2023 HSR&D/QUERI National Conference

4140 — Team-based genetic consultation: An effective system of care for equitable delivery of precision oncology services

Lead/Presenter: Maren Scheuner
All Authors: Scheuner MT (San Francisco VA Health Care System, UCSF School of Medicine), Lerner B (Boston VA Health Care System) Coeshott R (San Francisco VA Health Care System) Gable A (VA Greater Los Angeles VA Health Care System) Huynh A (VA Greater Los Angeles VA Health Care System) Sales P (San Francisco VA Health Care System) Hoggatt K (San Francisco VA Health Care System, UCSF School of Medicine) Hamilton A (VA Greater Los Angeles Health Care System, David Geffen School of Medicine at UCLA) Russell M (VA Greater Los Angeles Health Care System, David Geffen School of Medicine at UCLA)

A nontraditional, centralized telehealth genetics program in the Department of Veterans Affairs (VA), staffed by genetic counselors working independently, enables access to these genetics provides across the enterprise (currently about 80 VA facilities). However, the improved access is not equitable with more women and fewer non-White patients referred to the nontraditional program compared with VA traditional programs staffed by teams of clinical geneticists and genetic counselors serving patients at one or more VA facilities via multiple modes of delivery, including telehealth. Moreover, the nontraditional program hindered care coordination. VA patients with genetics referrals were 1.5 times more likely to have multiple cancer screening and preventive procedures within two years following their referral if they completed their genetic consultations, but only when completed with the VA traditional programs. We sought to understand the reasons for these differences in cancer screening and prevention uptake.

We reviewed randomly selected medical records of patients with cancer genetics referrals stratified by the VA nontraditional program and the VA traditional programs (142 records for each model). Using purposive sampling, we conducted semi-structured interviews with 15 genetics providers from both the VA nontraditional and VA traditional genetics programs, and with 36 clinicians from 13 VA facilities who referred to either the VA nontraditional or the VA traditional programs. We analyzed the annotated medical records and interview transcripts using a rapid assessment process. We characterized annotations as personalized recommendations (e.g., “begin colonoscopy at age 30 then every 1-2 years”), options for consideration (e.g., “consider bilateral mastectomy”), and generic messages (e.g., “refer to the American Cancer Society guideline”, “refer to your gastroenterologist or surgeon for cancer screening recommendations”).

Cancer screening or prevention was documented in 80 traditional-program records (141 annotations) and 106 nontraditional-program records (143 annotations). Personalized recommendations comprised 69% (97/141) of annotations within the traditional-program records and only 30% (43/143) within the nontraditional-program records. Generic messages comprised 17% (24/141) of annotations in the traditional-program records and 51% (73/143) in nontraditional-program records. From interview data, we learned referring clinicians expected a breadth of services from genetics providers, including management and screening recommendations, and referring clinicians stated their role was to follow through on recommendations made. Under the traditional programs, geneticists formulated recommendations documented by themselves or the genetic counselors. Under the nontraditional program, scope of practice limited how the genetic counselors addressed cancer screening and prevention.

Personalized recommendations were typical of traditional-program records, whereas nontraditional-program records usually had generic messages. Compared with the nontraditional program, the traditional programs are more patient-centered and better meet 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 for a more patient-centered, coordinated, and effective system of care delivered by all VA genetics programs. This might be especially important to ensure equity in delivery of cancer screening and preventive services, especially for women at risk for cancer referred to the nontraditional program.