impacts
Personalized recommendations were typical of traditional-model records, whereas nontraditional-model records usually had generic messages. Compared with the nontraditional model, the traditional model was more patient-centered and better meets expectations of referring clinicians, which might explain in part the differences in patient uptake of cancer screening and preventive procedures.
As the demand for genetic services grows, the VA should promote team-based care under the traditional model for a more patient-centered, coordinated, and effective system of care for precision oncology.
