Impact of family history and decision support on high-risk cancer screening

描述（由申请人提供）： 对退伍军人医疗保健的预期影响。退伍军人健康管理局（VA）没有系统范围的，全面的，有效的方法来评估家庭健康史（FHH）或提供决策支持。标准化FHH评估伴随决策支持有助于实现3个重要目标：1）识别高风险患者，2）遗传咨询转介遗传性癌症综合征风险患者，3）为所有风险水平的患者推荐基于指南的预防性护理。接受适当的预防性护理将有助于预防或至少改善致命疾病的早期发现，改善数千名退伍军人的生活，并降低退伍军人事务部医疗保健系统的医疗保健费用。项目背景。尽管FHH被普遍认为是常见慢性疾病的一个重要风险因素，但它很少在临床实践中作为结构化风险评估的一部分使用。GMM 1）向医生、患者和社区提供关于FHH重要性的教育; 2）包含一个基于健康IT的平台（MeTree），该平台使用患者输入的数据对患者进行风险分层，并为医生和患者生成风险分层、基于证据的预防性护理建议; 3）向患者和提供者提供资源，以有效解释FHH信息并遵守建议。收集FHH以告知VA中结直肠癌（CRC）的预防性护理很重要，因为CRC风险较高的患者在VA中没有得到很好的表征或记录，并且目前没有系统地评估或测量高风险与平均风险的预防策略。项目目标。本研究的目的是评估GMM识别CRC风险增加患者的可行性和有效性。这一目标将在一项为期4年的混合方法研究中实现，其目的如下：目的1：通过比较研究入组前病历中的高风险识别率与MeTree完成后的高风险识别率，确定通过MeTree收集FHH是否改善了CRC家族风险较高患者的识别。目标二：评估为患者和PCP提供决策支持是否可改善风险适当的PCP转诊以及患者对CRC筛查/监测的接受。目标3：通过定性访谈，评估PCP的决策支持经验和对工作流程的影响，并获得信息，以告知行政领导人在VA医疗保健系统中的最终实施。目标4：对在VA实施FHH收集和GMM决策支持进行成本后果和成本影响分析。项目方法。符合条件的患者年龄为40-65岁，参加初级保健，没有CRC个人病史，并对FHH有一定的了解。在目标1中，将进行回顾性病历审查，以确定目标2随机试验入组患者病历中记录CRC FHH的基线率。在目标2中，知情同意的患者将被随机分配，以提供患者输入的FHH，并在入组时或12个月后接受患者和提供者决策支持（等待列表对照）。主要结局是入组后12个月患者的风险适当的CRC筛查/监测转诊。次要结果包括患者对建议的接受和入选后12个月的遗传咨询转诊。在目标3中，将与医生和诊所领导进行定性访谈;数据将使用传统的内容分析进行分析。在目标4中，将从行政数据库和患者病历中获取数据，以进行预算影响分析。

DESCRIPTION (provided by applicant): Anticipated impact on veterans' healthcare. The Veterans Health Administration (VA) has no system-wide, comprehensive, validated method for assessing family health history (FHH) or providing decision support. A standardized FHH assessment accompanied by decision support facilitates 3 important objectives: 1) identification of patients at higher risk, 2) genetic consultation referral for patients at risk for hereditary cancer syndromes, and 3) recommendation of guideline-based preventive care for patients of all risk levels. Receipt of appropriate preventive care will help prevent, or at least improve early detection of, deadly diseases, improving lives of thousands of Veterans and reducing health care costs to the VA healthcare system. Project background. Although FHH is commonly accepted as an important risk factor for common, chronic diseases, it is rarely used in clinical practice as part of a structured risk assessment .To facilitate use of FHH in primary care, the Genomic Medicine Model (GMM) was developed. The GMM 1) provides education to physicians, patients, and communities on the importance of FHH; 2) contains a health IT-based platform (MeTree) that uses patient-entered data to risk-stratify patients and generate risk-stratified, evidence-based preventive care recommendations for physicians and patients; and 3) provides resources to patients and providers to effectively interpret FHH information and adhere to recommendations. Collection of FHH to inform preventive care for colorectal cancer (CRC) in VA is important because patients at higher risk for CRC are not well-characterized or documented in VA and high-risk versus average-risk prevention strategies currently are not systematically assessed or measured. Project objectives. The goal of this study is to evaluate the feasibility and effectiveness of the GMM for identifying patients at increased risk for CRC. This goal will be achieved in a 4-year mixed methods study with the following aims: Aim 1: Determine whether FHH collection via MeTree improves identification of patients at higher familial risk for CRC by comparing rates of high-risk identification in the medical record prior to study enrollment to rate of high-risk identification following MeTree completion. Aim 2: Evaluate whether providing decision support to patients and PCPs improves risk-appropriate PCP referrals for, and patient uptake of, CRC screening/surveillance. Aim 3: Assess experience with decision support and effects on workflow from PCPs, and obtain information to inform eventual implementation in the VA healthcare system from administrative leaders, via qualitative interviews. Aim 4: Conduct cost-consequence and budget-impact analyses of implementing FHH collection and GMM decision support in VA. Project methods. Eligible patients are aged 40-65 years, enrolled in primary care, do not have a personal history of CRC, and have some knowledge of FHH. In Aim 1, a retrospective chart review will be conducted to determine the baseline rate of documenting FHH of CRC in the medical record for patients enrolled in the Aim 2 randomized trial. In Aim 2, consented patients will be randomized to provide patient-entered FHH and receive patient and provider decision support at enrollment or 12 months later (wait-list control). The primary outcome is risk-appropriate CRC screening/surveillance referral for patients 12 months post-enrollment. Secondary outcomes include patient uptake of recommendations and referral for genetic consultation 12 months post-enrollment. In Aim 3, qualitative interviews will be conducted with physicians and clinic leaders; data will be analyzed using conventional content analysis. In Aim 4, data will be obtained from the administrative databases and patient medical records to conduct a budget impact analysis.