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Voils CI, Coffman CJ, Wu RR, Grubber JM, Fisher DA, Strawbridge EM, Sperber N, Wang V, Scheuner MT, Provenzale D, Nelson RE, Hauser E, Orlando LA, Goldstein KM. A Cluster Randomized Trial of a Family Health History Platform to Identify and Manage Patients at Increased Risk for Colorectal Cancer. J Gen Intern Med 2023; 38:1375-1383. [PMID: 36307642 PMCID: PMC10160317 DOI: 10.1007/s11606-022-07787-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/06/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Obtaining comprehensive family health history (FHH) to inform colorectal cancer (CRC) risk management in primary care settings is challenging. OBJECTIVE To examine the effectiveness of a patient-facing FHH platform to identify and manage patients at increased CRC risk. DESIGN Two-site, two-arm, cluster-randomized, implementation-effectiveness trial with primary care providers (PCPs) randomized to immediate intervention versus wait-list control. PARTICIPANTS PCPs treating patients at least one half-day per week; patients aged 40-64 with no medical conditions that increased CRC risk. INTERVENTIONS Immediate-arm patients entered their FHH into a web-based platform that provided risk assessment and guideline-driven decision support; wait-list control patients did so 12 months later. MAIN MEASURES McNemar's test examined differences between the platform and electronic medical record (EMR) in rates of increased risk documentation. General estimating equations using logistic regression models compared arms in risk-concordant provider actions and patient screening test completion. Referral for genetic consultation was analyzed descriptively. KEY RESULTS Seventeen PCPs were randomized to each arm. Patients (n = 252 immediate, n = 253 control) averaged 51.4 (SD = 7.2) years, with 83% assigned male at birth, 58% White persons, and 33% Black persons. The percentage of patients identified as increased risk for CRC was greater with the platform (9.9%) versus EMR (5.2%), difference = 4.8% (95% CI: 2.6%, 6.9%), p < .0001. There was no difference in PCP risk-concordant action [odds ratio (OR) = 0.7, 95% CI (0.4, 1.2; p = 0.16)]. Among 177 patients with a risk-concordant screening test ordered, there was no difference in test completion, OR = 0.8 [0.5,1.3]; p = 0.36. Of 50 patients identified by the platform as increased risk, 78.6% immediate and 68.2% control patients received a recommendation for genetic consultation, of which only one in each arm had a referral placed. CONCLUSIONS FHH tools could accurately assess and document the clinical needs of patients at increased risk for CRC. Barriers to acting on those recommendations warrant further exploration. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT02247336 https://clinicaltrials.gov/ct2/show/NCT02247336.
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Affiliation(s)
- Corrine I Voils
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA.
| | - Cynthia J Coffman
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - R Ryanne Wu
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Deborah A Fisher
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Nina Sperber
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Virginia Wang
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Maren T Scheuner
- San Francisco VA Health Care System, San Francisco, VA, USA
- Departments of Medicine and Pediatrics, University of California at San Francisco, San Francisco, CA, USA
| | - Dawn Provenzale
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Cooperative Studies Program Epidemiology Center, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Richard E Nelson
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Elizabeth Hauser
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Lori A Orlando
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Karen M Goldstein
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Patient navigation for hereditary colorectal cancer: Design of a randomized controlled trial to determine the effectiveness of pathways to genetic counseling. Contemp Clin Trials 2022; 116:106735. [PMID: 35331945 DOI: 10.1016/j.cct.2022.106735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/28/2022] [Accepted: 03/17/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Diagnosis of Lynch and other hereditary colorectal cancer (CRC) syndromes through germline genetic testing has important implications for treatment and risk-management, yet guideline-recommended genetic counseling referral and attendance is suboptimal. METHODS Our team developed an adapted patient navigation program-Pathways to Genetic Counseling-to address multilevel barriers to genetic counseling referral and receipt. This paper describes the methods of a randomized controlled trial (RCT) testing Pathways to Genetic Counseling's effectiveness at increasing genetic counseling attendance in the University of Washington Medicine health system. We will identify CRC patients eligible for genetic counseling (diagnosed before age 50 or at any age with evidence of inherited mismatch repair deficiency) through a combination of structured electronic health record queries and manual chart review. Patients will be randomized 1:1 prior to consent and receive either care as usual (no contact) or be invited to participate in patient navigation. We will use chart review to compare rates of genetic counseling referral and attendance within six months of randomization, regardless of patients' engagement with navigation. We plan to identify and randomize 161 eligible CRC patients over a nine-month period beginning in late 2021. DISCUSSION Our pragmatic RCT design will provide real-world data on the potential for patient navigation to address longstanding care gaps in preventive genomic medicine. If effective, we hope to pilot Pathways to Genetic Counseling in additional settings with a long-term goal of improving appropriate diagnosis of hereditary CRC syndromes and subsequent cascade screening of eligible family members.
