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Jahan M, Bartholomeuz T, Milburn N, Rogers V, Sibbering M, Robertson J. Transforming the 2-week wait (2WW) pathway: management of breast pain in primary care. BMJ Open Qual 2022; 11:bmjoq-2021-001634. [PMID: 35289304 PMCID: PMC8921922 DOI: 10.1136/bmjoq-2021-001634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 02/24/2022] [Indexed: 11/10/2022] Open
Abstract
Breast pain has no association with breast cancer yet is a frequent reason for referral from Primary to Secondary Care, often on an urgent (2-week wait) referral. The referral often causes significant patient anxiety, further heightened by screening mammograms and/or ultrasound scans in the absence of an associated red flag symptom or finding by the patient or general practitioner. This paper reports the pilot implementation of a specialist Primary Care Breast Pain Clinic in Mid-Nottinghamshire where patients were seen, examined without any imaging and assessed for their risk of familial breast cancer: numerous studies have reported 15%–>30% of patients with breast pain only have a family history of breast cancer. 177 patients with breast pain only were seen in this clinic between March, 2020 and April, 2021 with a 6-month interim suspension due to COVID-19. The mean age of patients was 48.4 years (range: 16–86). 172/177 (97.2%) patients required no imaging although there were three (1.7%) inappropriate referrals and two additional abnormalities (1.1%—hamartoma, thickening/tethering) that were referred onward. There were no cancers. 21 (12.4%) patients were identified to have an increased familial risk of breast cancer and were referred to the specialist familial cancer service. 170/177 patients completed an anonymous questionnaire on leaving the clinic. 167/169 (99%) were reassured regarding their breast pain, 155/156 (99%) were reassured of the Familial Risk Assessment, 162/168 (96%) were reassured regarding their personal risk assessment while 169/170 (99%) were ‘extremely likely/likely to recommend the service’. This specialist Primary Care Breast Pain Clinic provides service improvement across all levels of care (Primary, Secondary and Tertiary). Patients were successfully managed in the community with high levels of patient satisfaction and together this obviated referral to secondary care. The familial breast cancer risk assessment also helped identify unmet need in the community.
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Affiliation(s)
- Mohamed Jahan
- Breast Surgery, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, UK
| | - Thilan Bartholomeuz
- Primary Care, Mid-Nottinghamshire Integrated Care Partnership, Nottingham, UK
| | - Nikki Milburn
- Breast Surgery, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, UK
| | - Veronica Rogers
- Breast Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Mark Sibbering
- Breast Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - John Robertson
- Breast Surgery, University of Nottingham Faculty of Medicine and Health Sciences, Derby, UK
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Unim B, Pitini E, Lagerberg T, Adamo G, De Vito C, Marzuillo C, Villari P. Current Genetic Service Delivery Models for the Provision of Genetic Testing in Europe: A Systematic Review of the Literature. Front Genet 2019; 10:552. [PMID: 31275354 PMCID: PMC6593087 DOI: 10.3389/fgene.2019.00552] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 05/24/2019] [Indexed: 11/13/2022] Open
Abstract
Background: The provision of genetic services, along with research in the fields of genomics and genetics, has evolved in recent years to meet the increasing demand of consumers interested in prediction of genetic diseases and various inherited traits. The aim of this study is to evaluate genetic services in order to identify and classify delivery models for the provision of genetic testing in European and in extra-European countries. Methods: A systematic review of the literature was conducted using five electronic resources. Inclusion criteria were that studies be published in English or Italian during the period 2000-2015 and carried out in European or extra-European countries (Canada, USA, Australia, or New Zealand). Results: 148 genetic programs were identified in 117 articles and were delivered mostly in the UK (59, 40%), USA (35, 24%) or Australia (16, 11%). The programs were available nationally (66; 45%), regionally (49; 33%) or in urban areas (21, 14%). Ninety-six (64%) of the programs were integrated into healthcare systems, 48 (32.21%) were pilot programs and five (3%) were direct-to-consumer genetic services. The genetic tests offered were mainly for BRCA1/2 (59, 40%), Lynch syndrome (23, 16%), and newborn screening (18, 12%). Healthcare professionals with different backgrounds are increasingly engaged in the provision of genetic services. Based on which healthcare professionals have prominent roles in the respective patient care pathways, genetic programs were classified into five models: (i) the geneticists model; (ii) the primary care model; (iii) the medical specialist model; (iv) the population screening programs model; and (v) the direct-to-consumer model. Conclusions: New models of genetic service delivery are currently under development worldwide to address the increasing demand for accessible and affordable services. These models require the integration of genetics into all medical specialties, collaboration among different healthcare professionals, and the redistribution of professional roles. An appropriate model for genetic service provision in a specific setting should ideally be defined according to the type of healthcare system, the genetic test provided within a genetic program, and the cost-effectiveness of the intervention. Only applications with proven efficacy and cost-effectiveness should be implemented in healthcare systems and made available to all citizens.
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Affiliation(s)
- Brigid Unim
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Erica Pitini
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | | | - Giovanna Adamo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Carolina Marzuillo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Paolo Villari
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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Genetic cancer risk assessment in general practice: systematic review of tools available, clinician attitudes, and patient outcomes. Br J Gen Pract 2018; 69:e97-e105. [PMID: 30510097 DOI: 10.3399/bjgp18x700265] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/18/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A growing demand for cancer genetic services has led to suggestions for the involvement of GPs. How, and in which conditions, they can be involved, and whether there are important barriers to implementation should be ascertained. AIM To review the tools available, clinician attitudes and experiences, and the effects on patients of genetic cancer risk assessment in general practice. DESIGN AND SETTING Systematic review of papers published worldwide between 1996 and 2017. METHOD The MEDLINE (via Ovid), EMBASE, Cochrane Library, CINAHL, and PsycINFO databases and grey literature were searched for entries dating from January 1996 to December 2017. Study quality was assessed with relevant Critical Appraisal Skills Programme tool checklists and a narrative synthesis of findings was conducted. RESULTS In total, 40 studies were included in the review. A variety of testing and screening tools were available for genetic cancer risk assessment in general practice, principally for breast, breast-ovarian, and colorectal cancer risk. GPs often reported low knowledge and confidence to engage with genetic cancer risk assessment; however, despite time pressures and concerns about confidentiality and the impact of results on family members, some recognised the potential importance relating to such a development of the GP's role. Studies found few reported benefits for patients. Concerns about negative impacts on patient anxiety and cancer worries were largely not borne out. CONCLUSION GPs may have a potential role in identifying patients at risk of hereditary cancer that can be facilitated by family-history tools. There is currently insufficient evidence to support the implementation of population-wide screening for genetic cancer risk, especially given the competing demands of general practice.
