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)没有全系统范围的全面、有效的方法来评估家庭健康史(FHH)或提供决策支持。伴随着决策支持的标准化FHH评估促进了3个重要目标：1)识别高风险患者，2)遗传癌症综合征风险患者的遗传咨询转介，以及3)为所有风险水平的患者推荐基于指南的预防护理。接受适当的预防性护理将有助于预防或至少改善对致命疾病的早期发现，改善成千上万退伍军人的生活，并降低退伍军人医疗保健系统的医疗成本。项目背景。虽然FHH被普遍认为是常见慢性疾病的重要危险因素，但它很少用于临床实践中，作为结构化风险评估的一部分。为了促进FHH在初级保健中的使用，开发了基因组医学模型(GMM)。GMM 1)向医生、患者和社区提供有关FHH重要性的教育；2)包含一个基于医疗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基于证据的风险分层预防护理建议；以及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以指导VA的结直肠癌(CRC)预防护理是重要的，因为VA中没有很好地描述或记录患有CRC的高危患者，而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。这项研究的目的是评估GMM在识别结直肠癌高危患者方面的可行性和有效性。这一目标将在一项为期4年的混合方法研究中实现，目标如下：目标1：通过比较研究登记前医疗记录中的高风险识别率和MeTree完成后的高风险识别率，确定通过MeTree收集FHH是否能改善对结直肠癌家族风险较高的患者的识别。目的2：评估为患者和初级保健医生提供决策支持是否改善了结直肠癌筛查/监测中适合风险的初级保健医生转诊和患者的接受程度。目标3：评估决策支持方面的经验和初级保健医生对工作流程的影响，并通过定性访谈，从行政领导那里获得信息，以便最终在退伍军人保健系统中实施。目标4：在退伍军人事务部实施FHH收集和GMM决策支持的成本-后果和预算影响分析。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有一定了解。在AIM 1中，将进行回顾性图表审查，以确定在AIM 2随机试验中登记的患者的病历中记录结直肠癌FHH的基线比率。在目标2中，同意的患者将被随机提供患者输入的FHH，并在登记时或12个月后接受患者和提供者的决策支持(等待名单对照)。主要结果是对登记后12个月的患者进行风险适当的结直肠癌筛查/监测转诊。次要结果包括患者在登记12个月后对建议的接受和遗传咨询的转诊。在目标3中，将与医生和临床领导进行定性访谈；数据将使用传统的内容分析进行分析。在目标4中，将从行政数据库和病人病历中获取数据，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.