Genetic counseling has benefits for health care decision-making and is now considered standard of care. The VA established the Genomic Medicine Service (GMS) in Salt Lake City, Utah to provide genomic services and counseling as a part of VA Patient Care Services. Because in-person genetic counseling is not feasible for most Veterans, GMS uses either telephone or videoconferencing for counseling. Each of these counseling delivery alternatives has its advantages and disadvantages, which vary depending on provider or patient's perspective.
To facilitate GMS' ability to provide high-quality genetic counseling for the entire VA health care system, we conducted a study to assess the following aims:
1) Compare retention of genetic counseling information provided to patients via telephone versus videoconferencing;
2) Use validated survey to quantitatively assess satisfaction with genetic counseling conducted via telephone versus videoconferencing;
3) Conduct interviews with patients and counselors to qualitatively assess positive and negative aspects of their experience, barriers, and facilitators with genetic counseling via telephone or videoconferencing;
4) Conduct an incremental cost analysis of the videoconferencing genetic counseling modality.
Since it is a common, relatively non-complex reason for referral, polyposis cases were ideal for comparison of the two delivery modalities. Per NCCN guidelines, inclusion criteria included patient's age 50 or greater, a finding of 10 or more lifetime adenomatous polyps or sessile polyps, no contributing family history, and the patient must be able to be reached by telephone and speak English. Exclusion criteria include complex family history (family members with other cancers) or one suggestive of a known colon cancer syndrome, unwillingness to travel to a VA site with videoconferencing capability, or diagnosis of colon cancer.
Patients with polyps referred to GMS for genetic counseling were screened and eligible subjects were consented and randomized by a research assistant at GMS. Genetic counseling was conducted either by telephone or videoconferencing as usual. Following the genetic counseling session, the patients' contact information was forwarded to the Durham project coordinator. She conducted the quantitative interview and invited participation to the qualitative interviews. Drs. Sperber and Voils conducted the qualitative interviews.
Demographic information and numeracy preferences and perceived ability using the Subjective Numeracy Scale was collected during the quantitative interview. To assess knowledge retention, GMS developed 8 questions to assess polyposis and colon cancer knowledge. Responses to these questions were collected at the time of enrollment, and again during the quantitative interview. We used the Genetic Counselor Satisfaction Scale to measure subjects' satisfaction with their genetic counseling. Lastly, questions were asked regarding VA travel reimbursement, and distance and time needed to travel to outpatient clinics for cost analyses.
In the qualitative interviews we probed participants and counselors to discuss specific aspects of each modality including the ease of use, navigation, and adaptability of each modality, conveying and comprehending genetic and numeric information, and perceived advantages and disadvantages of each modality.
Economic analysis included incremental and variable costs incurred by videoconference subjects. These costs included VA travel reimbursement for qualified Veterans to travel to videoconferencing sites. We also estimated the societal cost, namely productivity loss cost and out-of-pocket travel cost. Cost data was collected via participant self-report. To calculate productivity loss cost, we applied the most current average hourly wage rate in the US, $24.96. To calculate travel cost for the Veterans who did not receive travel reimbursement from the VA, the allowed IRS rate of 23 cents per mile was applied.
Univariate analysis and parametric or nonparametric group means comparisons were conducted to analyze the quantitative data. Qualitative interview analyses were conducted with Atlas.ti qualitative analysis software. A directed approach was used for content analysis.
Patient Characteristics. More patients were willing to participate in the study if they were randomized to the telephone arm (n=19) than the videoconference arm (n=8). Nonetheless, the two arms had similar demographics and numeracy skills.
Information Retention. Before receiving genetic counseling, of the 8 true/false questions regarding polyps and colon cancer, telephone subjects answered a mean of 4.7 (SD=1.4) questions correctly whereas videoconference subjects answered 5.6 (SD=1.2) questions correctly (p=0.13). After genetic counseling, the number of questions telephone subjects were able to answer correctly remained at 4.7 (SD=1.2), whereas videoconference subjects improved to 6.5 (SD=0.9) correctly answered (p=0.001).
Satisfaction. Both videoconference and telephone subjects were highly satisfied with the genetic counseling they received. Out of a possible 30 points, videoconference subjects provided a mean satisfaction score of 27 (SD=3.0) and telephone subjects had a slightly lower score of 25 (SD=2.6) (p=0.16).
Cost Analysis. The expected cost for travel reimbursement by VA for videoconference patients was $10.25. For those who did not receive travel reimbursement their travel cost was $5.25 ($15.60 if outlier included). The incremental productivity loss cost due to having to travel to an outpatient clinic was $61.57. The total additional expected costs incurred by videoconference patients ranged from $74.45 -$81.57.
Qualitative Assessment. We spoke with 6 patients who received phone counseling, 7 patients who received videoconference counseling and 5 counselors. Patients generally reported satisfaction with their telegenomic counseling, regardless of whether it was by phone or video modality. While both counselors and patients described the phone as an adequate way to transmit information, the counselors preferred videoconferencing over phone because they found that patients were more likely to keep their appointment, less likely to be distracted, and more likely to ask questions when using videoconferencing than telephone. Both counselors and patients reported ability to read the others' body language as an advantage of video over phone. For counselors, an additional advantage to video was being able to see reaction on someone's face, for example, whether or not someone looks confused. For patients, an additional advantage was being able to trust the counselor's "sincerity."
Genetic counseling via telephone was liked by patients because of its convenience and may be adequate for counseling. Patients exhibited better information retention via videoconferencing and counselors had a clear preference for this modality. However, the substantial additional cost of counseling via videoconference, most of it borne by the patient, should be taken into consideration when considering how genetic counseling is delivered.
None at this time.
Attitudes/Beliefs, Organizational Structure, Patient Preferences, Telemedicine