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Vande Perre P, Toledano D, Corsini C, Escriba E, Laporte M, Bertet H, Yauy K, Toledano A, Galibert V, Baudry K, Clotet L, Million E, Picot M, Geneviève D, Pujol P. Role of the general practitioner in the care of BRCA1 and BRCA2 mutation carriers: General practitioner and patient perspectives. Mol Genet Genomic Med 2018; 6:957-965. [PMID: 30308700 PMCID: PMC6305637 DOI: 10.1002/mgg3.464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/12/2018] [Accepted: 07/20/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND General practitioners (GPs) have an increasing role in referring patients with putative mutation in BRCA1/2 genes for genetics consultation and for long-term follow-up of mutation carriers. METHODS We compared the expectations of the GPs' role according to BRCA1/2 mutation carriers and to GPs themselves. RESULTS Overall, 38% (58/152) of eligible GPs and 70% (176/252) of eligible patients were surveyed. Although 81% of GPs collected the family history, only 24% considered that they know criteria indicating genetics consultation and 39% sufficient knowledge of BRCA1/2 guidelines to answer patients' questions. Twelve% of GPs were aware of the French national guidelines. Among unsatisfied patients, 40% felt that their GP was able to answer (moderately, sufficiently, or completely) specific questions about BRCA1/2 care as compared with 81% in satisfied patients. Only 33% of GPs reported being informed directly by the geneticist about the patients' results. GPs' main expectations for their role in BRCA1/2 carrier care were psychological support and informing relatives about screening (72% and 71%, respectively), which contrasts with the perceptions of patients, who mainly requested medical advice for BRCA1/2-related care (51%). CONCLUSION There is an important need for GP training and enhancing interactions between GPs and geneticists to improve the GP's role in BRCA1/2 screening and management.
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Affiliation(s)
- Pierre Vande Perre
- Department of Cancer GeneticsMontpellier University Hospital (CHRU)MontpellierFrance
- Université Toulouse III Paul SabatierToulouseFrance
| | - Daniel Toledano
- Department of Cancer GeneticsBreast Disease CenterSaint Louis HospitalParisFrance
| | - Carole Corsini
- Department of Cancer GeneticsMontpellier University Hospital (CHRU)MontpellierFrance
| | - Elsa Escriba
- Department of Cancer GeneticsMontpellier University Hospital (CHRU)MontpellierFrance
| | - Marine Laporte
- Department of Cancer GeneticsMontpellier University Hospital (CHRU)MontpellierFrance
| | - Helena Bertet
- Epidemiology and Clinical Research DepartmentINSERM U1411Clinical Investigation CentreMontpellier University HospitalMontpellierFrance
| | - Kevin Yauy
- Department of GeneticsMontpellier University Hospital (CHRU)MontpellierFrance
- University of MontpellierMontpellierFrance
| | - Alain Toledano
- Department of RadiotherapyHartmann Radiotherapy CenterAmerican Hospital of ParisNeuillyFrance
| | - Virginie Galibert
- Department of Cancer GeneticsMontpellier University Hospital (CHRU)MontpellierFrance
| | - Karen Baudry
- Department of Cancer GeneticsMontpellier University Hospital (CHRU)MontpellierFrance
| | - Lucie Clotet
- University Department of General MedicineUniversity of MontpellierMontpellierFrance
| | - Elodie Million
- University Department of General MedicineUniversity of MontpellierMontpellierFrance
| | - Marie‐Christine Picot
- Department of Medical StatisticsINSERM U1046CNRS UMR 9214University of MontpellierMontpellierFrance
| | - David Geneviève
- Department of GeneticsMontpellier University Hospital (CHRU)MontpellierFrance
- University of MontpellierMontpellierFrance
| | - Pascal Pujol
- Department of Cancer GeneticsMontpellier University Hospital (CHRU)MontpellierFrance
- University of MontpellierMontpellierFrance
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Sollie A, Helsper CW, Ader RJM, Ausems MGEM, van der Wouden JC, Numans ME. Primary care management of women with breast cancer-related concerns-a dynamic cohort study using a network database. Eur J Cancer Care (Engl) 2016; 25:1005-1014. [PMID: 27302697 DOI: 10.1111/ecc.12526] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2016] [Indexed: 01/06/2023]
Abstract
The aim of this study was to determine the incidence, management and diagnostic outcomes of breast cancer-related concerns presented in primary care. A dynamic cohort study was performed in the anonymised routine electronic medical records (EMRs) extracted from 49 General Practices in the Netherlands (163,471 person-years, women aged 18-75). Main Outcome Measures were: (1) incidence rates for breast cancer-related concerns in Primary Care, (2) proportions of these women with and without symptoms of the breast referred for further investigation, (3) proportions of referrals (not) according to the guideline and (4) proportions of women with breast cancer-related concerns diagnosed with breast cancer during follow-up. Breast cancer-related concerns are presented frequently in Primary Care (incidence rate 25.9 per 1,000 women annually). About half these women are referred for further investigation. There is room to improve General Practitioner management, mainly for women with an increased lifetime risk of developing breast cancer. Information concerning family history of cancer is often missing in the EMR. Since cancer is rarely diagnosed during follow-up, particularly when symptoms are absent, reduction of unnecessary concerns is plausible if identification of those without an increased risk is improved.
