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Genetics Education for Canadian Primary Care Providers: Knowledge Translation Initiatives

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Genetics Education for Canadian Primary Care Providers: Knowledge Translation Initiatives June C Carroll MD CCFP Sydney G Frankfort Chair in Family Medicine – PowerPoint PPT presentation

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Title: Genetics Education for Canadian Primary Care Providers: Knowledge Translation Initiatives


1
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

2
Objectives
  • To present several knowledge translation (KT)
    initiatives in genetics education for PCPs in
    Ontario, Canada
  • Brief description
  • Evaluation
  • Lessons learned for future primary care genetics
    KT initiatives

3
Challenge
  • How to deliver genetics education to PCPs?
  • 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
  • Relevant to primary care practice
  • Enhance primary care role
  • Build on existing skills and knowledge

4
Examples of KT Initiatives in Genetics Education
for PCPs in Ontario
  • The Genetics Education Project
  • Hereditary CRC Project
  • GenetiKit project

5
  • Purpose
  • To develop and evaluate genetics educational
    materials for PCPs
  • To increase capacity in primary care genetics
  • Needs assessment
  • Carroll et al Can Fam Physician 2003

6
  • Development of educational materials
  • PowerPoint modules with speaker notes
  • 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
  • Based on needs assessment
  • Multidisciplinary team
  • Input from consumers
  • Case-based, practical materials

7
  • Method
  • Interactive peer resource workshop
  • Participants
  • Evaluation
  • Pre-/post-intervention
  • Questionnaire 6 months later evaluating
  • Knowledge
  • Confidence in core clinical genetics skills
  • Attitudes to genetic testing
  • Teaching activities related to genetics
  • Funded by Ontario Womens Health Council, Ontario
    Ministry of Health and Long-Term Care

8
  • Analysis
  • Differences between Q1 and Q3 on variables of
    interest
  • McNemars test for matched categorical variables
  • Wilcoxon signed ranks test for paired data
    (plt0.05)
  • Results
  • 21/29 completed Q1 Q3
  • 14 FP, 5 RN, 1 NP, 1 other
  • 17 (81) women
  • 18 (86) urban/suburban

9

How would you rate your current level of
knowledge in genetics? (1poor, 5excellent) n21
Q1 Median (range) Q3 Median (range) p-value
Prenatal genetic issues 3 (1-5) 3 (2-5) 0.37
Adult-onset genetic disorders (e.g. cancer, HH, AD) 2 (1-5) 3 (1-4) 0.001
10

Confidence in carrying out each of the
following (1low confidence, 5high confidence)
n21
Q1 Median Q3 Median p-value
Assess risk for hereditary disorders 3 (1-5) 3.5 (2-5) 0.033
Decide who should be offered ref for GC/GT based on FH 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
11

Attitudes toward genetic testing for hereditary
diseases (1strongly disagree, 5strongly agree)
n21
Q1 n () agree str agree Q3 n () agree str agree p-value
Genetic testing is beneficial in the management of adult-onset genetic diseases. 8 (38) 14 (68) 0.031
12

Confidence serving as an informal resource to
HCPs in your community about genetic
issues (1not very confident, 5very confident)
n21
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
13
  • Results
  • 19/21 (90) more confident dealing with genetic
    issues
  • How would they change their practices?
  • 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

14
Genetic Risk Assessment and Management of
Patients with a Family History of Colorectal
Cancer
  • Objective
  • To determine if a CRC Risk triage/management tool
    would improve FPs ability to
  • correctly assess CRC risk
  • recommend appropriate risk-specific surveillance
  • recommend appropriate genetics referral
  • Method
  • Recruited FPs in ON and NL
  • Received CCS CRC risk triage/management tool
  • Pre/Post questionnaire study with CRC vignettes

15
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16
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17
Genetic Risk Assessment and Management of
Patients with a Family History of Colorectal
Cancer
  • Method
  • 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
  • CRC risk assessment, surveillance plan, and
    genetics referral plan as response to vignettes
    (measured using paired t-tests).

18
Genetic Risk Assessment and Management of
Patients with a Family History of Colorectal
Cancer
  • Results
  • 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.

19
Genetic Risk Assessment and Management of
Patients with a Family History of Colorectal
Cancer
  • Results
  • FPs overall risk triage of 8 CRC case vignettes
    improved significantly
  • measured by the mean score of pooled correct
    responses
  • Pre3.5/8.0, Post5.7/8.0, plt0.001
  • FPs correct choice of surveillance
    recommendations improved significantly
  • appropriate choice of screening method, age to
    start and screening frequency
  • Pre17.7/24.0, Post20.3/24.0, plt0.001

20
Genetic Risk Assessment and Management of
Patients with a Family History of Colorectal
Cancer
  • Results
  • FPs ability to offer appropriate genetics
    referral recommendations significantly improved
  • Pre5.0/8.0, Post6.5/8.0, plt0.001
  • Follow up study
  • Funded by CIHR

21
  • To develop and evaluate a multi-faceted knowledge
    translation intervention to improve the delivery
    of genetics services by family physicians
  • Specific Objectives
  • To improve
  • genetics referral decisions
  • confidence in core genetics competencies
  • Knowledge relevant to primary care
  • Funded by CIHR

22
  • RCT
  • Intervention - 3 distinct KT strategies
  • 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

23
  • Primary endpoint intention to refer to cancer
    genetics clinic
  • 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

24
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25
Variable p value
Intention to Refer - total mean score /10 for vignettes I 7.8 (SE 0.2) C 6.4 (SE 0.3) lt0.001
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) lt0.001
Confidence - total mean score for 11 items/ 55 I 42.6 (SE 1.0) C 33.9 (SE 1.3) lt0.001
26
What have we learned?
  • Complex educational interventions seem to have
    modest success in improving
  • appropriate genetics referral
  • confidence in core genetics competencies
  • knowledge
  • Educational interventions
  • Clinical relevance
  • Interactive
  • Tools
  • point of care, simple

27
What are the limitations of these studies?
  • Intermediate outcomes
  • Self-reported knowledge
  • Risk assessment/intention to refer/management
    intent based on clinical vignettes
  • Need more actual clinical outcomes
  • Track referrals and appropriateness of referrals
  • Track screening and clinical outcomes
  • Small numbers
  • Cost
  • Small effect size

28
What are the limitations of these studies?
  • KT literature
  • Majority of educational interventions with HCPs
    achieve only modest to moderate improvements in
    care
  • KT interventions effect on improvement in process
    of care
  • 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.

29
Future Horizon What do primary care providers
need?
  • Educational strategies
  • Practice Tools
  • Referral guidelines
  • Computer decision support
  • Family history tools
  • Development and evaluation of innovative models
    of genetics health service delivery
  • Evidence

30
Team members/authors
  • 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
  • June Carroll PI
  • Judith Allanson
  • Sean Blaine
  • Elizabeth Dicks
  • Mary Jane Esplen
  • Sandra Farrell
  • Gail Graham
  • Ian Graham
  • Jeremy Grimshaw
  • Jennifer MacKenzie
  • John McLaughlin

31
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
  • Click on Genetics
  • jcarroll_at_mtsinai.on.ca
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