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Barriers and Facilitators to Diffusion of Genomic Services for Colorectal Care in the Veterans Health Administration

Sperber N, Morris S, Voils CI, Knight S, Provenzale D. Barriers and Facilitators to Diffusion of Genomic Services for Colorectal Care in the Veterans Health Administration. Paper presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.




Abstract:

RESEARCH OBJECTIVE: Although advances in cancer genomics are rapidly being made, relatively little has been reported about effectively integrating genomic services into routine clinical care. There are established guidelines for when genomic services should be used for colorectal cancer (CRC), which indicate that all CRC patients under age 50 should receive at least one service; however, these guidelines have not been widely adopted. Accordingly, the study objective was to inform efficient delivery of genomic services for patients within the Veterans Health Administration (VA), an integrated health system that includes a new telegenomic counseling service. Specific goals were to identify barriers and facilitators to providing genomic services to individuals with hereditary CRC in the VA. A qualitative approach was used for in-depth exploration of how providers use genomic services for colorectal care. STUDY DESIGN: We conducted individual semi-structured interviews with providers at VA medical centers, inquiring about use of four genomic services: family history documentation, molecular analysis, genetic counseling, and genetic testing. Two theoretical frameworks, the Diffusion of Innovation Model and the Andersen Behavioral Model, informed data collection and analysis by specifying a priori factors known to be important for both diffusion and utilization of health services (e.g., provider characteristics including knowledge about services, structural characteristics including access to services, and innovational factors including ease of use). We analyzed data using directed content analysis, which includes a priori and data derived codes. POPULATION STUDIED: We obtained data from providers at 21 VA medical centers, representing diverse geographical regions and oncology volumes. We interviewed clinical providers (N = 54) within specialties that encounter CRC patients: Primary Care (PCP's) (n = 11), Oncology (n = 12), Surgery (n = 7), Gastroenterology (n = 17), and Pathology (n = 7). PRINCIPAL FINDINGS: Provider awareness of genomic services for CRC varied by specialty: PCP's generally lacked knowledge about availability of services to evaluate risk for hereditary CRC, whereas gastroenterologists and oncologists were more likely to consider using genomic services in CRC care. Among providers who were aware of the VA telegenomic counseling service, some said that having this service available through the VA facilitated referrals for genetic counseling, whereas others were unable to connect to the service, due to center or individual-level barriers. Other providers, unaware of the VA telegenomic service, said that they wished to have VA resources to support using genomics for detection of familial cancer syndromes. Providers at two of the 21 centers reported routine molecular testing for new CRC diagnoses. Additionally, family history documentation for CRC patients was generally not completed according to current guidelines; GI providers or surgeons were more likely to obtain patients' family history to screen for hereditary CRC at time of colonoscopy or surgery, but with limited detail due to lack of time and open-access scheduling. CONCLUSION: Use of genomic services for CRC care requires integration into the VA healthcare system; however, incomplete understanding about available clinical services and methods to access them are factors limiting implementation. IMPLICATIONS FOR POLICY OR PRACTICE: Policies could encourage adherence to current clinical guidelines for detecting hereditary CRC, such as by supporting routine tumor analysis for CRC patients under age 50 and providing a standardized template for collecting family health history. Additional communication with providers should be initiated in order to establish and disseminate well-defined processes for accessing genomic services.





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