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Affiliation(s)
- A Sollie
- Department of General Practice & Elderly Care Medicine, VU University Medical Centre and EMGO+ Institute for Health and Care Research, Amsterdam, The Netherlands. .,Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - C W Helsper
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - R J M Ader
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M G E M Ausems
- Department of Medical Genetics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J C van der Wouden
- Department of General Practice & Elderly Care Medicine, VU University Medical Centre and EMGO+ Institute for Health and Care Research, Amsterdam, The Netherlands
| | - M E Numans
- Department of General Practice & Elderly Care Medicine, VU University Medical Centre and EMGO+ Institute for Health and Care Research, Amsterdam, The Netherlands.,Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. What is the evidence on interventions to manage referral from primary to specialist non-emergency care? A systematic review and logic model synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03240] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BackgroundDemand management describes any method used to monitor, direct or regulate patient referrals. Several strategies have been developed to manage the referral of patients to secondary care, with interventions targeting primary care, specialist services, or infrastructure.ObjectiveThis research aimed to conduct an inclusive systematic review and logic model synthesis in order to better understand factors impacting on the effectiveness of interventions targeting referral between primary and secondary medical health care.DesignThe approach combined systematic review with logic modelling synthesis techniques to develop an evidence-based framework of factors influencing the pathway between interventions and system-wide changes.SettingPrimary health care.Main outcome measuresReferral from primary to secondary care.Review methodsSystematic searches were undertaken to identify recent, relevant studies. Quality of individual studies was appraised, with consideration of overall strength of evidence. A narrative synthesis and logic model summary of the data was completed.ResultsFrom a database of 8327 unique papers, 290 were included in the review. The intervention studies were grouped into four categories of education interventions (n = 50); process change interventions (n = 49); system change interventions (n = 38); and patient-focused interventions (n = 3). Effectiveness was assessed variously in these papers; however, there was a gap regarding the mechanisms whereby these interventions lead to demand management impacts. The findings suggest that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions. Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient. System changes including the community provision of specialist services by general practitioners, outreach provision by specialists and the return of inappropriate referrals appeared to have evidence of effect. The pathway whereby interventions might lead to service-wide impact was complex, with multiple factors potentially acting as barriers or facilitators to the change process. Factors related, first, to the doctor (including knowledge, attitudes and beliefs, and previous experiences of a service), second, to the patient (including condition and social factors) and, third, to the influence of the doctor–patient relationship. We also identified a number of potentially influential factors at a local level, such as perceived waiting times and the availability of a specialist. These elements are key factors in the pathway between an intervention and intended demand management outcomes influencing both applicability and effectiveness.ConclusionsThe findings highlight the complexity of the referral process and multiple elements that will impact on intervention outcomes and applicability to a local area. Any interventions seeking to change referral practice need to address factors relating to the individual practitioner, the patient and also the situation in which the referral is taking place. These conclusions apply especially to referral management in a UK context where this whole range of factors/issues lies well within the remit of the NHS. This work highlights that intermediate outcomes are important in the referral pathway. It is recommended that researchers include measure of these intermediate outcomes in their evaluation of intervention effectiveness in order to determine where blocks to or facilitators of system-wide impact may be occurring.Study registrationThe study is registered as PROSPERO CRD42013004037.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Buckley Woods
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Lee
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Nick Payne
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Melanie Rimmer
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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7
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Blank L, Baxter S, Woods HB, Goyder E, Lee A, Payne N, Rimmer M. Referral interventions from primary to specialist care: a systematic review of international evidence. Br J Gen Pract 2014; 64:e765-74. [PMID: 25452541 PMCID: PMC4240149 DOI: 10.3399/bjgp14x682837] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 06/11/2014] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure. AIM To review the international evidence on interventions to manage referral from primary to specialist care. DESIGN AND SETTING Systematic review. METHOD Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions. RESULTS The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no 'magic bullet' to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts. CONCLUSIONS To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision.
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Affiliation(s)
- Lindsay Blank
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Susan Baxter
- School of Health and Related Research, University of Sheffield, Sheffield
| | | | - Elizabeth Goyder
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Andrew Lee
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Nick Payne
- School of Health and Related Research, University of Sheffield, Sheffield
| | - Melanie Rimmer
- School of Health and Related Research, University of Sheffield, Sheffield
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Hilgart JS, Coles B, Iredale R. Cancer genetic risk assessment for individuals at risk of familial breast cancer. Cochrane Database Syst Rev 2012; 2012:CD003721. [PMID: 22336791 PMCID: PMC7154385 DOI: 10.1002/14651858.cd003721.pub3] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The recognition of an inherited component to breast cancer has led to an increase in demand for information, reassurance, and genetic testing, which has resulted in the creation of genetic clinics for familial cancer. The first step for patients referred to a cancer genetic clinic is a risk assessment. OBJECTIVES To evaluate the impact of cancer genetic risk-assessment services on patients at risk of familial breast cancer. SEARCH METHODS The specialised register maintained by the Cochrane Breast Cancer Group was searched on 16th February 2005. We also searched MEDLINE, EMBASE, CINAHL, PsycLIT, CENTRAL, DARE, ASSIA, Web of Science, SIGLE and LILACS. The original searches covered the period 1985 to February 2005. We also handsearched relevant journals. For this review update the search was repeated through to April 2011. SELECTION CRITERIA We considered trials looking at interventions for cancer genetic risk-assessment services for familial breast cancer for inclusion. Trials assessed outcomes such as understanding of risk, satisfaction and psychological well-being. We excluded studies if they concerned cancers other than breast cancer or if participants were not at risk of inherited breast cancer. We also excluded trials concerning the provision of general cancer genetic information or education as this review was concerned with the delivery of genetic risk assessment. Participants could be individuals of any age or gender, with or without a known BRCA mutation, but without a previous history of breast cancer or any other serious illness. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. Additional information was sought from investigators as necessary. Due to the heterogeneity of both the interventions and outcomes, we reported data descriptively. MAIN RESULTS In this review update, we included five new trials, bringing the total number of included studies to eight. The included trials (pertaining to 10 papers), provided data on 1973 participants and assessed the impact of cancer genetic risk assessment on outcomes including perceived risk of inherited cancer, and psychological distress. This review suggests that cancer genetic risk-assessment services help to reduce distress, improve the accuracy of the perceived risk of breast cancer, and increase knowledge about breast cancer and genetics. The health professional delivering the risk assessment does not appear to have a significant impact on these outcomes. AUTHORS' CONCLUSIONS This review found favourable outcomes for patients after risk assessment for familial breast cancer. However, there were too few papers to make any significant conclusions about how best to deliver cancer genetic risk-assessment services. Further research is needed assessing the best means of delivering cancer risk assessment, by different health professionals, in different ways and in alternative locations.
