Transcript Integrating Genetics into Primary Care: An Overview of

Genetics Education for Canadian Primary
Care Providers:
Knowledge Translation Initiatives
June C Carroll MD CCFP
Sydney G Frankfort Chair in Family Medicine
Associate Professor, Department of Family Medicine
Mount Sinai Hospital, University of Toronto
12th Annual NCHPEG Meeting
Bethesda, Maryland
September 23, 2009
Objectives
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To present several knowledge
translation (KT) initiatives in genetics
education for PCPs in Ontario, Canada
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Brief description
Evaluation
Lessons learned for future primary care
genetics KT initiatives
Challenge
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How to deliver genetics education to PCPs?
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Rapidly evolving body of knowledge
Complex ethical/legal/social issues
Time pressures
Lack of awareness of new genetics services
Educational efforts likely to be successful if:
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Relevant to primary care practice
Enhance primary care role
Build on existing skills and knowledge
Examples of KT Initiatives in Genetics
Education for PCPs in Ontario
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The Genetics Education Project
Hereditary CRC Project
GenetiKit project
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Purpose:
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To develop and evaluate genetics educational materials
for PCPs
To increase capacity in primary care genetics
Needs assessment
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Carroll et al Can Fam Physician 2003
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Development of educational materials
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PowerPoint modules with speaker notes
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Hereditary cancers, hemochromatosis, AZ, PN screening, NBS
Designed for use by participants as peer resources
PN genetic screening monographs
Risk assessment/management tools
 http://www.mtsinai.on.ca/FamMedGen/
Principles
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Based on needs assessment
Multidisciplinary team
Input from consumers
Case-based, practical materials
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Method:
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Interactive peer resource workshop
Participants
Evaluation:
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Pre-/post-intervention
Questionnaire 6 months later evaluating:
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Knowledge
Confidence in core clinical genetics skills
Attitudes to genetic testing
Teaching activities related to genetics
Funded by Ontario Women’s Health Council, Ontario Ministry of
Health and Long-Term Care
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Analysis:
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Differences between Q1 and Q3 on variables of
interest:
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McNemar’s test for matched categorical variables
Wilcoxon signed ranks test for paired data (p<0.05)
Results:
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21/29 completed Q1 & Q3
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14 FP, 5 RN, 1 NP, 1 other
17 (81%) women
18 (86%) urban/suburban
How would you rate your current level of knowledge
in genetics? (1=poor, 5=excellent) n=21
Prenatal genetic
issues
Adult-onset genetic
disorders
(e.g. cancer, HH, AD)
Q1
Median
(range)
3
(1-5)
Q3
Median
(range)
3
(2-5)
p-value
2
(1-5)
3
(1-4)
0.001
0.37
Confidence in carrying out each of the following:
(1=low confidence, 5=high confidence) n=21
Q1
Median
Q3
Median
p-value
Assess risk for hereditary
disorders
Decide who should be offered ref
for GC/GT based on FH
3 (1-5)
3.5 (2-5)
0.033
3 (2-4)
3 (3-5)
0.003
Discuss the benefits, risks and
limitations of genetic testing
3 (2-4)
4 (2-5)
0.033
Attitudes toward genetic testing for hereditary diseases
(1=strongly disagree, 5=strongly agree) n=21
Genetic testing is beneficial
in the management of
adult-onset genetic diseases.
Q1
n (%)
agree +
str agree
Q3
n (%)
agree +
str agree
p-value
8 (38)
14 (68)
0.031
Confidence serving as an informal resource to HCPs in your
community about genetic issues
(1=not very confident, 5=very confident) n=21
Q1
Median
(range)
Q3
Median
(range)
p-value
Prenatal genetic issues
2 (1-5)
3 (1-5)
0.176
Adult-onset genetic
disorders
1 (1-4)
3 (1-4)
0.006
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Results:
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19/21 (90%) – more confident dealing
with genetic issues
How would they change their practices?
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15/21 (71%) – improve FH taking
10/21 (48%) – increase teaching of genetics
10/21 (48%) – increased knowledge of
genetics
Accepted for publication Can Fam Physican 2009
Genetic Risk Assessment and Management of
Patients with a Family History of Colorectal Cancer
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Objective:
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To determine if a CRC Risk triage/management tool
would improve FPs’ ability to:
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correctly assess CRC risk
recommend appropriate risk-specific surveillance
recommend appropriate genetics referral
Method:
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Recruited FPs in ON and NL
Received CCS CRC risk triage/management tool
Pre/Post questionnaire study with CRC vignettes
Genetic Risk Assessment and Management of
Patients with a Family History of Colorectal Cancer
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Method
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Intervention: CCS CRC triage/management
card
8 CRC case vignettes representing the
broadest spectrum of CRC family history
(population, low, moderate, and high risk for
hereditary CRC)
Outcomes:
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CRC risk assessment, surveillance plan, and
genetics referral plan as response to vignettes
(measured using paired t-tests).
