1038 — Genetics providers are key to the integration of genetic testing within the practice of frontline clinicians

Lead/Presenter: Maren Scheuner, 
All Authors: Scheuner MT (San Francisco VA Health Care System, UCSF School of Medicine), Sales P (San Francisco VA Health Care System) Hoggatt K (San Francisco VA Health Care System, UCSF School of Medicine) Zhang N (San Francisco VA Health Care System) Whooley MA (San Francisco VA Health Care System, UCSF School of Medicine) Kelley MJ (VA National Oncology Program Office)

Objectives:
Genetic information can transform health care by making it more personalized and proactive, resulting in improved health outcomes through better diagnosis, prognosis, risk assessment, prevention, and treatment. The number of genetics professionals has not kept pace with the demand for genetic services, and there is limited ability to grow the genetics workforce in the near term. Frontline clinicians will become key to ensuring access to genetic testing. We sought to understand the use of genetic tests in the practice of frontline clinicians within the US Department of Veterans Affairs (VA).

Methods:
We administered a web-based survey to clinicians at 20 VA facilities with precision oncology expertise. We assessed clinician experience and confidence with genetic testing, preferences for roles and responsibilities relating to genetic testing, and genetics education needs. Physicians, nurse practitioners (NPs), physician assistants (PAs), and pharmacists were eligible. We excluded genetics providers and clinicians not seeing patients. We used multiple logistic regression to evaluate associations between clinician characteristics and currently ordering genetic tests.

Results:
The response rate was 11.3% (1,207/10,680) and 909 were eligible. The majority were physicians (63.0%), followed by NPs (21.9%), pharmacists (10.1%), and PAs (5%). Most (59.0%) were non-cancer specialists, 30.8% were primary care clinicians and 10.2% were cancer specialists. Only 20.8% reported feeling prepared to use genetic tests, 28.9% had referred at least one patient to genetics in the past year, and 13.0% were currently ordering genetic tests, though usually only one or two a year. Delivery of genetic tests without involving genetics providers was preferred by only 7.9%. Characteristics positively associated with currently ordering genetic tests included cancer specialty (OR = 2.52, 95% CI: 1.17-5.43, p = .02), seeing patients in both clinical and research settings compared with clinical only (OR = 2.46, 95% CI: 1.15-5.24, p = .02), believing improving genetics knowledge could alter their practice (OR = 1.85, 95% CI: 1.29-2.66, p = .001), feeling prepared to use genetic tests (OR = 7.72, 95% CI: 4.75-12.53, p < .001), and referral of at least one patient to genetics in the past year (OR = 3.48, 95% CI: 1.75-6.91, p < .001). On average, 17.2% had attended genetics education in the past year (primary care, 9.3%; non-cancer specialists, 21.3%; and cancer specialists, 17.2%, p < .001). On average, 45% thought improving genetic testing knowledge could change their practice (primary care, 48.6%; non-cancer specialists, 43.3%; and cancer specialists, 44.1%, p = .09). The top-rated educational priorities included: common genetic disorders relevant to their practice, recognizing patients who may benefit from genetic testing, pharmacogenetic tests to inform treatment, and knowing the different types of genetic tests. The clinical genetics team was the preferred choice for how to receive updates on genetics.

Implications:
Genetic testing is infrequently used by frontline clinicians in the VA and these clinicians remain underprepared to use genetic tests in their practice. As clinicians use genetic testing in their practice, there is a paradoxical positive association with genetics referrals.

Impacts:
The demand for genetics providers should increase as frontline clinicians integrate genetics into their practice. These findings should be considered in workforce planning, and the education and training of frontline clinicians.