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Affiliation(s)
- Jennifer S Hilgart
- Institute of Medical Genetics, Cardiff University, Heath Park, Cardiff, Wales, UK, CF14 4XN
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Holloway SM, Lampe AK, Lam WWK. Paediatric referral and attendance rates for the clinical genetics service in south-east Scotland--a comparison of a regional clinic with satellite clinics. Scott Med J 2010; 55:10-3. [PMID: 20218272 DOI: 10.1258/rsmsmj.55.1.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS In some studies the establishment of specialist satellite clinics nearer to the homes of patients has resulted in increased referral and attendance rates, particularly amongst populations in lower socio-economic groups. We investigated the effect on these rates of establishing satellite genetic counselling clinics for families with paediatric conditions in South East Scotland. METHODS AND RESULTS Families offered appointments at a clinic at the regional paediatric hospital were compared with those offered appointments at a satellite clinic at a local district general hospital. Both groups of families were more socially deprived than the general population (regional clinic p < 0.001, satellite clinics p < 0.05), and in both groups attendance rate at first appointment was 88% and inversely related to social deprivation. There was no evidence of greater attendance amongst more deprived patients at the satellite clinics compared to the regional clinic. CONCLUSION Our study found no evidence that the establishment of satellite clinics for genetic counselling in South East Scotland increases attendance by families with paediatric conditions in lower socio-economic groups. This suggests that factors other than clinic location determine referral and attendance rates, and these may include understanding of the reason for referral and the advantage of attendance.
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Affiliation(s)
- S M Holloway
- Clinical Scientist, Clinical Genetics Unit, Western General Hospital, Edinburgh, EH4 2XU.
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10
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White DB, Bonham VL, Jenkins J, Stevens N, McBride CM. Too many referrals of low-risk women for BRCA1/2 genetic services by family physicians. Cancer Epidemiol Biomarkers Prev 2009; 17:2980-6. [PMID: 18990739 DOI: 10.1158/1055-9965.epi-07-2879] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The increasing availability and public awareness of BRCA1/2 genetic testing will increase women's self-referrals to genetic services. The objective of this study was to examine whether patient characteristics influence the referral decisions of family physicians when a patient requests BRCA1/2 genetic testing. Family physicians (n = 284) completed a Web-based survey in 2006 to assess their attitudes and practices related to the use of genetics in their clinical practice. Using a 2 x 2 x 2 factorial design, we tested the effects of a hypothetical patient's race, level of worry, and insurance status on the decisions of family physicians to refer her for BRCA1/2 testing. The patient was not appropriate for referral based on U.S. Preventive Services Task Force guidelines. No patient characteristics were associated with the family physicians' referral decisions. Although referral was not indicated, only 8% did not refer to genetic services; 92% referred for genetic services, and 50% referred to genetic counseling. Family physicians regarded it unlikely that the patient carried a mutation, but 65% of family physicians believed that if they refused to refer for genetic services it would harm their relationship with the patient. Despite scarce and costly genetic services, family physicians were likely to inappropriately refer a low-risk patient who requested BRCA1/2 testing. The implications of this inappropriate referral on women's screening behavior, genetic services, and health care costs are unknown. Clinicians and patients could benefit from education about the appropriate use of genetic services so that both are more comfortable with a decision against referral.
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Affiliation(s)
- Della Brown White
- Social and Behavioral Research Branch, National Human Genome Research Institute, NIH, 31 Center Drive, Building 31, Room B1B54G, Bethesda, MD 20892-2073, USA.
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Akbari A, Mayhew A, Al-Alawi MA, Grimshaw J, Winkens R, Glidewell E, Pritchard C, Thomas R, Fraser C. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev 2008; 2008:CD005471. [PMID: 18843691 PMCID: PMC4164370 DOI: 10.1002/14651858.cd005471.pub2] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved. OBJECTIVES To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness. SEARCH STRATEGY We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. Updated searches were conducted in MEDLINE and the EPOC specialised register up to October 2007. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes. DATA COLLECTION AND ANALYSIS A minimum of two reviewers independently extracted data and assessed study quality. MAIN RESULTS Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Four studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices, a new slot system for referrals and requiring a second 'in-house' opinion prior to referral), all of which were effective. Four studies (five comparisons) evaluated financial interventions. One study evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates. AUTHORS' CONCLUSIONS There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.
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Affiliation(s)
- Ayub Akbari
- Department of Medicine/Division of Nephrology, Kidney Research Center/University of Ottawa, Ottawa Hospital, Riverside Hospitall, 1967 Rverside Drive, Suite 5-25, Ottawa, Ontario, Canada, K1H 7W9.
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12
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Predicting breast cancer risk: implications of a “weak” family history. Fam Cancer 2008; 7:361-6. [DOI: 10.1007/s10689-008-9197-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 05/06/2008] [Indexed: 11/27/2022]
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13
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Holloway SM, Bernhard B, Campbell H, Cetnarskyj R, Lam WWK. Inequality of use of cancer genetics services by members of breast, ovarian and colorectal cancer families in South East Scotland. Fam Cancer 2008; 7:259-64. [PMID: 18246448 DOI: 10.1007/s10689-008-9184-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Accepted: 01/18/2008] [Indexed: 01/25/2023]
Abstract
Some studies have found a deficiency of male, younger and more socially deprived individuals amongst referrals to and/or attendees at cancer genetics clinics. We investigated this inequality of use of genetics services from data on 4,178 Scottish patients with a family history of breast and/or ovarian cancer (BOC) or colorectal cancer (CRC) referred from 2000--2006. Some 98% BOC and 60% CRC referrals were female. Median age of female referrals was greater in the CRC than the BOC group (45.3 vs. 38.7 years, P < 0.001). Both groups of referrals were less socially deprived than the general population (P < 0.001) and the CRC less deprived than the BOC group (P < 0.001). Some 88% patients attended the first appointment offered. Attendance was greater in the CRC group (P < 0.001) and in older patients (P < 0.001) and in the BOC group was highly significantly lower in more socially deprived patients (P < 0.001). Male relatives may feel counselling is less relevant and relatives of both sexes may delay counselling until approaching the age of onset of cancer in a relative. We suggest that medical professionals and the general public may have more knowledge about the genetics of BOC than of CRC. Thus relatives in CRC families seeking counselling are likely to be those with access to more information. The lower attendance amongst more deprived relatives in BOC families may result from poor understanding of the reason for referral. These findings confirm the need to provide male, younger and more socially deprived relatives with more helpful information on cancer genetics.
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Affiliation(s)
- Susan M Holloway
- Department of Clinical Genetics, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, UK.