Genetic Risk Assessment and Management of
Patients with a Family History of Colorectal Cancer
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Results:
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Random list of FPs in ON (485) and NL (175)
mailed letters of invitation
51/86 (59%) Ontario and 25/35 (71%)
Newfoundland FPs completed the study.
Genetic Risk Assessment and Management of
Patients with a Family History of Colorectal Cancer
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Results:
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FPs’ overall risk triage of 8 CRC case vignettes
improved significantly
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measured by the mean score of pooled correct
responses
Pre=3.5/8.0, Post=5.7/8.0, p<0.001
FPs’ “correct” choice of surveillance
recommendations improved significantly
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appropriate choice of screening method, age to
start and screening frequency
Pre=17.7/24.0, Post=20.3/24.0, p<0.001
Genetic Risk Assessment and Management of
Patients with a Family History of Colorectal Cancer
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Results:
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FPs’ ability to offer “appropriate” genetics
referral recommendations significantly
improved
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Pre=5.0/8.0, Post=6.5/8.0, p<0.001
Follow up study
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Funded by CIHR
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To develop and evaluate a multi-faceted knowledge
translation intervention to improve the delivery of
genetics services by family physicians
Specific Objectives:
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To improve
 genetics referral decisions
 confidence in core genetics competencies
 Knowledge relevant to primary care
Funded by CIHR
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RCT
Intervention - 3 distinct KT strategies
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interactive educational workshop
portfolio of 1° care-appropriate genetics tools
IT-based knowledge service called Gene Messenger
 “just-in-time” information
 1-2 page critical review of genetic test or
disorder featured in mainstream print media
 “bottom line” recommendations for primary
care provider
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Primary endpoint: intention to refer to cancer
genetics clinic
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based on responses to 10 clinical scenarios (BrCa)
Secondary endpoint: confidence in core genetics
competencies
Analysis of covariance controlling for baseline
scores
Sample size: needed 126 participants for 80%
power of detecting effect size of 0.5 of SD for
primary endpoint, for an alpha of 0.05
950 FPs invited
- 892 eligible
125/892 (14%)
participated
Control Group:
64/125 (51%)
Intervention Group:
61/125 (49%)
32/64 (50%)
completed Q1 & Q2
48/61 (79%)
completed Q1 &Q2
Variable
p value
Intention to Refer
- total mean score /10 for vignettes
I: 7.8 (SE 0.2)
C: 6.4 (SE 0.3)
<0.001
Over Referral
- # of cases where scenario did not
indicate referral
I: .78 (SE: 0.2)
C: 1.2 (SE 0.2)
0.059
Under Referral
- # of cases where pt not referred
but scenario met referral criteria
I: 1.4 (SE: 0.2)
C: 2.4 (SE: 0.2)
Confidence
- total mean score for 11 items/ 55
I: 42.6 (SE: 1.0)
C: 33.9 (SE: 1.3)
<0.001
<0.001
What have we learned?
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Complex educational interventions seem to
have modest success in improving:
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Educational interventions:
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“appropriate” genetics referral
confidence in core genetics competencies
knowledge
Clinical relevance
Interactive
Tools:
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point of care, simple
What are the limitations of these studies?
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Intermediate outcomes
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Self-reported knowledge
Risk assessment/intention to refer/management
intent based on clinical vignettes
Need more actual clinical outcomes
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Track referrals and appropriateness of referrals
Track screening and clinical outcomes
Small numbers
Cost
Small effect size
What are the limitations of these
studies?
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KT literature
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Majority of educational interventions with HCPs achieve
only modest to moderate improvements in care
KT interventions effect on improvement in process of
care:
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Dissemination of educational materials: 8.1%
Combination of educational materials and meetings: 1.9-10%
Grimshaw et al. Effectiveness and efficacy of guideline
dissemination and implementation strategies. Health Technol
Assess 2004.
Future Horizon – What do
primary care providers need?
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Educational strategies
Practice Tools
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Referral guidelines
Computer decision support
Family history tools
Development and evaluation of innovative
models of genetics health service delivery
Evidence
Team members/authors
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June Carroll PI
Judith Allanson
Sean Blaine
Elizabeth Dicks
Mary Jane Esplen
Sandra Farrell
Gail Graham
Ian Graham
Jeremy Grimshaw
Jennifer MacKenzie
John McLaughlin
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Wendy Meschino
Fiona Miller
Joanne Permaul
Pretti Prakash
Andrea L Rideout
Heidi Rothenmund
Kara Semotiuk
Cheryl Shuman
Sherry Taylor
Ellen Warner
Brenda J Wilson
G Worrall
For more info:
Web site for
educational materials:
 http://www.mtsinai.on.ca/FamMedGen/
Web site for Gene Messengers:
 http://www.cfp.ca/misc/collections.dtl
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Click on Genetics
[email protected]