Quality assurance in medical and public health genetics services: a systematic review

Service provision of genetics health care in Portugal

In recent decades, genetics has undergone important technological advances. The rapid shift to genomics has made a strong impact on health systems around the world. In Portugal, this huge increase in consultations and typologies of genetic tests has joined the serious limitations of the few existing genetics services. The following study aims to characterize the current state of the network of genetics services in Portugal regarding its functioning, main challenges, and opportunities. Five semi-structured interviews were conducted, corresponding to 83.33% of the directors of the public genetics services of the National Health Service. Four thematic categories emerged from the analysis: (1) specialty and technical developments, (2) structural difficulties, (3) potentialities, and (4) future directions. The developments are due to the emergence of more comprehensive genetic applications, specific protocols and patient referral standards, and accreditation of services. The main difficulties encountered in the functioning of the services were difficulty in obtaining funding, lack of human resources, service overload, and lack of exclusive time for training and research. The potentialities mentioned were the establishment of multidisciplinary teams and the best articulation with specialists from other areas. Among the various future directions pointed out, better management of patients' waiting lists, the importance of research, the simplification of test request procedures, and the creation of specialized units inside the genetic services, were reported. The results showed several gaps in the practice of medical genetics that should be addressed with the development of public policies for the recognition and restructuring of medical genetics in health care.

Barriers and strategies to integrate medical genetics and primary care in underserved populations: a scoping review

Despite clinical and technological advances, serious gaps remain in delivering genetic services due to disparities in workforce distribution and lack of coverage for genetic testing and counseling. Genetic services delivery, particularly in medically underserved populations, may rely heavily on primary care providers (PCPs). This study aims to identify barriers to integrating genetic services and primary care, and strategies to support integration, by conducting a scoping review. Literature synthesis found barriers most frequently cited by PCPs including insufficient knowledge about genetics and risk assessment, lack of access to geneticists, and insufficient time to address these challenges. Telegenetics, patient-centered care, and learning communities are strategies to overcome these barriers. Telegenetics supplements face-to-face clinics by providing remote access to genetic services. It may also be used for physician consultations and education. Patient-centered care allows providers, families, and patients to coordinate services and resources. Access to expert information provides a critical resource for PCPs. Learning communities may represent a mechanism that facilitates information exchange and knowledge sharing among different providers. As PCPs often play a crucial role caring for patients with genetic disorders in underserved areas, barriers to primary care-medical genetics integration must be addressed to improve access. Strategies, such as telegenetics, promotion of evidence-based guidelines, point-of-care risk assessment tools, tailored education in genetics-related topics, and other system-level strategies, will facilitate better genetics and primary care integration, which in turn, may improve genetic service delivery to patients residing in underserved communities.

Developing a genetic services assessment tool to inform quality improvement efforts in state genetic service delivery

PURPOSE

The Institute of Medicine recommended the utilization of metrics to improve quality in health care, although they have rarely been used in genetics. This study developed and tested a set of metrics for a quality assessment tool for genetic services METHODS: A systematic review of literature, guidelines, and consensus statements identified candidate measures for a possible assessment tool. An expert panel conducted a modified Delphi technique to rank the metrics. Ratings were computed to generate a score for each metric, creating a set of metrics for consensus discussions, pilot testing, and feasibility testing in eight Midwestern states.

RESULTS

The panel reduced 61 candidate metrics to 21 for pilot testing in two states, which further limited and refined the set to 16 metrics. These 16 were categorized into five domains: service capacity, access to care, data systems, performance reporting, and workforce. Further feasibility testing in one Regional Genetics Collaborative identified the tool's usefulness and barriers to implementation.

CONCLUSIONS

These quality metrics for both clinical and public health genetics across the lifespan may help medical professionals and policymakers evaluate quality and cost-effectiveness of genetic services on a statewide basis and stimulate outcome-oriented, health services research in medical genetics and genomics.

Value of Genetic Testing for Hereditary Colorectal Cancer in a Probability-Based US Online Sample

BACKGROUND

. While choices about genetic testing are increasingly common for patients and families, and public opinion surveys suggest public interest in genomics, it is not known how adults from the general population value genetic testing for heritable conditions. We sought to understand in a US sample the relative value of the characteristics of genetic tests to identify risk of hereditary colorectal cancer, among the first genomic applications with evidence to support its translation to clinical settings.

METHODS

. A Web-enabled choice-format conjoint survey was conducted with adults age 50 years and older from a probability-based US panel. Participants were asked to make a series of choices between 2 hypothetical blood tests that differed in risk of false-negative test, privacy, and cost. Random parameters logit models were used to estimate preferences, the dollar value of genetic information, and intent to have genetic testing.

RESULTS

. A total of 355 individuals completed choice-format questions. Cost and privacy were more highly valued than reducing the chance of a false-negative result. Most (97% [95% confidence interval (CI)], 95%-99%) would have genetic testing to reduce the risk of dying of colorectal cancer in the best scenario (no false negatives, results disclosed to primary care physician). Only 41% (95% CI, 25%-57%) would have genetic testing in the worst case (20% false negatives, results disclosed to insurance company).

CONCLUSIONS

. Given the characteristics and levels included in the choice, if false-negative test results are unlikely and results are shared with a primary care physician, the majority would have genetic testing. As genomic services become widely available, primary care professionals will need to be increasingly knowledgeable about genetic testing decisions.