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Sperber NR, Dong OM, Roberts MC, Dexter P, Elsey AR, Ginsburg GS, Horowitz CR, Johnson JA, Levy KD, Ong H, Peterson JF, Pollin TI, Rakhra-Burris T, Ramos MA, Skaar T, Orlando LA. Strategies to Integrate Genomic Medicine into Clinical Care: Evidence from the IGNITE Network. J Pers Med 2021; 11:647. [PMID: 34357114 PMCID: PMC8306482 DOI: 10.3390/jpm11070647] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/29/2021] [Accepted: 07/02/2021] [Indexed: 11/16/2022] Open
Abstract
The complexity of genomic medicine can be streamlined by implementing some form of clinical decision support (CDS) to guide clinicians in how to use and interpret personalized data; however, it is not yet clear which strategies are best suited for this purpose. In this study, we used implementation science to identify common strategies for applying provider-based CDS interventions across six genomic medicine clinical research projects funded by an NIH consortium. Each project's strategies were elicited via a structured survey derived from a typology of implementation strategies, the Expert Recommendations for Implementing Change (ERIC), and follow-up interviews guided by both implementation strategy reporting criteria and a planning framework, RE-AIM, to obtain more detail about implementation strategies and desired outcomes. We found that, on average, the three pharmacogenomics implementation projects used more strategies than the disease-focused projects. Overall, projects had four implementation strategies in common; however, operationalization of each differed in accordance with each study's implementation outcomes. These four common strategies may be important for precision medicine program implementation, and pharmacogenomics may require more integration into clinical care. Understanding how and why these strategies were successfully employed could be useful for others implementing genomic or precision medicine programs in different contexts.
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Affiliation(s)
- Nina R. Sperber
- Duke Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27701, USA
- Durham VA Health Care System, Durham, NC 27705, USA
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC 27708, USA; (O.M.D.); (G.S.G.); (T.R.-B.); (L.A.O.)
| | - Olivia M. Dong
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC 27708, USA; (O.M.D.); (G.S.G.); (T.R.-B.); (L.A.O.)
| | - Megan C. Roberts
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Paul Dexter
- Regenstrief Institute, Indianapolis, Indiana University School of Medicine and Clem McDonald Center for Biomedical Informatics, Indianapolis, IN 46202, USA;
| | - Amanda R. Elsey
- Center for Pharmacogenomics and Precision Medicine, Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL 32610, USA; (A.R.E.); (J.A.J.)
| | - Geoffrey S. Ginsburg
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC 27708, USA; (O.M.D.); (G.S.G.); (T.R.-B.); (L.A.O.)
| | - Carol R. Horowitz
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Julie A. Johnson
- Center for Pharmacogenomics and Precision Medicine, Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL 32610, USA; (A.R.E.); (J.A.J.)
| | - Kenneth D. Levy
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, 950 W. Walnut Street, Indianapolis, IN 46202, USA; (K.D.L.); (T.S.)
| | - Henry Ong
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (H.O.); (J.F.P.)
| | - Josh F. Peterson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (H.O.); (J.F.P.)
| | - Toni I. Pollin
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Tejinder Rakhra-Burris
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC 27708, USA; (O.M.D.); (G.S.G.); (T.R.-B.); (L.A.O.)
| | - Michelle A. Ramos
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Todd Skaar
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, 950 W. Walnut Street, Indianapolis, IN 46202, USA; (K.D.L.); (T.S.)
| | - Lori A. Orlando
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC 27708, USA; (O.M.D.); (G.S.G.); (T.R.-B.); (L.A.O.)