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Holloway S, Porteous M, Cetnarskyj R, Anderson E, Campbell J, Steel M, Campbell H. Long-term attendance at follow-up of women assessed as being at increased risk of developing breast cancer in south-east Scotland. Public Health Genomics 2007; 10:252-60. [PMID: 17895631 DOI: 10.1159/000106564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Women with a family history of breast cancer increasingly seek genetic advice and screening. In the present study we investigated referral rates and factors associated with long-term attendance for screening in Scotland. METHODS We investigated referral rates to the genetic service over a 21-month period and long-term attendance for screening amongst the 226 women at increased risk of developing breast cancer. RESULTS The overall annual referral rate was 0.31 per 1,000 patients on general practitioners' lists. Some 98% of women for whom it was appropriate attended at least one screening appointment and 88% were continuing to attend appointments for surveillance up to 5 years later. Attendance was significantly lower among more socially deprived patients (p < 0.01). CONCLUSIONS These results suggest that as increasing numbers of women with a positive family history seek risk assessment and screening, current facilities may be inadequate.
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Affiliation(s)
- Susan Holloway
- Department of Clinical Genetics, Molecular Medicine Centre, Edinburgh, UK
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15
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Tozer D, Lugton C. Cancer genetics in rural primary care: a pilot nurse-led service using a new mobile IT system. Fam Cancer 2007; 6:221-9. [PMID: 17520350 DOI: 10.1007/s10689-007-9133-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Accepted: 04/04/2007] [Indexed: 10/23/2022]
Abstract
Somerset has a relatively high incidence of cancer. The county is very rural with pockets of deprivation and sizeable areas of poor access to services. The Cancer Plan advocates early identification of cancer and identified the genetic revolution as having the potential to predict risk, and detect and diagnose cancer early. This innovative Public Health led pilot takes specialist cancer genetics services into primary care. It explores a new service model that is patient focused, provides services close to home and reduces hospital visits and pressure on genetics departments. People who believe they are at increased risk of developing cancer, due to family history, are assessed by nurse specialists at their local surgery and triaged into population, medium and high risk groups. Patient pathways have been streamlined for breast, ovarian and colorectal cancers, which are known to have a genetic link and there may be advantage in increased surveillance and/or genetic testing. People are given the opportunity to understand their personal level of risk and make choices about lifestyles and interventions. To support the delivery of cancer genetics services in primary care a bespoke software package has been developed building on a commercial programme already established in many genetics departments. Electronic transmission of pedigrees from primary to tertiary care assists the lean pathways and the incorporation of a new risk calculator based on NICE guidelines for familial breast cancer is being assessed.
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Affiliation(s)
- Debbie Tozer
- Public Health Department, Somerset PCT, Wynford House, Lufton Way, Lufton, Yeovil, Somerset, BA22 8HR, UK.
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Drury N, Bethea J, Guilbert P, Qureshi N. Genetics Support to Primary Care Practitioners—A Demonstration Project. J Genet Couns 2007; 16:583-91. [PMID: 17497110 DOI: 10.1007/s10897-007-9096-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2006] [Accepted: 02/22/2007] [Indexed: 11/29/2022]
Abstract
Primary care practitioners need to be supported by specialist genetics services to enable them to cope effectively with the expanding relevance of genetics to their patients. Genetic counselors could be effective in such a role. This exploratory project set out to improve the Primary-Tertiary interface through piloting such a service to general practice for 1 year. Tailored genetic educational outreach was delivered by a genetic counselor to ten randomly selected general practices in central England for 12 months. A range of services were provided to the practices these included facilitated genetic update sessions, a responsive advice service and referral guidelines. The service was evaluated through pre and post intervention questionnaires and via seven semi-structured interviews. This article presents a description of the development and delivery of this service and also reports on the experiences of a sample of the participants. Participants reported positive attitudes to the service and said that they had gained knowledge and confidence, as well as recognized limitations and gaps in their current knowledge. The consistent link with a specialist genetics service provided by a genetic counselor had a positive impact during the project and participants have continued to utilize the genetic counselor for advice and support with genetic patient issues since the project was completed. This is the first example of this model of service provision. Further research, utilizing a larger sample and other measures of behavioral change needs to be carried out to assess whether this model should be adopted on a wider basis.
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Affiliation(s)
- N Drury
- Nottingham Regional Clinical Genetics Service, Nottingham University Hospitals NHS Trust, City Hospital Campus, Hucknall Road, Nottingham NG5 1PB, UK.
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17
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Sivell S, Iredale R, Gray J, Coles B. Cancer genetic risk assessment for individuals at risk of familial breast cancer. Cochrane Database Syst Rev 2007:CD003721. [PMID: 17443529 DOI: 10.1002/14651858.cd003721.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The recognition of an inherited component to breast cancer has led to an increase in demand for information, reassurance, and genetic testing, resulting in the creation of genetics clinics for familial cancer. The first step for patients referred to a cancer genetic clinic is a risk assessment. OBJECTIVES To evaluate the impact of cancer genetic risk assessment services on patients at risk of familial breast cancer. SEARCH STRATEGY The specialised register maintained by the Cochrane Breast Cancer Group was searched. We also searched MEDLINE, EMBASE, CINAHL, PsycLIT, CENTRAL, DARE, ASSIA, Web of Science, SIGLE and LILACS. The searches covered the period 1985 to February 2005. We also hand-searched relevant journals. SELECTION CRITERIA Trials looking at interventions for cancer genetic risk assessment delivery for familial breast cancer were considered for inclusion. Trials assessed outcomes such as understanding of risk, satisfaction and psychological well-being. Studies were excluded if they concerned cancers other than breast cancer or if participants were not at risk of breast cancer. Trials concerning the provision of information or education were also excluded as it was intended to review these separately. Participants could be individuals of any age or gender, with or without a known BRCA mutation, but without a previous history of breast cancer or any other serious illness. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. Additional information was sought from investigators as necessary. Due to the heterogeneity of both the interventions and outcomes, data were analysed descriptively. MAIN RESULTS Fifty-eight papers were identified as relevant to the review, 54 of these were subsequently excluded. The three included trials (pertaining to five papers), provide data on 1251 participants and assessed the impact of cancer genetic risk assessment on outcomes including perceived risk, and psychological distress. This review suggests that cancer genetic risk assessment services help to reduce distress, improve the accuracy of the perceived risk of, and increase knowledge about, breast cancer and genetics. The health professional delivering the risk assessment does not appear to have a significant impact on these outcomes. AUTHORS' CONCLUSIONS This review found favourable outcomes for patients' risk assessment for familial breast cancer. However, there were too few papers to make any significant conclusions about how best to deliver cancer genetic risk assessment services. Further research is needed assessing the best means of delivering cancer risk assessment, by different health professionals, in different ways and in alternative locations.
