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2019 HSR&D/QUERI National Conference Abstract

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4111 — Variations in care delivery models for genomic medicine consults in VA

Lead/Presenter: Alexis Huynh,  COIN - Los Angeles
All Authors: Huynh A (VA Greater Los Angeles Healthcare System), Chanfreau-Coffinier C (Salt Lake City VA, VINCI), Lerner B (VA Boston Healthcare System) Russell MM (VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA) Scheuner MT (San Francisco VA Healthcare System, UCSF School of Medicine)

Objectives:
VA has two types of healthcare models to fulfill genomic medicine consults: a traditional model led by a medical geneticist and a non-traditional model comprised of a team of genetic counselors. We sought to examine whether there are differences in reason for referral or completion of the consult request by genetic healthcare model.

Methods:
We conducted a retrospective study using the VA Corporate Data Warehouse to identify all genomic medicine consult requests from 2010-2017. We extracted data describing patient characteristics, consult status, referral reason, and year of request. The association of these variables with genetic healthcare model was evaluated using a logistic regression model.

Results:
There were 24,956 unique patients with genomic medicine consults from 2010-2017; with the majority (58.5%) referred to the non-traditional model. Mean age was 50.6 years (SD, 14.9), 51% were female, and 63.1% white. Cancer was the most common referral reason (39.5%), followed by gastrointestinal disorders/colon polyps (6.6%), neurological/psychiatric disorders (5.4%), and reproductive concerns (2.9%). Under the non-traditional model, consults were less likely to be completed (OR = 0.88 [0.82-0.95]), and the referrals were 18-37% less likely to be anything but cancer or neurological/psychiatric disorders (P < 0.001). Other significant associations with the non-traditional model include: female sex (OR = 1.73 [1.61-1.87]); age less than 40 (OR = 0.83 [0.77-0.89]); and compared to whites, Hispanic (OR = 0.60 [0.54-0.67]), African American (OR = 0.77 [0.72-0.84]) or other race (OR = 0.52 [0.46-0.58]).

Implications:
There are significant differences in the delivery of genomic medicine within the VA according to the genetic healthcare model used. The traditional model led by medical geneticists receives a greater breadth of consult requests, serves a more diverse patient population, and is more likely to complete consults compared to the non-traditional model. Further work is needed to understand these differences, and to determine whether there are additional differences in care coordination by care model.

Impacts:
As the demand for genomic medicine continues to grow, the VA should consider how best to respond by assessing the capacity of existing care models in relationship to clinical reasons for referral, and ensuring use of available healthcare models do not increase disparities in access to genomic medicine.