Tailored Hospital-based Risk Reduction to Impede Vascular Events After Stroke (THRIVES) study: qualitative phase protocol

BACKGROUND

There is an urgent need to develop effective strategies to improve stroke outcomes in Sub-Saharan Africa (SSA), where use of evidence-based therapies among patients receiving conventional care is poor. Designs of behavioral interventions to improve stroke care in SSA need to be sensitive to both individual and community factors (including local perceptions and public policies) contributing to the likelihood of compliance with recommended therapeutic goals. This article presents a community-based participatory research protocol that will evaluate systems and processes affecting the continuum of stroke-preventive care in an SSA country.

METHODS

Phase 1 of the Tailored Hospital-based Risk Reduction to Impede Vascular Events study will be implemented from 2013 to 2014 at 4 different types of hospital settings in Nigeria. Six adult stroke survivor focus group discussions and six caregiver focus group discussions, each lasting about 120 minutes will be conducted. Each group will comprise 6 to 8 participants. We will also conduct 22 semi-structured key informant interviews (informed by the Theoretical Domains Framework) with several types of providers and hospital administrators. Purposive and maximum variation sampling will be used to identify and recruit participants from participating hospitals. Transcript data will be analyzed by reviewers in an iterative process to identify recurrent and unifying themes using a constructivist variant of the grounded theory methodology, and will involve participatory co-analysis with key stakeholders to enhance authenticity and veracity of findings.

DISCUSSION

On the basis of the results of Tailored Hospital-based Risk Reduction to Impede Vascular Events phase 1, we intend to develop a culturally sensitive, system-appropriate, multipronged intervention whose efficacy to boost adherence to evidence-based stroke-preventive care will be tested in a future randomized trial (phase 2).

Randomized controlled trial of a multipronged intervention to improve blood pressure control among stroke survivors in Nigeria

RATIONALE

Stroke is the second-leading cause of death in low- and middle-income countries, but use of evidence-based therapies for stroke prevention in such countries, especially those in Africa, is extremely poor. This study is designed to enhance the implementation and sustainability of secondary stroke-preventive services following hospital discharge.

AIM/HYPOTHESIS

The primary study aim is to test whether a Chronic Care Model-based initiative entitled the Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke (THRIVES) significantly improves blood pressure control after stroke.

DESIGN

This prospective triple-blind randomized controlled trial will include a cohort of 400 patients with a recent stroke discharged from four medical care facilities in Nigeria. The culturally sensitive, system-appropriate intervention comprises patient report cards, phone text messaging, an educational video, and coordination of posthospitalization care.

STUDY OUTCOMES

The primary outcome is improvement of blood pressure control. Secondary endpoints include control of other stroke risk factors, medication adherence, functional status, and quality of life. We will also perform a cost analysis of THRIVES from the viewpoint of government policy-makers.

DISCUSSION

We anticipate that a successful intervention will serve as a scalable model of effective postdischarge chronic blood pressure management for stroke in sub-Saharan Africa and possibly for other symptomatic cardiovascular disease entities in the region.

Empowerment: qualitative underpinning of a new clinical genetics-specific patient-reported outcome

Recent qualitative research developed a new construct labelled Empowerment describing a new patient outcome from using clinical genetics services that included four dimensions: Knowledge and Understanding, Decision-Making, Instrumentality and Future-Orientation. The aim of this study was to explore the validity, relevance and importance of the Empowerment construct for use as a patient-reported outcome (PRO) for clinical genetics services, and to refine the construct if necessary. Qualitative research (interviews and focus groups) was conducted in the UK with 12 patients, 15 representatives from patient support groups, 10 genetics clinicians and 4 service commissioners. Participants were asked to (1) describe what they think are the patient benefits from using clinical genetics services and (2) critique the Empowerment construct as a PRO. Interviews and focus groups were transcribed in full and analyzed using grounded theory. Findings confirmed the relevance and importance of the Empowerment construct, and identified Emotional Regulation as a further dimension of Empowerment. Data analysis also resulted in refinement of the construct, by renaming the other four dimensions to be Cognitive Control, Decisional Control, Behavioural Control and Hope. Empowerment has the potential to be a useful PRO to evaluate interventions in clinical genetics, and for use in clinical practice to generate data for continuous quality improvement. A study is underway to operationalise Empowerment by developing a psychometrically sound PRO measure that will take the form of a short questionnaire.

Labor and delivery nurse staffing as a cost-effective safety intervention

Numerous studies have identified a relationship between staffing levels and nurse-sensitive outcomes for medical and surgical patients, but little has been published on the impact of nurse-sensitive outcomes for the childbearing family and even less that examines the relationship of intrapartum staffing on adverse perinatal outcomes. Using a derivation of Donabedian's classic structure, process, and outcomes framework, a model is proposed, which would allow obstetrical primary care providers and administrators alike the opportunity to examine the influence of nurse staffing on adverse obstetrical events, including unanticipated cesarean birth in low-risk women or newborn intensive care unit admissions. It is recognized that hospitals carry a significant burden in the prevention of adverse outcomes that range from nurse staffing levels to the internal process and infrastructure of the hospital setting. Patient outcomes are a direct result not only of the patient's health status and characteristics (eg, socioeconomic position and ethnicity), but also of interactions with the healthcare delivery system. As such, the opportunity to examine hospital characteristics (structure and processes) that may be detrimental to safe patient outcomes is of paramount importance in providing optimal outcomes for childbearing women and their families.