Genetic Consultation Provided by VA Facilities or Centralized VA Virtual Care is More Timely and Better Coordinated than Community Care Options

BACKGROUND:
Medical genetics is a specialty that is difficult to access because of insufficient numbers of clinicians to meet the demand. Telehealth can enable broader access; however, evidence of the influence of telehealth on care coordination and healthcare equity is lacking. This study assessed care coordination and equity in the delivery of genetic care for the care models available to VA patients (i.e., VA-traditional, centralized VA-telehealth, and non-VA care). Traditional VA genetics programs comprise small teams of clinical geneticists and genetic counselors serving VA facilities via multiple delivery modes. Genetic services became more widely available in 2010 when the VA Genomic Medicine Service launched a program that embodies the goals of a centralized virtual care program. The program is staffed by a team of genetic counselors that serves about 80 VA facilities nationwide via telehealth. Using VA data, investigators identified 24,778 Veterans (12,671 or 51% women) with a genetic consultation referral from January 1, 2010 to December 31, 2017. Multivariate regression models were used to examine associations between patient and consultation characteristics and the type of genetic care model referral, completion of genetic consultation, and whether the Veteran had cancer surveillance or risk-reducing procedures within two years following their genetics referral.

FINDINGS:

• The VA genetic care models – both traditional and centralized telehealth – had better care coordination than non-VA care.
• Veterans referred to non-VA care completed their consult only 57% of the time compared with 75% if referred to the VA-traditional model and 73% with the centralized VA-telehealth model.
• Completion of a genetic consultation if referred to non-VA care was almost 3 times longer than with either VA model (140 days vs 55 days for VA-traditional and 45 days for VA-telehealth).
• The centralized VA-telehealth model was associated with exacerbated healthcare disparities based on self-reported race or ethnicity and gender compared with the VA traditional model.
• Veterans reporting their race as Asian, American Indian, Alaskan Native, Hawaiian and other Pacific Islander, and unknown were 46% less likely to be referred to the centralized VA-telehealth model compared to the VA-traditional model. Black Veterans were significantly less likely to complete a consultation compared to White Veterans, but only if referred to the centralized VA-telehealth model. Also, women Veterans were 50% more likely to be referred to the centralized VA-telehealth model than the VA traditional model.

IMPLICATIONS:

• VA should assess structural barriers to using centralized telehealth services and the needs and preferences of vulnerable subpopulations in order to find solutions that mitigate health disparities and improve access.

LIMITATIONS:

• The observational study design limits the findings to associations, and there may be confounding from unmeasured variables.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D. Dr. Scheuner is part of the San Francisco VA Healthcare System; Dr. Huynh is with HSR&D’s Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP); and Dr. Chanfreau-Coffinier is part of the Veterans Affairs Informatics and Computing Infrastructure (VINCI).

Scheuner M, Huynh A, Chanfreau-Coffinier C, et al. Demographic Differences among US Department of Veterans Affairs Patients Referred for Genetic Consultation to a Centralized VA Telehealth Program, VA Medical Centers, or the Community. JAMA Network Open. April 11, 2022;5(4):e226687.