The use of family history in primary health care: a qualitative study

Development of a computer-based tool to obtain a family health history in Vietnam

Background: Family health history (FHH) is central to human genomic profiling construction; however, there is no protocol for documenting FHH in a pedigree format in Vietnam.Aim: A "Gia Su Suc Khoe" (GSSK) tool was developed to create a user-friendly interface for collecting FHH and offering diseases' risk assessment.Results: A tool was described (https://giasusuckhoe.vn/) with good feedback from genetic counselors and family-medicine doctors. Among 20 surveys, 100% of respondents noted that the report accurately reflected their FHH and were satisfied with the tool's display. About 74% of familial conditions were covered. Overall, all constructive feedback has been adapted into the updated version.Conclusion: Gia Su Suc Khoe has the potential to significantly improve healthcare delivery and outcomes in Vietnam.

Cardiovascular (Framingham) and type II diabetes (Finnish Diabetes) risk scores: a qualitative study of local knowledge of diet, physical activity and body measurements in rural Rakai, Uganda

BACKGROUND

Non-communicable diseases such as cardiovascular conditions and diabetes are rising in sub-Saharan Africa. Prevention strategies to mitigate non-communicable diseases include improving diet, physical activity, early diagnosis, and long-term management. Early identification of individuals at risk based on risk-score models - such as the Framingham Risk Score (FRS) for 10-year risk of cardiovascular disease and the Finnish type 2 Diabetes risk score (FINDRISC) for type 2 diabetes which are used in high-income settings - have not been well assessed in sub-Saharan Africa. The purpose of this study was to qualitatively assess local knowledge of components of these risk scores in a rural Ugandan setting.

METHODS

Semi-structured qualitative in-depth interviews were conducted with a purposively selected sample of 15 participants who had responded to the FRS and FINDRISC questionnaires and procedures embedded in the Rakai Community Cohort Study. Data were summarized and categorized using content analysis, with support of Atlas.ti.

RESULTS

Participants described local terms for hypertension ("pulessa") and type 2 diabetes ("sukaali"). Most participants understood physical activity as leisure physical activity, but when probed would also include physical activity linked to routine farm work. Vegetables were typically described as "plants", "leafy greens", and "side dish". Vegetable and fruit consumption was described as varying seasonally, with peak availability in December after the rainy season. Participants perceived themselves to have good knowledge about their family members' history of type 2 diabetes and hypertension.

CONCLUSIONS

While most items of the FRS and FINDRISC were generally well understood, physical activity needs further clarification. It is important to consider the seasonality of fruits and vegetables, especially in rural resource-poor settings. Current risk scores will need to be locally adapted to estimate the 10-year risk of cardiovascular diseases and type 2 diabetes in this setting.

Family history recording in UK general practice: the lIFeLONG study

BACKGROUND

In order to integrate genomic medicine into routine patient care and stratify personal risk, it is increasingly important to record family history (FH) information in general/family practice records. This is true for classic genetic disease as well as multifactorial conditions. Research suggests that FH recording is currently inadequate.

OBJECTIVES

To provide an up-to-date analysis of the frequency, quality, and accuracy of FH recording in UK general/family practice.

METHODS

An exploratory study, based at St Leonard's Practice, Exeter-a suburban UK general/family practice. Selected adult patients registered for over 1 year were contacted by post and asked to complete a written FH questionnaire. The reported information was compared with the patients' electronic medical record (EMR). Each EMR was assessed for its frequency (how often information was recorded), quality (the level of detail included), and accuracy (how closely the information matched the patient report) of FH recording.

RESULTS

Two hundred and forty-one patients were approached, 65 (27.0%) responded and 62 (25.7%) were eligible to participate. Forty-three (69.4%) EMRs contained FH information. The most commonly recorded conditions were bowel cancer, breast cancer, diabetes, and heart disease. The mean quality score was 3.64 (out of 5). There was little negative recording. 83.2% of patient-reported FH information was inaccurately recorded or missing from the EMRs.

CONCLUSION

FH information in general/family practice records should be better prepared for the genomic era. Whilst some conditions are well recorded, there is a need for more frequent, higher quality recording with greater accuracy, especially for multifactorial conditions.

How is family health history discussed in routine primary healthcare? A qualitative study of archived family doctor consultations

OBJECTIVES

Family health history underpins genetic medicine. Our study aimed to explore language and patterns of communication relating to family health history observed in interactions between general practitioners (GPs) and their patients within routine primary care consultations.

