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.
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.
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DOI：
10.1001/jamanetworkopen.2022.6687
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发表时间：
2022-04-01
影响因子：
13.8
通讯作者：
Russell, Marcia M.
中科院分区：
文献类型：
--
作者：
Scheuner, Maren T.;Huynh, Alexis K.;Chanfreau-Coffinier, Catherine;Lerner, Barbara;Gable, Alicia R.;Lee, Martin;Simon, Alissa;Coeshott, Randall;Hamilton, Alison B.;Patterson, Olga, V;DuVall, Scott;Russell, Marcia M.
本横断面研究评估了集中远程医疗和传统遗传护理模式为美国退伍军人事务部患者提供的遗传护理的护理协调和公平性。集中远程医疗模式如何与护理协调和遗传服务提供的公平性相关联？在这项对24778名遗传转诊成人患者进行的全国性横断面研究中，与传统遗传服务相比，某些种族和族裔群体被转诊到集中远程医疗模式的可能性显著降低，而被转诊到远程医疗模式的黑人患者完成咨询的可能性显著降低。如果患者完成了咨询，他们更有可能接受多种癌症预防程序，但前提是他们完成了传统的遗传服务。这些研究结果表明，虽然集中式远程医疗模式可能会改善获得遗传学临床医生的机会，但与传统的医疗模式相比，护理协调可能会受到损害，医疗保健差距可能会加剧。远程医疗使遗传学临床医生能够接触到，但对护理协调的影响尚不清楚。评估集中远程医疗和传统遗传保健模式提供的遗传保健的护理协调和公平性。这项横断面研究包括2010年至2017年在美国退伍军人事务部（VA）医疗保健系统中进行遗传咨询的患者，随访2年。如果患者被转介进行研究、细胞遗传学或传染病检测，或者他们的护理模式无法确定，则排除患者。遗传护理模式，包括VA远程医疗（即，一个集中的遗传咨询师团队为全国范围内的VA设施提供服务），VA传统（即，由临床遗传学家和遗传咨询师提供的区域服务）和非VA护理（即，由VA购买的社区护理）。采用多变量回归模型评估患者和会诊特征与遗传护理模式转诊类型之间的关系；协商完成;并且在转诊后2年内进行过0次、1次或2次以上的癌症监测（如结肠镜检查）和降低风险的手术（如双侧乳房切除术）。本研究共纳入24 778例遗传转诊患者，其中女性12 671例（51.1%），50岁及以上患者13 193例（53.2%），白人15 639例（63.1%），癌症相关转诊患者15 438例（62.3%）。va -远程保健模式接受了24 778次咨询中的14 580次（58.8%）。与va -传统模式相比，亚洲患者、美洲印第安人或阿拉斯加土著患者、夏威夷或太平洋岛民患者被转介到va -远程医疗的可能性低于白人患者（or, 0.54; 95% CI, 0.35-0.84）。与va -传统模式相比，非va护理完成咨询的可能性更低（OR, 0.45; 95% CI, 0.35-0.57）；VA模型之间在完成咨询方面没有差异。黑人患者完成会诊的可能性低于白人患者（OR, 0.84; 95% CI, 0.76-0.93），但仅限于va远程医疗模式。如果患者完成了咨询（OR, 1.55; 95% CI, 1.40-1.72），但只有当他们完成了va -传统模型的咨询时，患者才更有可能进行多种癌症预防手术。在这项横断面研究中，va远程医疗模式与改善获得遗传学临床医生的机会有关，但也与加剧医疗保健差距和阻碍护理协调有关。解决结构性障碍以及弱势亚群体的需求和偏好，可以补充集中式远程保健方法，改善护理协调，并有助于减轻保健差距。
This cross-sectional study assesses care coordination and equity of genetic care delivered by centralized telehealth and traditional genetic care models for US Department of Veteran Affairs patients. How is a centralized telehealth model associated with care coordination and equity of genetic services delivery? In this national cross-sectional study of 24 778 adult patients with genetic referrals, certain racial and ethnic groups were significantly less likely to be referred to a centralized telehealth model than traditional genetic services, and completing consultations was significantly less likely for Black patients referred to the telehealth model. Patients were more likely to have multiple cancer preventive procedures if they completed their consultations but only if completed with traditional genetic services. These findings suggest that, while a centralized telehealth model may improve access to genetics clinicians, care coordination may be compromised, and health care disparities may be exacerbated compared with a traditional care model. Telehealth enables access to genetics clinicians, but impact on care coordination is unknown. To assess care coordination and equity of genetic care delivered by centralized telehealth and traditional genetic care models. This cross-sectional study included patients referred for genetic consultation from 2010 to 2017 with 2 years of follow-up in the US Department of Veterans Affairs (VA) health care system. Patients were excluded if they were referred for research, cytogenetic, or infectious disease testing, or if their care model could not be determined. Genetic care models, which included VA-telehealth (ie, a centralized team of genetic counselors serving VA facilities nationwide), VA-traditional (ie, a regional service by clinical geneticists and genetic counselors), and non-VA care (ie, community care purchased by the VA). Multivariate regression models were used to assess associations between patient and consultation characteristics and the type of genetic care model referral; consultation completion; and having 0, 1, or 2 or more cancer surveillance (eg, colonoscopy) and risk-reducing procedures (eg, bilateral mastectomy) within 2 years following referral. In this study, 24 778 patients with genetics referrals were identified, including 12 671 women (51.1%), 13 193 patients aged 50 years or older (53.2%), 15 639 White patients (63.1%), and 15 438 patients with cancer-related referrals (62.3%). The VA-telehealth model received 14 580 of the 24 778 consultations (58.8%). Asian patients, American Indian or Alaskan Native patients, and Hawaiian or Pacific Islander patients were less likely to be referred to VA-telehealth than White patients (OR, 0.54; 95% CI, 0.35-0.84) compared with the VA-traditional model. Completing consultations was less likely with non-VA care than the VA-traditional model (OR, 0.45; 95% CI, 0.35-0.57); there were no differences in completing consultations between the VA models. Black patients were less likely to complete consultations than White patients (OR, 0.84; 95% CI, 0.76-0.93), but only if referred to the VA-telehealth model. Patients were more likely to have multiple cancer preventive procedures if they completed their consultations (OR, 1.55; 95% CI, 1.40-1.72) but only if their consultations were completed with the VA-traditional model. In this cross-sectional study, the VA-telehealth model was associated with improved access to genetics clinicians but also with exacerbated health care disparities and hindered care coordination. Addressing structural barriers and the needs and preferences of vulnerable subpopulations may complement the centralized telehealth approach, improve care coordination, and help mitigate health care disparities.
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DOI：
10.1038/s41436-021-01162-5
发表时间：
2021-08
期刊：
Genetics in medicine : official journal of the American College of Medical Genetics
影响因子：
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