Cancer Genetics Toolkit Improves Quality and Frequency of Family History Documentation among VA Primary Care Patients

BACKGROUND:
Hereditary breast-ovarian cancer (HBOC) and Lynch syndrome are relatively common hereditary cancer syndromes associated with high risks and early-onset for breast, ovarian, colon, endometrial, and other cancers, necessitating more intensive screening and prevention options. Documenting family history is important for recognizing individuals who may have a predisposition to HBOC or Lynch syndrome, particularly individuals without a personal history of cancer who may have the most to gain from genetic risk assessment and resulting recommendations for risk-appropriate cancer screening and prevention. To address the need for clinician education and systems improvement, investigators in this study developed a cancer genetics toolkit designed to improve familial risk assessment and appropriate referrals for HBOC and Lynch syndrome. This pilot study evaluated the impact of the toolkit by comparing clinician behaviors relating to documentation of cancer family history and referral for genetic consultation before and after its implementation in women's primary care clinics within the VA Greater Los Angeles Healthcare System. Investigators used interviews, surveys, and chart reviews to assess changes in the frequency of cancer family history documentation in the electronic health record (EHR), as well as referrals for genetic consultation for a 6-month period before (4/09 through 9/09) and for 18 months during toolkit implementation (4/10 through 9/11). Seven VA clinicians and trainees participated in the pre/post surveys and interviews, and 2,321 unique patients were seen in the women's clinics during the implementation phase.

FINDINGS:

• The cancer genetics toolkit used in this study increased the frequency and improved the quality of the cancer family history documented by primary care clinicians; increased recognition of high-risk Veterans, which is critical for the delivery of risk-appropriate preventive care; and increased the numbers of appropriate referrals for genetic consultation.
• The toolkit increased cancer family history documentation by almost 10% (27% pre- and 36% post-implementation). The clinical reminder (EHR alert to collect cancer family history every three years) was a key component of the toolkit; when used, it was associated with a two-fold increase in cancer family history documentation, and history was more complete. Use of the reminder also increased efficiencies relating to documentation of cancer family history, as clinicians began to rely on the reminder to trigger systematic questioning.
• Veterans whose clinicians completed the reminder were twice as likely to be referred for genetic consultation (10% vs. 4%).

LIMITATIONS:

• The pre/post-design without a control group could not account for temporal trends that might have influenced the cancer family history documentation.

AUTHOR/FUNDING INFORMATION:
This project was supported by a cooperative agreement with the CDC National Office of Public Health Genomics. Dr. Yano was supported by an HSR&D Senior Research Career Scientist Award. Drs. Scheuner, Hamilton, Goldzweig, Lee, Mittman, and Yano are part of HSR&D's Center for the Study of Healthcare Provider Behavior, Sepulveda, CA.

Scheuner M, Hamilton A, Peredo J, Sale T, Austin C, Gilman S, Bowen M, Goldzweig C, Lee M, Mittman B, and Yano E. A Cancer Genetics Toolkit Improves Access to Genetic Services through Documentation and Use of the Family History by Primary Care Clinicians. Genetics in Medicine June 13, 2013;e-pub ahead of print.