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Zhao N, Cao Y, Yang J, Li H, Wu K, Wang J, Peng T, Cai K. Serum Tumor Markers Combined With Clinicopathological Characteristics for Predicting MMR and KRAS Status in 2279 Chinese Colorectal Cancer Patients: A Retrospective Analysis. Front Oncol 2021; 11:582244. [PMID: 34221952 PMCID: PMC8247475 DOI: 10.3389/fonc.2021.582244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 05/03/2021] [Indexed: 12/09/2022] Open
Abstract
Although serum tumor markers (STMs), clinicopathological characteristics and the status of KRAS and MMR play an important role in optimizing the treatment and prognosis of colorectal cancer, their interrelationships remain largely unknown. A retrospective analysis of 2279 patients who tested for KRAS and MMR status, and STM measurements prior to treatment over the past four years was conducted. Of the 784 patients tested for KRAS and 2279 patients tested for MMR status, KRAS mutations and dMMR were identified in 276 patients (35.20%) and 177 patients (7.77%), respectively. Logistic regression analysis demonstrated that right colon, well and moderate differentiation and negative CA19-9 were independent predictors for KRAS mutations. The ROC curve yielded an AUC of 0.609 through the combination of these three factors. Age < 65 was an independent predictive factor for dMMR, along with tumor size > 4.6 cm, right colon, poor differentiation, harvested lymph nodes ≥ 22, no lymph node metastasis, no perineural invasion, negative CEA and positive CA72-4. When the nine criteria were used together, the AUC was 0.849. In summary, both STMs and clinicopathological characteristics were found to be significantly associated with the status of KRAS and MMR. The combination of these two factors possessed a strong predictive power for KRAS mutations and dMMR among CRC patients.
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Affiliation(s)
- Ning Zhao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yinghao Cao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Yang
- Department of Gastrointestinal Surgery, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hang Li
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ke Wu
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiliang Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Peng
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kailin Cai
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Lederle M, Tempes J, Bitzer EM. Application of Andersen's behavioural model of health services use: a scoping review with a focus on qualitative health services research. BMJ Open 2021; 11:e045018. [PMID: 33952550 PMCID: PMC8103375 DOI: 10.1136/bmjopen-2020-045018] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Qualitative methods have become integral in health services research, and Andersen's behavioural model of health services use (BMHSU) is one of the most commonly employed models of health service utilisation. The model focuses on three core factors to explain healthcare utilisation: predisposing, enabling and need factors. A recent overview of the application of the BMHSU is lacking, particularly regarding its application in qualitative research. Therefore, we provide (1) a descriptive overview of the application of the BMHSU in health services research in general and (2) a qualitative synthesis on the (un)suitability of the model in qualitative health services research. METHODS We searched five databases from March to April 2019, and in April 2020. For inclusion, each study had to focus on individuals ≥18 years of age and to cite the BMHSU, a modified version of the model, or the three core factors that constitute the model, regardless of study design, or publication type. We used MS Excel to perform descriptive statistics, and applied MAXQDA 2020 as part of a qualitative content analysis. RESULTS From a total of 6319 results, we identified 1879 publications dealing with the BMSHU. The main methodological approach was quantitative (89%). More than half of the studies are based on the BMHSU from 1995. 77 studies employed a qualitative design, the BMHSU was applied to justify the theoretical background (62%), structure the data collection (40%) and perform data coding (78%). Various publications highlight the usefulness of the BMHSU for qualitative data, while others criticise the model for several reasons (eg, its lack of cultural or psychosocial factors). CONCLUSIONS The application of different and older models of healthcare utilisation hinders comparative health services research. Future research should consider quantitative or qualitative study designs and account for the most current and comprehensive model of the BMHSU.
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Affiliation(s)
- Mareike Lederle
- Public Health and Health Education, Pädagogische Hochschule Freiburg, Freiburg im Breisgau, Germany
| | - Jana Tempes
- Public Health and Health Education, Pädagogische Hochschule Freiburg, Freiburg im Breisgau, Germany
| | - Eva M Bitzer
- Public Health and Health Education, Pädagogische Hochschule Freiburg, Freiburg im Breisgau, Germany
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Learning from scaling up ultra-rapid genomic testing for critically ill children to a national level. NPJ Genom Med 2021; 6:5. [PMID: 33510162 PMCID: PMC7843635 DOI: 10.1038/s41525-020-00168-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/15/2020] [Indexed: 12/25/2022] Open
Abstract
In scaling up an ultra-rapid genomics program, we used implementation science principles to design and investigate influences on implementation and identify strategies required for sustainable “real-world” services. Interviews with key professionals revealed the importance of networks and relationship building, leadership, culture, and the relative advantage afforded by ultra-rapid genomics in the care of critically ill children. Although clinical geneticists focused on intervention characteristics and the fit with patient-centered care, intensivists emphasized the importance of access to knowledge, in particular from clinical geneticists. The relative advantage of ultra-rapid genomics and trust in consistent and transparent delivery were significant in creating engagement at initial implementation, with appropriate resourcing highlighted as important for longer term sustainability of implementation. Our findings demonstrate where common approaches can be used and, significantly, where there is a need to tailor support by professional role and implementation phase, to maximize the potential of ultra-rapid genomic testing to improve patient care.
