THE ROLE OF PRIMARY CARE IN PROVIDING GENETICS SERVICES TO UNDERSERVED POPULATIONS: A SYSTEMATIC REVIEW
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1 THE ROLE OF PRIMARY CARE IN PROVIDING GENETICS SERVICES TO UNDERSERVED POPULATIONS: A SYSTEMATIC REVIEW FMSRE FINAL PRESENTATION JULY 25, 2017 PRESENTED BY: ASHTEN DUNCAN PROJECT MENTOR: DR. ANN CHOU
2 PRESENTATION OVERVIEW 1. Study Situation & Background 2. Research Question 3. Study Design & Methods 4. Search Terms for the Review 5. Original Plan vs. Reality 6. Results 7. Major Themes of the Findings 8. Implications for Research Question 9. The Next Step: For the Project 10. The Next Step: For Me
3 STUDY SITUATION & BACKGROUND The field of medical genetics has become increasingly complex due to humankind s ever-expanding knowledge of the subject. While much progress has been made in improving access to and knowledge of genetic services, serious gaps exist in the delivery of genetic services to medically underserved populations. These gaps are created by disparities in the distribution of the medical genetic workforce. To bridge these gaps, improving the integration of genetic services with primary care has been singled out as a priority.
4 RESEARCH QUESTION What is the role of primary care providers (PCPs) in the provision of genetic services to underserved populations?
5 RESEARCH QUESTION (CONT.) Dimensions/sub-questions of the main research question include: 1. What are the comfort level and perceived level of competency for PCPs when it comes to delivering genetic services? 2. How are genetic services being delivered today? 3. What types of barriers (systems-level or otherwise) exist between PCPs and the provision of genetic services? 4. What support resources and integration strategies exist to facilitate the adoption of genetic services in the primary care setting?
6 STUDY DESIGN & METHODS A systematic review was conducted to answer the research question and its four dimensions. Using Ovid MEDLINE, the search strategies for the review focused on three broad topics: medical genetics/geneticists and patient-centered care interface of genetics, underserved/vulnerable populations, and primary care/patient-centered care barriers for PCPs and available primary care support and integration strategies
7 STUDY DESIGN & METHODS (CONT.) References from the Ovid MEDLINE searches were extracted and exported to an EndNote library for further analysis. References in the library were excluded if they met one or more of seven exclusion criteria or if they were already included in systematic reviews.
8 STUDY DESIGN & METHODS (CONT.) Articles included in the review were assigned to one of four categories for analysis: Genetic Education / Literacy in Primary Care Delivery of Genetic Services Barriers to Primary Care Delivery Primary Care Support and Integration Strategies
9 SEARCH TERMS FOR THE REVIEW patient-centered care delivery of health care primary health care child health services medical homes primary health care underserved populations vulnerable populations rural populations genetic risk assessment geneticist genetics population medical general genetic diseases inborn diagnosis prenatal diagnosis genetic counseling patient anxiety access to geneticists insufficient time access to counseling services primary health care barriers to health care infrastructural financial legal professional frustration with genetic testing industry Telegenetics Telemedicine ECHO model / project ECHO learning communities rural populations disease management model patient satisfaction.
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11 ORIGINAL PLAN VS. REALITY Original Plan Devise appropriate search strategies Create an EndNote library with relevant sources Create a flowchart summarizing literature review Prepare evidence tables analyzing selected titles Reality Devise appropriate search strategies Create an EndNote library with relevant sources Create a flowchart summarizing literature review Prepare evidence tables analyzing selected titles
12 RESULTS A total of 47 articles were selected for analysis. Of those articles, we identified: 11 cross-sectional studies 9 reviews 3 randomized controlled trials 3 implementation studies 21 other studies and articles
13 TABLE I. Evidence Table for Genetic Education / Literacy in Primary Care References, Country Study / article type Objective Data collection or population studied Selected findings and conclusions Lopes-Junior et al. [2017], Brazil Cross-sectional study To determine the level of genetics-related education, knowledge, and experiences among nurses and physicians who provide primary care in São Paulo Data were obtained from questionnaires that were completed by 24 physicians and 30 nurses. Roughly 85% of respondents stated that they received some genetic content during their undergraduate education. Despite this, about 78% indicated that they did not feel prepared to deliver genomics-based health care in primary care. It was concluded that primary care nurses and physicians lack the knowledge to provide genomics-based health care. Paneque et al. [2016], Portugal, UK, and the Netherlands Systematic review To evaluate genetics educational interventions in the context of primary care to determine if there is a common theme to direct guidelines Following the guidelines from the Centre for Reviews and Dissemination, five relevant electronic databases were searched. The results were coded and categorized. Current literature is insufficient about how to inform educational interventions in genetics for primary care providers. Educational initiatives should be assessed using changes in practice to determine if they are effective in causing significant changes in practice in genetic risk assessment and appropriate management of patients.
14 MAJOR THEMES FROM REVIEW: BARRIERS PCPs identified the following barriers to providing genetics services: insufficient time to provide services a lack of clinical guidelines a lack of access to appropriate genetics resources a lack of training in genetics
15 MAJOR THEMES: STRATEGIES FOR INTEGRATION Use telegenetics: Patients are generally just as satisfied (if not more satisfied) with telegenetics services as they are with face-to-face consultations. Project ECHO is described as being a practical way to connect PCPs in underserved areas with specialists, such as geneticists. Promote patient-centered medical homes (PCMHs): PCMH can enhance access to and quality of care.
16 MAJOR THEMES: STRATEGIES FOR INTEGRATION Educate PCPs on the many tools that are available to facilitate gathering information on family history and hereditary risk factors. Patients need to be educated more on the benefits and harms of genetic testing.
17 IMPLICATIONS FOR RESEARCH QUESTION Due to the population size and distribution of the US, PCPs are now becoming the front line in providing genetic services, especially to medically underserved populations. Many of the barriers described earlier can be addressed using support resources and integration strategies like Project ECHO and patient-centered medical homes.
18 IMPLICATIONS FOR RESEARCH QUESTION (CONT.) The results of many of the studies support the idea that the US government should increase funding for telemedicine communication systems in order to improve the quality of care being delivered. Since PCPs do not receive adequate training in genetics, a twofold approach involving a restructuring of postgraduate training for primary care specialties and increasing the use of models like ECHO to provide education to practicing providers should be used.
19 THE NEXT STEP: FOR THE PROJECT The information presented in this paper will help to set the stage for future implementation projects. The work is almost done for this project; only a few more elements need to be added before it is ready for publication. Besides publication in a journal, we anticipate giving oral and poster presentations of the study and its results.
20 THE NEXT STEP: FOR ME Doing this review has greatly expanded my knowledge of expectations of and obstacles facing PCPs around the world. the I believe that I now have a good amount of foundational knowledge for future research of the topics covered this summer. I anticipate working on another project with Dr. Chou that was originally intended to be worked on this summer but was postponed due to schedule conflicts. It involves the role of medical genetics in the PCMH model.
21 QUESTIONS?
22 THANK YOU FOR YOUR ATTENTION!
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