DESIGN

Secondary analysis of patient and GP routine consultation data (n=252).

PARTICIPANTS

Consultations that included 'family health history' were eligible for inclusion (n=58).

PRIMARY OUTCOMES

A qualitative inductive analysis of the interactions from consultation transcripts.

RESULTS

46/58 conversations about family health history were initiated by the GP. Most discussions around family history lasted for between approximately 1 to 2 min. Patients were invited to share family health history through one of two ways: non-specific enquiry (eg, by asking the patient about 'anything that runs in the family'); or specific enquiry where they were asked if they had a 'strong family history' in relation to a particular condition, for example, breast cancer. Patients often responded to either approach with a simple no, but fuller negative responses also occurred regularly and typically included an account of some kind (eg, explaining family relationships/dynamics which impeded or prevented the accessibility of information).

CONCLUSIONS

Family health history is regarded as a genetic test and is embedded in the sociocultural norms of the patient from whom information is being sought. Our findings highlight that it is more complex than asking simply if 'anything' runs in the family. As the collection of family health history is expected to be more routine, it will be important to also consider it from sociocultural perspectives in order to help mitigate any inequities in how family history is collected, and therefore used (or not) in a person's healthcare. Orientating an enquiry away from 'anything' and asking more specific details about particular conditions may help facilitate the dialogue.

Simple risk score to screen for prediabetes: A cross-sectional study from the Qatar Biobank cohort

AIMS/INTRODUCTION

The progression from prediabetes to type 2 diabetes is preventable by lifestyle intervention and/or pharmacotherapy in a large fraction of individuals with prediabetes. Our objective was to develop a risk score to screen for prediabetes in the Middle East, where diabetes prevalence is one of the highest in the world.

MATERIALS AND METHODS

In this cross-sectional, case-control study, we used data of 4,895 controls and 2,373 prediabetic adults obtained from the Qatar Biobank cohort. Significant risk factors were identified by logistic regression and other machine learning methods. The receiver operating characteristic was used to calculate the area under curve, cut-off point, sensitivity, specificity, positive and negative predictive values. The prediabetes risk score was developed from data of Qatari citizens, as well as long-term (≥15 years) residents.

RESULTS

The significant risk factors for the Prediabetes Risk Score in Qatar were age, sex, body mass index, waist circumference and blood pressure. The risk score ranges from 0 to 45. The area under the curve of the score was 80% (95% confidence interval 78-83%), and the cut-off point of 16 yielded sensitivity and specificity of 86.2% (95% confidence interval 82.7-89.2%) and 57.9% (95% confidence interval 65.5-71.4%), respectively. Prediabetes Risk Score in Qatar performed equally in Qatari nationals and long-term residents.

CONCLUSIONS

Prediabetes Risk Score in Qatar is the first prediabetes screening score developed in a Middle Eastern population. It only uses risk factors measured non-invasively, is simple, cost-effective, and can be easily understood by the general public and health providers. Prediabetes Risk Score in Qatar is an important tool for early detection of prediabetes, and can help tremendously in curbing the diabetes epidemic in the region.

Using Personal Genomic Data within Primary Care: A Bioinformatics Approach to Pharmacogenomics

One application of personalized medicine is the tailoring of medication to the individual, so that the medication will have the highest chance of success. In order to individualize medication, one must have a complete inventory of all current pharmaceutical compounds (a detailed formulary) combined with pharmacogenetic datasets, the genetic makeup of the patient, their (medical) family history and other health-related data. For healthcare professionals to make the best use of this information, it must be visualized in a way that makes the most medically relevant data accessible for their decision-making. Similarly, to enable bioinformatics analysis of these data, it must be prepared and provided through an interface for controlled computational analysis. Due to the high degree of personal information gathered for such initiatives, privacy-sensitive implementation choices and ethical standards are paramount. The Personal Genetic Locker project provides an approach to enable the use of personal genomic data in primary care. In this paper, we provide a description of the Personal Genetic Locker project and show its utility through a use case based on open standards, which is illustrated by the 4MedBox system.