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Underutilization of Lynch Syndrome Screening at Two Large Veterans Affairs Medical Centers. Dig Dis Sci 2020; 65:3305-3315. [PMID: 32500284 DOI: 10.1007/s10620-020-06340-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/12/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Lynch syndrome (LS) is the most common hereditary colorectal cancer (CRC) syndrome, yet is grossly under-recognized. Multiple professional societies recommend screening all CRCs for LS by performing tumor testing. The veterans affairs system has not adopted universal tumor testing as a national performance metric and leaves screening for LS to clinical care at individual sites. AIMS Describe adherence to LS screening in the VA system. METHODS Dual-center, retrospective review of all CRCs diagnosed between 2010 and 2016. Rates of tumor testing, personal and family history of cancer were extracted from the medical record. Univariate and multivariate regression analysis was performed to determine predictors of tumor-based screening for LS. RESULTS A total of 421 cancers were reviewed. 15.1% of all cancers underwent either MSI and/or IHC for LS screening over the study period. There was improvement in LS screening from 3% of all CRCs in 2010 to 45% of all CRCs in 2016. 34% and 70% of patients did not have documentation of CRC in first- and second-degree relatives, respectively. Of the 73 patients who met one of the Revised Bethesda Criteria or had a PREMM1,2,6 score of ≥ 5, 34% and 56% underwent tumor testing, respectively. Younger age, non-Caucasian race, meeting Bethesda or PREMM1,2,6 criteria and right-sided tumor location were predictors of undergoing tumor testing. CONCLUSIONS CRC tumor screening for LS is grossly inadequate when left to routine clinical care. Our results lend support to implementation of reflexive universal tumor testing within the VA system.
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Scheuner MT, Myrie K, Peredo J, Hoffman-Hogg L, Lundquist M, Guerra SL, Ball D. Integrating Germline Genetics Into Precision Oncology Practice in the Veterans Health Administration: Challenges and Opportunities. Fed Pract 2020; 37:S82-S88. [PMID: 32908356 PMCID: PMC7473729 DOI: 10.12788/fp.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The advent of germline testing as a standard-of-care practice for certain tumor types and patients presents unique opportunities and challenges for the field of precision oncology. This article describes strategies to address workforce capacity, organizational structure, and genetics education needs within the US Department of Veterans Affairs (VA) with the expectation that these approaches may be applicable to other health care systems. OBSERVATIONS Germline information can have health, reproductive, and psychosocial implications for veterans and their family members, which can pose challenges when delivering germline information in the setting of cancer care. Additional challenges include the complexity inherent in the interpretation of germline information, the national shortage of genetics professionals, limited awareness and knowledge about genetic principles among many clinicians, and organizational barriers, such as the inability to order genetic tests and receive results in the electronic health record. These challenges demand thoughtful implementation planning at the health care system level to develop sustainable strategies for the delivery of high-quality genetic services in precision oncology practice. CONCLUSIONS The VA is uniquely positioned to address the integration of germline genetic testing into precision oncology practice due to its outsized role in treating veterans with cancer, training the health care workforce, and developing, testing, and implementing innovative models of clinical care.