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Young D, McLeish L, Sullivan F, Pitkethly M, Reis M, Goudie D, Vysny H, Ozakinci G, Steel M. Familial breast cancer: management of 'lower risk' referrals. Br J Cancer 2006; 95:974-8. [PMID: 17047645 PMCID: PMC2360713 DOI: 10.1038/sj.bjc.6603389] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Up to 40% of referrals from primary care to ‘breast cancer family clinics’ prove to be of women whose assessed risk falls below the guidelines' threshold for management in secondary or tertiary care, despite recommendations that they should be screened out at primary care level. A randomised trial, involving 87 such women referred to the Tayside Familial Breast Cancer Service compared two ways of communicating risk information, letter or personal interview. Both were found to be acceptable to referred women and to their family doctors, although the former expressed a slight preference for interview. Only four women returned to their family doctors with continuing concerns about breast cancer. Nevertheless, understanding of information provided by either route was unsatisfactory, with apparent confusion about both absolute and relative risks of breast cancer. Substantial minorities appear to believe that they are at no increased risk at all, or even below the population level of risk, while others remain convinced that their personal risk has been underestimated. Family history record forms, completed by the referred women, preferably with the assistance of relatives, are crucial to full assessment of familial risk but one quarter of women referred to the Tayside Familial Breast Cancer Service currently do not complete and return these forms ahead of their clinic appointment. Further collaboration between primary care and the Breast Cancer Family Service is required to improve provision for concerned women whose risks fall below the threshold for special surveillance and to maximise effective use of the family history record form.
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Affiliation(s)
- D Young
- Tayside Breast Cancer Family Clinic, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - L McLeish
- Tayside Breast Cancer Family Clinic, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - F Sullivan
- Community Health Sciences Division, University of Dundee Medical School, McKenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - M Pitkethly
- Community Health Sciences Division, University of Dundee Medical School, McKenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - M Reis
- Tayside Breast Cancer Family Clinic, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - D Goudie
- Tayside Breast Cancer Family Clinic, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - H Vysny
- Tayside Breast Cancer Family Clinic, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
- Bute Medical School, University of St Andrews, St Andrews, Fife KY16 9TS, UK
| | - G Ozakinci
- Bute Medical School, University of St Andrews, St Andrews, Fife KY16 9TS, UK
| | - M Steel
- Tayside Breast Cancer Family Clinic, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
- Bute Medical School, University of St Andrews, St Andrews, Fife KY16 9TS, UK
- Bute Medical School, University of St Andrews, St Andrews, Fife KY16 9TS, UK. E-mail:
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Reis MM, Young D, McLeish L, Goudie D, Cook A, Sullivan F, Vysny H, Fordyce A, Black R, Tavakoli M, Steel M. Analysis of referrals to a multi-disciplinary breast cancer genetics clinic: practical and economic considerations. Fam Cancer 2006; 5:297-303. [PMID: 16819594 DOI: 10.1007/s10689-006-7849-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2005] [Accepted: 03/04/2006] [Indexed: 11/30/2022]
Abstract
Analysis of activity was undertaken in an established regional clinic providing risk assessment, counselling, screening and management for women with a family history of breast or ovarian cancer. The objectives were to determine: (1) how closely the route and pattern of referrals matched official guidelines (2) whether the previously recorded socio-economic imbalance among clinic clientele persisted and (3) the economic and practical consequences of committing resources to verification and extension of reported family histories. The findings were: (1) after some years of operation, the proportion of referrals direct from primary care had increased from less than 50% to over 75%, with a concomitant slight decrease in overall referral rate; (2) the socio-economic distribution of patients referred had become less selective and (3) extension and verification of reported family histories led to a redistribution of risk categories, increasing the proportion of referrals judged to be in the "low risk" category, from 25% (based on referral letter alone) to 41% (at the end of the process). The costs associated with this approach are offset by the savings generated and it allows specialised counselling and screening services to be targeted more efficiently.
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Affiliation(s)
- Marta M Reis
- Tayside Breast Cancer Family Clinic, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
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20
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Holloway S, Porteous M, Cetnarskyj R, Rush R, Appleton S, Gorman D, Campbell H. Referrals of patients to colorectal cancer genetics services in south-east Scotland. Fam Cancer 2005; 4:151-61. [PMID: 15951967 DOI: 10.1007/s10689-004-4488-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2004] [Accepted: 09/30/2004] [Indexed: 12/25/2022]
Abstract
The discovery that genetic factors are involved in the aetiology of colorectal cancer, has prompted many relatives of affected individuals to seek genetic counselling and screening. This paper describes the demand for genetic services by families with colorectal cancer in south-east Scotland, their expectations and views of the service offered. The annual referral rate over the 21-month study period, for patients with a family history of colorectal cancer, was 0.11 per 1000 patients on general practitioner lists. This is one third of the rate for patients with a family history of breast cancer and in comparison with the breast cancer group, relatives of colorectal cancer patients were significantly older and less socially deprived. Approximately one third were referred via a hospital specialist unit. One hundred patients were included in the study. Mean (+/- standard deviation) age was 43 (+/- 10.7 years), 75 were female and 31 were self referrals. Before the consultation, almost half the patients had an inflated perception of their risk and there was little change at follow-up. There was an improvement in objective understanding after counselling which was sustained up to 6 months but only two thirds remembered their objective risk accurately. Most patients were satisfied with the consultation. Our findings suggest the need to educate individuals, in particular men, younger people and the more socially deprived, about the relevance of a family history of colorectal cancer and to facilitate patients' comprehension of their risk status.
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Affiliation(s)
- Susan Holloway
- Department of Clinical Genetics, Molecular Medicine Centre, Western General Hospital, Edinburgh, Scotland, UK
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21
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Grimshaw JM, Winkens RAG, Shirran L, Cunningham C, Mayhew A, Thomas R, Fraser C. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev 2005:CD005471. [PMID: 16034981 DOI: 10.1002/14651858.cd005471] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved. OBJECTIVES To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness. SEARCH STRATEGY We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed study quality. MAIN RESULTS Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Three studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices and requiring a second 'in-house' opinion prior to referral), all of which were effective. Five studies (six comparisons) evaluated financial interventions. Two studies evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates. AUTHORS' CONCLUSIONS There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.
