Understanding the genetic/genomic basis for a disease can improve quality of care through better diagnosis, treatment and prevention. In past decades, the focus of genomic medicine has been on the rare chromosomal and single gene disorders. Genomic discoveries in the next decade will increase the availability of genomic applications in testing and therapeutics for all genetic disease, including multifactorial conditions like coronary heart disease, diabetes and cancer. With genomic medicine expanding beyond its traditional boundaries, questions remain about how genetic services can best be delivered to an increasing number of people. The VA is in a unique position to investigate these issues; it is a large, integrated national healthcare system that is a model for health care reform and improved delivery systems and is viewed as a leader in health services genomics research. OBJECTIVES: The goal of this proposal is to understand the organizational level needs relating to the adoption and delivery of evidence-based genomic applications within the VA. To accomplish this goal we propose the following aims: (1) investigate prevailing approaches for delivery of genetic/genomic medicine, (2) assess the organization and practice of genomic medicine within the VHA nationwide, (3) identify the environmental and organizational determinants of adoption of genomic medicine within the VA, and (4) use expert panel methods to integrate findings from Aims 1, 2 and 3 into recommendations for VA organization and practice of genomic medicine. METHODS: Using a participatory, multi-method approach, we will use semi-structured interviews of key VA provider types to develop, pilot test, administer and analyze the results of key informant organizational surveys of relevant specialties (e.g., primary care, cardiology, oncology, neurology and pathology) measuring the organizational and practice system features of genomic medicine services at individual VA health care facilities nationwide (Aims 1 and 2). We will create an analytic dataset by merging data from Aim 2 with data sources that capture key environmental characteristics including variables from the Area Resource File, InterStudy data and VA administrative data (Aim 3). We will use an expert consensus development process that will evaluate the findings of Aims 1, 2 and 3 to arrive at recommendations for VA organization and practice relating to genomic medicine (Aim 4).
The proposed study will provide empiric data that could be used to inform the development and future evaluation of genomic medicine health services within and likely outside the VA, including strategic planning;service organization, manpower planning and capacity building;service review, assessment and evaluation;and guideline development. In addition, our work should indirectly inform other core activities involving integration of genome-based science and technology, including public policy analyses and processes, communication and stakeholder engagement, and education and training of health professionals.