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Affiliation(s)
- Maren T Scheuner
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
| | - Kenute Myrie
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
| | - Jane Peredo
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
| | - Lori Hoffman-Hogg
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
| | - Margaret Lundquist
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
| | - Stephanie L Guerra
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
| | - Douglas Ball
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
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Dragojlovic N, Borle K, Kopac N, Ellis U, Birch P, Adam S, Friedman JM, Nisselle A, Elliott AM, Lynd LD. The composition and capacity of the clinical genetics workforce in high-income countries: a scoping review. Genet Med 2020; 22:1437-1449. [PMID: 32576987 DOI: 10.1038/s41436-020-0825-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/24/2020] [Accepted: 04/26/2020] [Indexed: 01/25/2023] Open
Abstract
As genetics becomes increasingly integrated into all areas of health care and the use of complex genetic tests continues to grow, the clinical genetics workforce will likely face greatly increased demand for its services. To inform strategic planning by health-care systems to prepare to meet this future demand, we performed a scoping review of the genetics workforce in high-income countries, summarizing all available evidence on its composition and capacity published between 2010 and 2019. Five databases (MEDLINE, Embase, PAIS, CINAHL, and Web of Science) and gray literature sources were searched, resulting in 162 unique studies being included in the review. The evidence presented includes the composition and size of the workforce, the scope of practice for genetics and nongenetics specialists, the time required to perform genetics-related tasks, case loads of genetics providers, and opportunities to increase efficiency and capacity. Our results indicate that there is currently a shortage of genetics providers and that there is a lack of consensus about the appropriate boundaries between the scopes of practice for genetics and nongenetics providers. Moreover, the results point to strategies that may be used to increase productivity and efficiency, including alternative service delivery models, streamlining processes, and the automation of tasks.
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Affiliation(s)
- Nick Dragojlovic
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Kennedy Borle
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Nicola Kopac
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Ursula Ellis
- Woodward Library, University of British Columbia, Vancouver, BC, Canada
| | - Patricia Birch
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Shelin Adam
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Jan M Friedman
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Amy Nisselle
- Australian Genomics Health Alliance, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | | | - Alison M Elliott
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada.,BC Women's Hospital Research Institute, Vancouver, BC, Canada
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada. .,Centre for Health Evaluation and Outcomes Sciences, Providence Health Research Institute, Vancouver, BC, Canada.
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10
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Wadovski R, Nogueira R, Chimenti P. Genetic services diffusion in the precision medicine ecosystem. INTERNATIONAL JOURNAL OF PHARMACEUTICAL AND HEALTHCARE MARKETING 2020. [DOI: 10.1108/ijphm-02-2019-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Genetic knowledge is advancing steadily while at the same time DNA sequencing prices are dropping fast, but the diffusion of genetic services (GS) has been slow. The purpose of this paper is to identify GS diffusion drivers in the precision medicine (PM) ecosystem.
Design/methodology/approach
After reviewing the literature on innovation diffusion, particularly on GS diffusion, the PM ecosystem actors are interviewed to obtain their perspective. Using content analysis, the interviewees’ visions were interplayed with the literature to achieve driver conceptualization, which posteriorly originated broad themes.
Findings
The results indicate that GS diffusion depends on satisfying aspects from three broad themes and respective drivers: technology (evidence strength and credibility, customization, knowledge, data and information, tech evolution speed and cost), human (ethics, privacy and security and user power) and business (prevention, holistic view of the individual, public policy and regulation, business model and management).
Practical implications
The main management implications refer to considering health care in a multidisciplinary way, investing in the propagation of genetic knowledge, standardizing medical records and interpreting data.
Originality/value
This study, to the best of authors’ knowledge, is the first attempt to understand GS diffusion from a broad perspective, taking into account the PM stakeholders’ view. The 13 drivers offer a comprehensive understanding of how GS could spread in health care and they can assist researchers and practitioners to discuss and set strategies based on an initial structured map.
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11
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Delivering genomic medicine in the United Kingdom National Health Service: a systematic review and narrative synthesis. Genet Med 2019; 21:2667-2675. [PMID: 31186523 DOI: 10.1038/s41436-019-0579-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/30/2019] [Indexed: 01/28/2023] Open
Abstract
PURPOSE We sought to assess the readiness of the United Kingdom (UK) National Health Service to implement a Genomic Medicine Service. We conducted a systematic literature review to identify what is known about factors related to the implementation of genomic medicine in routine health care and to draw out the implications for the UK and other settings. METHODS Relevant studies were identified in Web of Science and PubMed from their date of inception to April 2018. The review included primary research studies using quantitative, qualitative, or mixed methods, and systematic reviews. A narrative synthesis was conducted. RESULTS Fifty-five studies met our inclusion criteria. The majority of studies reviewed were conducted in the United States. We identified four domains: (1) systems, (2) training and workforce needs, (3) professional attitudes and values, and (4) the role of patients and the public. CONCLUSION Mainstreaming genomic medicine into routine clinical practice requires actions at each level of the health-care system. Our synthesis emphasized the organizational, social, and cultural implications of reforming practice, highlighting that demonstration of clinical utility and cost-effectiveness, attending to the compatibility of genomic medicine with clinical principles, and involving and engaging patients are key to successful implementation.
