Anticipated impact on veterans'healthcare. The Veterans Health Administration (VA) has no system-wide, comprehensive, validated method for assessing family health history (FHH) or providing decision support. A standardized FHH assessment accompanied by decision support facilitates 3 important objectives: 1) identification of patients at higher risk, 2) genetic consultation referral for patients at risk for hereditary cancer syndromes, and 3) recommendation of guideline-based preventive care for patients of all risk levels. Receipt of appropriate preventive care will help prevent, or at least improve early detection of, deadly diseases, improving lives of thousands of Veterans and reducing health care costs to the VA healthcare system. Project background. Although FHH is commonly accepted as an important risk factor for common, chronic diseases, it is rarely used in clinical practice as part of a structured risk assessment .To facilitate use of FHH in primary care, the Genomic Medicine Model (GMM) was developed. The GMM 1) provides education to physicians, patients, and communities on the importance of FHH;2) contains a health IT-based platform (MeTree) that uses patient-entered data to risk-stratify patients and generate risk-stratified, evidence-based preventive care recommendations for physicians and patients;and 3) provides resources to patients and providers to effectively interpret FHH information and adhere to recommendations. Collection of FHH to inform preventive care for colorectal cancer (CRC) in VA is important because patients at higher risk for CRC are not well-characterized or documented in VA and high-risk versus average-risk prevention strategies currently are not systematically assessed or measured. Project objectives. The goal of this study is to evaluate the feasibility and effectiveness of the GMM for identifying patients at increased risk for CRC. This goal will be achieved in a 4-year mixed methods study with the following aims:
Aim 1 : Determine whether FHH collection via MeTree improves identification of patients at higher familial risk for CRC by comparing rates of high-risk identification in the medical record prior to study enrollment to rate of high-risk identification following MeTree completion.
Aim 2 : Evaluate whether providing decision support to patients and PCPs improves risk-appropriate PCP referrals for, and patient uptake of, CRC screening/surveillance.
Aim 3 : Assess experience with decision support and effects on workflow from PCPs, and obtain information to inform eventual implementation in the VA healthcare system from administrative leaders, via qualitative interviews.
Aim 4 : Conduct cost-consequence and budget-impact analyses of implementing FHH collection and GMM decision support in VA. Project methods. Eligible patients are aged 40-65 years, enrolled in primary care, do not have a personal history of CRC, and have some knowledge of FHH.
In Aim 1, a retrospective chart review will be conducted to determine the baseline rate of documenting FHH of CRC in the medical record for patients enrolled in the Aim 2 randomized trial.
In Aim 2, consented patients will be randomized to provide patient-entered FHH and receive patient and provider decision support at enrollment or 12 months later (wait-list control). The primary outcome is risk-appropriate CRC screening/surveillance referral for patients 12 months post-enrollment. Secondary outcomes include patient uptake of recommendations and referral for genetic consultation 12 months post-enrollment.
In Aim 3, qualitative interviews will be conducted with physicians and clinic leaders;data will be analyzed using conventional content analysis.
In Aim 4, data will be obtained from the administrative databases and patient medical records to conduct a budget impact analysis.

Public Health Relevance

People with a family history of colorectal cancer (CRC) are at increased risk for developing CRC themselves. A standardized, accurate method is needed to collect family health history from patients to determine what age to start screening, how often to be screened, and what type of screening test is appropriate. We are testing a process of collecting family history of CRC from patients, using the information to determine risk for CRC, and providing CRC screening recommendations to patients and primary care providers. If this process results in more appropriate referrals to CRC screening and genetic consultation, and increases patient use of recommended tests, then this program could be expanded for other cancers and diseases for which family history increases risk.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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HSR-1 Medical Care and Clinical Management (HSR1)
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Durham VA Medical Center
United States
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