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Affiliation(s)
- J M Grimshaw
- Ottawa Health Research Institute, 1053 Carling Avenue, Administration Building, Room 2-017, Ottawa, Ontario, Canada, AB25 2ZD.
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Iredale R, Jones L, Gray J, Deaville J. 'The edge effect': an exploratory study of some factors affecting referrals to cancer genetic services in rural Wales. Health Place 2005; 11:197-204. [PMID: 15774327 DOI: 10.1016/j.healthplace.2004.06.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2004] [Indexed: 10/26/2022]
Abstract
This exploratory study examines the role of rurality in referrals from primary care to the Cancer Genetics Service for Wales (CGSW) through a case study of referrals from Montgomeryshire, a predominantly rural area in mid-Wales located adjacent to the English border. Awareness of CGSW amongst practitioners is low. We found that rurality plays a role in referral behaviour as distance, time travelling and accessibility by car and public transport are all perceived to have an impact on the patient's decision to attend a clinic appointment. Some patients are being referred outside Wales as ease of access to services is considered more important than distance.
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Affiliation(s)
- Rachel Iredale
- Cancer Genetics Service for Wales, Institute of Medical Genetics, University of Wales College of Medicine, Heath Park, Cardiff, CF14 4XN, UK.
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Elwyn G, Edwards A, Iredale R, Davies P, Gray J. Identifying future models for delivering genetic services: a nominal group study in primary care. BMC FAMILY PRACTICE 2005; 6:14. [PMID: 15831099 PMCID: PMC1087483 DOI: 10.1186/1471-2296-6-14] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/11/2004] [Accepted: 04/14/2005] [Indexed: 11/10/2022]
Abstract
Background To enable primary care medical practitioners to generate a range of possible service delivery models for genetic counselling services and critically assess their suitability. Methods Modified nominal group technique using in primary care professional development workshops. Results 37 general practitioners in Wales, United Kingdom too part in the nominal group process. The practitioners who attended did not believe current systems were sufficient to meet anticipated demand for genetic services. A wide range of different service models was proposed, although no single option emerged as a clear preference. No argument was put forward for genetic assessment and counselling being central to family practice, neither was there a voice for the view that the family doctor should become skilled at advising patients about predictive genetic testing and be able to counsel patients about the wider implications of genetic testing for patients and their family members, even for areas such as common cancers. Nevertheless, all the preferred models put a high priority on providing the service in the community, and often co-located in primary care, by clinicians who had developed expertise. Conclusion There is a need for a wider debate about how healthcare systems address individual concerns about genetic concerns and risk, especially given the increasing commercial marketing of genetic tests.
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Affiliation(s)
- Glyn Elwyn
- Centre for Health Sciences Research, Cardiff University, 56 Park Place, Cardiff, CF10 3AT, Wales
| | - Adrian Edwards
- Centre for Health Sciences Research, Cardiff University, 56 Park Place, Cardiff, CF10 3AT, Wales
| | - Rachel Iredale
- Institute of Medical Genetics, Cardiff University, Heath Park, Cardiff, CF14 4XN, Wales
| | - Peter Davies
- Primary Care Group, University of Wales Swansea, SA2 8PP, Wales
| | - Jonathon Gray
- Institute of Medical Genetics, Cardiff University, Heath Park, Cardiff, CF14 4XN, Wales
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Skinner CS, Rawl SM, Moser BK, Buchanan AH, Scott LL, Champion VL, Schildkraut JM, Parmigiani G, Clark S, Lobach DF, Bastian LA. Impact of the Cancer Risk Intake System on patient-clinician discussions of tamoxifen, genetic counseling, and colonoscopy. J Gen Intern Med 2005; 20:360-5. [PMID: 15857495 PMCID: PMC1490091 DOI: 10.1111/j.1525-1497.2005.40115.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Cancer Risk Intake System (CRIS), a computerized program that "matches" objective cancer risks to appropriate risk management recommendations, was designed to facilitate patient-clinician discussion. We evaluated CRIS in primary care settings via a single-group, self-report, pretest-posttest design. Participants completed baseline telephone surveys, used CRIS during clinic visits, and completed follow-up surveys 1 to 2 months postvisit. Compared with proportions reporting having had discussions at baseline, significantly greater proportions of participants reported having discussed tamoxifen, genetic counseling, and colonoscopy, as appropriate, after using CRIS. Most (79%) reported CRIS had "caused" their discussion. CRIS is an easily used, disseminable program that showed promising results in primary care settings.
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Hopwood P, Wonderling D, Watson M, Cull A, Douglas F, Cole T, Eccles D, Gray J, Murday V, Steel M, Burn J, McPherson K. A randomised comparison of UK genetic risk counselling services for familial cancer: psychosocial outcomes. Br J Cancer 2004; 91:884-92. [PMID: 15305197 PMCID: PMC2409862 DOI: 10.1038/sj.bjc.6602081] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The aim of the study was to compare psychosocial outcomes for 50 new clinic attendees, referred for cancer genetic counselling to five UK centres. The centres represented England, Scotland and Wales, and were randomly selected from groups ranked by different levels of clinical activity in cancer genetics practice. Questionnaires assessed demographic data, risk perception, mental health and use of health services pre-consultation and at 1 and 12 months follow-up. Satisfaction was measured for attendees and referring doctors at follow-up. A total of 256 unaffected adults fulfilled the study criteria. The five centres varied widely with respect to service organisation and activity, but all had a greater proportion of unaffected attendees with a breast cancer risk (61–91%) than either a bowel cancer risk (0–33%) or ovarian cancer risk (3–25%). There were no significant differences in the psychosocial data between centres pre-counselling. No significant change over time occurred for any of the centres for risk perception or general psychological distress. There were significant differences between centres in reduction of cancer worry from baseline to 12 months and with the number of women who were recommended to have mammographic surveillance who had not received this. Overall, one-third of women for whom mammography had been recommended had not been screened within 1 year of follow-up. Subsequent attendance at the GP, but not at a hospital, was associated with risk level, but differences between centres could not be analysed. Satisfaction differed significantly between centres for 4 : 14 aspects of service provision and with 3 : 17 items concerning communication; satisfaction was high overall. Over 90% of referring doctors were moderately/very satisfied with the service, but 23% were dissatisfied with waiting times and 19% with access to preventive treatment. Results differed significantly between centres for doctor's satisfaction with the provision of referral criteria and prescribing information. In conclusion, there were relatively few significant differences in psychosocial outcomes between centres, considering the wide variation in service organisation and activity. These significant differences were not consistent across the centres, therefore, differences could not be linked to specific aspects of service provision.