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12
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Eriksson J, Amonkar M, Al-Jassar G, Lambert J, Malmenäs M, Chase M, Sun L, Kollmar L, Vichnin M. Mismatch Repair/Microsatellite Instability Testing Practices among US Physicians Treating Patients with Advanced/Metastatic Colorectal Cancer. J Clin Med 2019; 8:jcm8040558. [PMID: 31022981 PMCID: PMC6518162 DOI: 10.3390/jcm8040558] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 04/16/2019] [Accepted: 04/19/2019] [Indexed: 12/31/2022] Open
Abstract
The study objective was to assess US physicians’ Mismatch Repair/Microsatellite Instability (MMR/MSI) testing practices for metastatic colorectal cancer (mCRC) patients. A non-interventional, cross-sectional online survey was conducted among 151 physicians (91 oncologists, 15 surgeons and 45 pathologists) treating mCRC patients in the US. Eligible physicians were US-based with at least 5 years of experience treating CRC patients, had at least one mCRC patient in their routine care in the past 6 months, and had ordered at least one MMR/MSI test for CRC in the past 6 months. Descriptive and logistic regression analyses were performed. Awareness of specific MMR/MSI testing guidelines was high (n = 127, 84.1%). Of those, 93.7% (119/127) physicians had awareness of specific published guidelines with majority 67.2% (80/119) being aware of National Comprehensive Cancer Network (NCCN) guidelines. Universal testing for all CRC patients was performed by 68.9% (104/151) physicians, while 29.8% (45/151) selectively order the test for some CRC patients. Key barriers for testing included insufficient tissue sample (48.3%, 73/151), patient declined to have the test done (35.8%, 54/151) and insurance cost concerns for patients (31.1%, 47/151), while 27.2% (41/151) reported no barriers. The survey demonstrated high awareness and compliance with MMR/MSI testing guidelines although universal testing rates seem to be suboptimal.
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Affiliation(s)
| | | | | | | | | | | | - Lucy Sun
- ICON plc, Boston 02110, MA, USA.
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13
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Bednar EM, Walsh MT, Baker E, Muse KI, Oakley HD, Krukenberg RC, Dresbold CS, Jenkinson SB, Eppolito AL, Teed KB, Klein MH, Morman NA, Bowdish EC, Russ P, Wise EE, Cooper JN, Method MW, Henson JW, Grainger AV, Arun BK, Lu KH. Creation and Implementation of an Environmental Scan to Assess Cancer Genetics Services at Three Oncology Care Settings. J Genet Couns 2018; 27:10.1007/s10897-018-0262-4. [PMID: 29770910 PMCID: PMC6240000 DOI: 10.1007/s10897-018-0262-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/06/2018] [Indexed: 02/03/2023]
Abstract
An environmental scan (ES) is an efficient mixed-methods approach to collect and interpret relevant data for strategic planning and project design. To date, the ES has not been used nor evaluated in the clinical cancer genetics setting. We created and implemented an ES to inform the design of a quality improvement (QI) project to increase the rates of adherence to national guidelines for cancer genetic counseling and genetic testing at three unique oncology care settings (OCS). The ES collected qualitative and quantitative data from reviews of internal processes, past QI efforts, the literature, and each OCS. The ES used a data collection form and semi-structured interviews to aid in data collection. The ES was completed within 6 months, and sufficient data were captured to identify opportunities and threats to the QI project's success, as well as potential barriers to, and facilitators of guideline-based cancer genetics services at each OCS. Previously unreported barriers were identified, including inefficient genetic counseling appointment scheduling processes and the inability to track referrals, genetics appointments, and genetic test results within electronic medical record systems. The ES was a valuable process for QI project planning at three OCS and may be used to evaluate genetics services in other settings.
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Affiliation(s)
- Erica M Bednar
- The Department of Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Unit 1362 P.O. Box 301439, Houston, TX, 77230-1439, USA.