Is family history still underutilised? Exploring the views and experiences of primary care doctors in Malaysia

Family history has long been recognised as a non-invasive and inexpensive tool to identify individuals at risk of genetic conditions. Even in the era of evolving genetic and genomic technology, the role of family history in predicting individual risk for genetic testing and guiding in preventive interventions is still relevant, especially in low-resource countries. The aim of this study was to explore primary care doctors' views and experiences in family history taking and how they utilised family history in day-to-day clinical consultations in Malaysia. Four focus group discussions and six in-depth interviews involving 25 primary care doctors were conducted. Three themes emerged from the analysis: (1) primary care doctors considered family history as an important part of clinical assessment, (2) proactive versus reactive approach in collecting family history and (3) family history collection was variable and challenging. Family history was documented in either free text or pedigree depending on the perception of its appropriateness during the consultation. This study highlighted the need to improve the approach, documentation and the implementation of family history in the Malaysian primary care settings. Integrating family filing concept with built-in clinical decision support into electronic medical records is a potential solution in ensuring effective family history taking in primary care.

Genetics in primary care: validating a tool to pre-symptomatically assess common disease risk using an Australian questionnaire on family history

BACKGROUND

A positive family history for diabetes, cardiovascular diseases or various types of cancer increases the relative risk for these diseases by 2 to 5 times compared to people without a positive family history. Taking a family history in daily general practice is useful for early, pre-symptomatic risk assessment, but at the moment no standardized family history questionnaire is available in the Dutch language. In this study we used a 9-item questionnaire, previously developed and applied in an Australian study, to probe family history for 7 specific conditions. The aim of the present qualitative study was to test face and content validity of the Australian family history questionnaire in Dutch general practice and to advance the standardization of intake information at an international level. We conducted 10 cognitive interviews with patients over 4 rounds, using the verbal probing technique. This approach allows the collection of data through a series of probe questions, with the aim of obtaining detailed information. After each interview round we modified the questionnaire based on the answers of the interviewees. We also performed 10 semi-structured interviews with general practitioners (GPs) to get their opinion on the content and usability of the questionnaire in practice.

RESULTS

Patients varied in age and gender, and 4 patients were known to have a genetic disorder. The GPs varied in age, gender, clinical experience, type of practice and location. In the first round, seven problems were identified in the questionnaire in the categories Comprehension (1), Recall (2), Judgement (0), Response process (2) and Completeness, (2); by the fourth and final round no problems remained. The content and usability of the questionnaire were assessed positively.

CONCLUSIONS

When translated for everyday use in Dutch general practice, the Australian family history questionnaire showed a strong face and content validity, and GPs were positive regarding feasibility. Validation of this family history questionnaire could aid in the standardized integration of genetically relevant information in the electronic health record and clinical research. Conspicuous questionnaire information might alert the GP regarding specific conditions and enable detection of disease at an earlier stage. Additional questionnaire requirements needed however are accurate patient information and consistent, accessible locations in the electronic health record with a possibility to be automatically registered. By deriving a Dutch family history questionnaire convenient for GPs, we adapted a template that might also prove useful for other countries and other medical professionals. This development could make the rapid operationalization of readily available genetic knowledge feasible in daily practice and clinical research, leading to improved medical care.

Family health history reporting is sensitive to small changes in wording

PURPOSE

Family health history is often collected through single-item queries that ask patients whether their family members are affected by certain conditions. The specific wording of these queries may influence what individuals report.

METHODS

Parents of Boston Children's Hospital patients were invited to participate in a Web-based survey about the return of individual genomic research results regarding their children. Participants reported whether 11 types of medical conditions affected them or their family. Randomization determined whether participants were specifically instructed to consider their extended family.

RESULTS

Family health history was reported by 2,901 participants. Those asked to consider their extended family were more likely to report a positive family history for 8 of 11 medical conditions. The largest differences were observed for cancer (65.1 vs. 45.7%; P < 0.001), cardiovascular conditions (72.5 vs. 56.0%; P < 0.001), and endocrine/hormonal conditions (50.9 vs. 36.7%; P < 0.001).

CONCLUSIONS

Small alterations to the way family health history queries are worded can substantially change patient responses. Clinicians and researchers need to be sensitive about patients' tendencies to omit extended family from health history reporting unless specifically asked to consider them.Genet Med 18 12, 1308-1311.

Improving Utilization of the Family History in the Electronic Health Record

PURPOSE

The purpose of this article is to provide an overview of Family History in the Electronic Health Record and to identify opportunities to advance the contributions of nurses in obtaining, updating and assessing family history in order to improve the health of all individuals and populations.

ORGANIZING CONSTRUCT

The article presents an overview of the obstacles to charting Family History within the Electronic Health Record and recommendations for using specific Family History tools and core Family History data sets.