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Affiliation(s)
- P Hopwood
- Christie Hospital NHS Trust, The CRC Psychological Medicine Group, Stanley House, Wilmslow Road, Withington, Manchester, M20 4BX, UK.
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Hopwood P, van Asperen CJ, Borreani G, Bourret P, Decruyenaere M, Dishon S, Eisinger F, Evans DGR, Evers-Kiebooms G, Gangeri L, Hagoel L, Legius E, Nippert I, Rennert G, Schlegelberger B, Sevilla C, Sobol H, Tibben A, Welkenhuysen M, Julian-Reynier C. Cancer Genetics Service Provision: A Comparison of Seven European Centres. Public Health Genomics 2004; 6:192-205. [PMID: 15331865 DOI: 10.1159/000079381] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To conduct a survey in seven European cancer genetics centres to compare service provision, organisation and practices for familial breast and colon cancer consultations and testing. Information was obtained on aspects of services both nationally and locally. METHODS A detailed survey questionnaire was adapted collaboratively to obtain the required information. Initial survey data were collected within each centre and interim results were discussed at two European Workshops. Where differences in practice existed, details were clarified to ensure accuracy and adequacy of information. Participating centres were Haifa (Israel), Hannover (Germany), Leiden (The Netherlands), Leuven (Belgium), Manchester (UK), Marseille (France) and Milan (Italy), representing countries with populations ranging from 6.5 to 80 million. RESULTS The European countries diverged in regard to the number of cancer genetics centres nationally (from 8 in Belgium to 37 in France), and the average population served by each centre (from 0.59 million in Israel to 3.32 million in Italy). All centres offered free care at the point of access, but referral to specialist care varied according to national health care provision. At a centre level, staff roles varied due to differences in training and health care provision. The annual number of counsellees seen in each participating centre ranged from 200 to over 1,700. Access to breast surveillance or bowel screening varied between countries, again reflecting differences in medical care pathways. These countries converged in regard to the wide availability of professional bodies and published guidelines promoting aspects of service provision. Similarities between centres included provision of a multidisciplinary team, with access to psychological support, albeit with varying degrees of integration. All services were dominated (70-90%) by referrals from families with an increased risk of breast cancer despite wide variation in referral patterns. Collection of pedigree data and risk assessment strategies were broadly similar, and centres used comparable genetic testing protocols. Average consultation times ranged between 45 and 90 min. All centres had access to a laboratory offering DNA testing for breast and bowel cancer-predisposing genes, although testing rates varied, reflecting the stage of service development and the type of population. Israel offered the highest number of genetic tests for breast cancer susceptibility because of the existence of specific founder mutations, in part explaining why the cancer genetics service in Haifa differed most from the other six. CONCLUSION Despite considerable differences in service organisation, there were broad similarities in the provision of cancer genetic services in the centres surveyed.
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Affiliation(s)
- P Hopwood
- Psycho-Oncology, Christie Hospital NHS Trust, Manchester, UK.
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Holloway S, Porteous M, Cetnarskyj R, Anderson E, Rush R, Fry A, Gorman D, Steel M, Campbell H. Patient satisfaction with two different models of cancer genetic services in south-east Scotland. Br J Cancer 2004; 90:582-9. [PMID: 14760368 PMCID: PMC2409586 DOI: 10.1038/sj.bjc.6601562] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
There is a need to integrate primary- and secondary-care cancer genetic services, but the most appropriate model of service delivery remains unclear. This study reports patients' expectations of breast cancer genetic services and a comparison of their satisfaction with two service models. In the first model, risk assessment was carried out using mailed family history data. Women estimated as being at high/moderate risk were offered an appointment at the familial breast cancer clinic, and those at low risk were sent a letter of reassurance. In the second model, all women were seen by a genetic nurse specialist, who assessed risk, referred high/moderate-risk women to the above clinic and discharged those at low risk. Over 60% of all women in the study regarded access to breast screening by mammogram and regular check-ups as very important. This underlines the demand for a multidisciplinary service providing both clinical genetic and surgical services. Satisfaction was high with both models of service, although significantly lower among women not at increased cancer risk and thus not offered a clinical check-up and mammography. Increased cancer worry was associated with a greater expressed need for information and for reassurance through follow-up clinical checks and mammography. Better targeting of counselling to the expressed concerns and needs of these women is required to improve the service offered. GPs and patients expressed no clear preference for any specific service location or staffing configuration. The novel community service was less expensive in terms of both staff and patient costs. The potential to decrease health staff/patient contact time and to employ nurse practitioners with both clinical genetic and oncology training should be explored further. The rapidly rising demand for these services suggests that the evaluation of further new models needs to continue to be given priority to guide the development of cancer genetic services.
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Affiliation(s)
- S Holloway
- Department of Clinical Genetics, Molecular Medicine Centre, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - M Porteous
- Department of Clinical Genetics, Molecular Medicine Centre, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - R Cetnarskyj
- Department of Clinical Genetics, Molecular Medicine Centre, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
- Department of Public Health Sciences, University of Edinburgh Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - E Anderson
- Edinburgh Breast Unit, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
- SE Scotland Breast Screening Service, Ardmillan House, Ardmillan Terrace, Edinburgh EH11 2SL, UK
| | - R Rush
- Cancer Research UK, Edinburgh Oncology Unit, Western General Hospital, Crewe Road South, Edinburgh EH4 2XR, UK
| | - A Fry
- Cancer Research UK, Edinburgh Oncology Unit, Western General Hospital, Crewe Road South, Edinburgh EH4 2XR, UK
| | - D Gorman
- Lothian NHS Board, Deaconess House, 148 Pleasance, Edinburgh EH8 9RS, UK
| | - M Steel
- School of Biology, University of St Andrews, St Andrews, Fife KY16 9TS, UK
| | - H Campbell
- Department of Public Health Sciences, University of Edinburgh Medical School, Teviot Place, Edinburgh EH8 9AG, UK
- Department of Public Health Sciences, University of Edinburgh Medical School, Teviot Place, Edinburgh EH8 9AG, UK. E-mail:
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Affiliation(s)
- Caryn Lerman
- Department of Psychiatry, Abramson Cancer Center, University of Pennsylvania, 3535 Market Street, Suite 4100, Philadelphia, Pennsylvania 19104, USA.
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