- The Cancer Prevention and Control Platform, Moon Shots Program™, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Michael T Walsh
- The Cancer Prevention and Control Platform, Moon Shots Program™, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ellen Baker
- The Cancer Prevention and Control Platform, Moon Shots Program™, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kimberly I Muse
- The Department of Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Unit 1362 P.O. Box 301439, Houston, TX, 77230-1439, USA
| | - Holly D Oakley
- The Department of Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Unit 1362 P.O. Box 301439, Houston, TX, 77230-1439, USA
| | | | - Cara S Dresbold
- Oncology Genetic Counseling, Community Health Network, Indianapolis, IN, USA
| | - Sandra B Jenkinson
- Oncology Genetic Counseling, Community Health Network, Indianapolis, IN, USA
| | | | - Kelly B Teed
- Piedmont Cancer, Piedmont Healthcare, Atlanta, GA, USA
| | - Molly H Klein
- Piedmont Cancer, Piedmont Healthcare, Atlanta, GA, USA
| | | | | | - Pauline Russ
- Genetic Counseling Program, OhioHealth, Columbus, OH, USA
| | - Emaline E Wise
- Genetic Counseling Program, OhioHealth, Columbus, OH, USA
| | - Julia N Cooper
- Genetic Counseling Program, OhioHealth, Columbus, OH, USA
| | - Michael W Method
- Gynecologic Cancer Care, Community Health Network, Indianapolis, IN, USA
| | - John W Henson
- Piedmont Cancer, Piedmont Healthcare, Atlanta, GA, USA
| | | | - Banu K Arun
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karen H Lu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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14
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Schneider JL, Goddard KAB, Muessig KR, Davis JV, Rope AF, Hunter JE, Peterson SK, Acheson LS, Syngal S, Wiesner GL, Reiss JA. Patient and provider perspectives on adherence to and care coordination of lynch syndrome surveillance recommendations: findings from qualitative interviews. Hered Cancer Clin Pract 2018; 16:11. [PMID: 29760830 PMCID: PMC5946437 DOI: 10.1186/s13053-018-0090-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/26/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Patients with a genetic variant associated with Lynch syndrome (LS) are recommended to undergo frequent and repeated cancer surveillance activities to minimize cancer-related morbidity and mortality. Little is known about how patients and primary care providers (PCPs) track and manage these recommendations. We conducted a small exploratory study of patient and PCP experiences with recommended LS surveillance activities and communication with family members in an integrated health care system. METHODS We used in-depth interviews with patients and providers to understand how surveillance is coordinated and monitored following confirmation of LS. We recruited patients with a range of ages/gender, and providers with at least at least one patient with a molecular diagnosis of LS. All interviews were recorded, transcribed, and content analyzed by a trained qualitative methodologist. RESULTS Twenty-two interviews were completed with 12 patients and 10 providers. Most patients (10) had detailed knowledge of surveillance recommendations, but were less sure of time intervals. While all patients reported receiving initial education about their surveillance recommendations from a genetic counselor, seven did not follow-up with a genetic counselor in subsequent years. A third of patients described taking sole responsibility for managing their LS surveillance care. Lack of routine communication from the health system (e.g., prompts for surveillance activities), and provider engagement were surveillance barriers. PCPs were generally aware of LS, but had limited familiarity with surveillance recommendations. Most PCPs (7) viewed LS as rare and relied on patient and specialist expertise and support. Providers typically had 1 patient with LS in a panel of 1800 patients overall. Providers felt strongly that management of LS should be coordinated by a dedicated team of specialists. Most patients (92%) had at least one family member that sought LS testing, and common barriers for family members included lack of insurance, affordability, and fear of result. CONCLUSION The maximal benefits of screening for confirmation of LS will only be realized with adherence to recommended preventive care. Important factors to ensure patients receive recommended LS care include a comprehensive and coordinated monitoring program that includes reminder prompts, and increased PCP education of LS and associated surveillance recommendations.
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Affiliation(s)
- Jennifer L. Schneider
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
| | - Katrina A. B. Goddard
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
| | - Kristin R. Muessig
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
| | - James V. Davis
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
| | - Alan F. Rope
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
| | - Jessica E. Hunter
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
| | - Susan K. Peterson
- 0000 0001 2291 4776grid.240145.6Department of Behavioral Science, University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Louise S. Acheson
- 0000 0000 9149 4843grid.443867.aCase Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH USA
| | - Sapna Syngal
- 0000 0001 2106 9910grid.65499.37Dana-Farber Cancer Institute, Boston, MA USA
| | - Georgia L. Wiesner
- 0000 0001 2264 7217grid.152326.1Vanderbilt Hereditary Cancer Program, Department of Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University, Nashville, TN USA
| | - Jacob A. Reiss
- 0000 0004 0455 9821grid.414876.8Center for Health Research, Kaiser Permanente Northwest, Portland, OR USA
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