METHODS

Opportunities to advance nursing contributions in obtaining, updating, and assessing family history in order to improve the health of all individuals were identified. These opportunities are focused within the area of promoting the importance of communication within families and between healthcare providers to obtain, document, and update family histories.

FINDINGS

Nurses can increase awareness of existing resources that can guide collection of a comprehensive and accurate family history and facilitate family discussions. In this paper, opportunities to advance nursing contributions in obtaining, updating, and assessing family history in order to improve the health of all individuals were identified.

CONCLUSIONS

Aligned with the clinical preparation of nurses, family health should be used routinely by nurses for risk assessment and to help inform patient and family members on screening, health promotion, and disease prevention. The quality of family health information is critical in order to leverage the use of genomic healthcare information and derive new knowledge about disease biology, treatment efficacy, and drug safety. These actionable steps need to be performed in the context of promoting evidence-based applications of family history that will be essential for implementing personalized genomic healthcare approaches and disease prevention efforts.

CLINICAL RELEVANCE

Family health history is one of the most important tools for identifying the risk of developing rare and chronic conditions, including cardiovascular disease, cancer, and diabetes, and represents an integration of disease risk from genetic, environmental, and behavioral/lifestyle factors. In fact, family history has long been recognized as a strong independent risk factor for disease and is the current best practice used in clinical practice to guide risk assessment.

Discrepancy between clinician and research assistant in TIMI score calculation (TRIAGED CPU)

Introduction

Several studies have attempted to demonstrate that the Thrombolysis in Myocardial Infarction (TIMI) risk score has the ability to risk stratify emergency department (ED) patients with potential acute coronary syndromes (ACS). Most of the studies we reviewed relied on trained research investigators to determine TIMI risk scores rather than ED providers functioning in their normal work capacity. We assessed whether TIMI risk scores obtained by ED providers in the setting of a busy ED differed from those obtained by trained research investigators.

Methods

This was an ED-based prospective observational cohort study comparing TIMI scores obtained by 49 ED providers admitting patients to an ED chest pain unit (CPU) to scores generated by a team of trained research investigators. We examined provider type, patient gender, and TIMI elements for their effects on TIMI risk score discrepancy.

Results

Of the 501 adult patients enrolled in the study, 29.3% of TIMI risk scores determined by ED providers and trained research investigators were generated using identical TIMI risk score variables. In our low-risk population the majority of TIMI risk score differences were small; however, 12% of TIMI risk scores differed by two or more points.

Conclusion

TIMI risk scores determined by ED providers in the setting of a busy ED frequently differ from scores generated by trained research investigators who complete them while not under the same pressure of an ED provider.

Family history of cancer associated with breast tumor clinicopathological features

Hereditary breast cancers have unique clinicopathological characteristics. Therefore, the objective of this study was to establish the relationship between self-reported family history of cancer and clinicopathological features in breast cancer patients from Washington, DC. Data on incident breast cancer cases from 2000 to 2010 were obtained from the Washington, DC Cancer Registry. Variables such as estrogen (ER), progesterone (PR), and human epidermal growth factor 2 (HER2) receptor status, as well as stage and grade, were analyzed in those that self-reported with (n = 1,734) and without a family history of cancer (n = 1,712). The breast cancer molecular subtypes were compared when ER, PR, and HER2 statuses were available. Furthermore, tumor characteristics were compared by race/ethnicity. Regression and chi-square analyses were performed. A report of family history was associated with age (OR = 1.27 95 % CI: 1.09-1.48; p < 0.0001), high grade tumors (OR = 1.29 95 % CI: 1.05-1.58; p = 0.02), and having ER and PR negative breast cancer (OR = 1.26 95 % CI: 1.02-1.57; p = 0.029). When tumor characteristics were compared by race/ethnicity, those that self-reported as African American with a family history had a higher frequency of ER negative tumors (OR = 1.51 95 % CI: 1.09-2.08; p = 0.008), PR negative tumors (OR = 1.46 95 % CI: 1.09-1.94; p = 0.028), grade 3 tumors (OR = 1.42 95 % CI: 1.05-1.93; p < 0.0001), and ER/PR negative tumors (OR = 1.5 95 % CI: 1.088-2.064; p = 0.01). These results suggest that a positive family history of cancer in African Americans should increase suspicions of hereditary cancer. Therefore, behavioral risk reduction activities, such as collecting a family history, may reduce late stage diagnosis and cancer mortality.