Family history in primary care: understanding GPs' resistance to clinical genetics--qualitative study

Knowledge, Attitude, and Practice About the Process of Genetic Counselling Among Clinicians

Introduction Clinicians agree with the fact that the impact of genetics in the field of medicine is humongous. They have to cope with the rapid advances in the field of clinical genetics and offer the best treatment to the patients at the right time. Disease with an underlying genetic cause not only involves the patient but also the family and the community. In the process of genetic counseling, the patient and the family are educated about the genetic basis of the disorder. This helps the patient and the family to make a well-informed decision. It also helps to reduce the genetic burden of the disease in the community over a period of time. In this regard, knowledge, attitude, and practice about the process of genetic counseling among clinicians is imperative. Methods A structured pre-validated questionnaire was distributed amongst 60 clinicians from different departments. Their responses were assessed based on the Likert scale. The data obtained were analyzed using descriptive statistics and expressed in percentages.  Results In the present study, nearly 90% of the clinicians felt that it was important to gather a multi-generational family history of the patient and advise them about inheritance patterns, recurrence risk, and genetic tests for a disorder with an underlying genetic cause. The need to educate the family members regarding the importance of genetic tests and referral to appropriate support groups if they test positive for a genetic disorder receive a positive response. Mostly the participants agreed that parents of children and couples at risk of having a child affected by a genetic disease should undergo genetic counseling. Conclusion Clinicians may not always be aware of the underlying genetic cause and genetic tests available or may face a paucity of time to counsel the patient and the family. Genetic counseling needs to be done at length in multiple sessions, and it is essential to reduce the burden of genetic disorders in society.

The practice of genomic medicine: A delineation of the process and its governing principles

Genomic medicine, an emerging medical discipline, applies the principles of evolution, developmental biology, functional genomics, and structural genomics within clinical care. Enabling widespread adoption and integration of genomic medicine into clinical practice is key to achieving precision medicine. We delineate a biological framework defining diagnostic utility of genomic testing and map the process of genomic medicine to inform integration into clinical practice. This process leverages collaboration and collective cognition of patients, principal care providers, clinical genomic specialists, laboratory geneticists, and payers. We detail considerations for referral, triage, patient intake, phenotyping, testing eligibility, variant analysis and interpretation, counseling, and management within the utilitarian limitations of health care systems. To reduce barriers for clinician engagement in genomic medicine, we provide several decision-making frameworks and tools and describe the implementation of the proposed workflow in a prototyped electronic platform that facilitates genomic care. Finally, we discuss a vision for the future of genomic medicine and comment on areas for continued efforts.

General practitioners' (GPs) experience, attitudes and needs on clinical genetic services: a systematic review

OBJECTIVE

The proliferation and growing demands of genetic testing are anticipated to revolutionise medical practice. As gatekeepers of healthcare systems, general practitioners (GPs) are expected to play a critical role in the provision of clinical genetic services. This paper aims to review existing literature on GPs' experience, attitudes and needs towards clinical genetic services.

DESIGN

A systematic mixed studies review of papers published between 2010 and 2022.

ELIGIBILITY CRITERIA

The inclusion criterion was peer-reviewed articles in English and related to GPs' experience, views and needs on any genetic testing.

INFORMATION SOURCES

The PubMed, PsycINFO, Cochrane, EMBASE databases were searched using Mesh terms, Boolean and wildcards combinations to identify peer-reviewed articles published from 2010 to 2022. Study quality was assessed using Mixed Methods Appraisal Tool. Only articles that fulfilled the inclusion criteria were selected. A thematic meta-synthesis was conducted on the final sample of selected articles to identify key themes.

RESULTS

A total of 62 articles were included in the review. Uncertainty over GPs' role in providing genetic services were attributed by the lack of confidence and time constraints and rarity of cases may further exacerbate their reluctance to shoulder an expanded role in clinical genetics. Although educational interventions were found to increasing GPs' knowledge and confidence to carry out genetic tasks, varied interest on genetic testing and preference for a shared care model with other genetic health professionals have resulted in minimal translation to clinical adoption.

CONCLUSION

This review highlights the need for deeper exploration of GPs' varied experience and attitudes towards clinical genetic services to better facilitate targeted intervention in the adoption of clinical genetics.

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.

Introducing genetic testing with case finding for familial hypercholesterolaemia in primary care: qualitative study of patient and health professional experience

BACKGROUND

Familial hypercholesterolaemia (FH) is a common inherited condition causing elevated cholesterol, premature heart disease, and early death. Although FH can be effectively treated, over 80% of people with FH remain undetected.

AIM

To explore patient and health professional experiences of introducing genetic testing with case finding for FH in primary care.

DESIGN AND SETTING

Qualitative study in UK general practice.

METHOD

Semi-structured interviews with a purposeful sample of 41 participants (24 patients and 17 health professionals) from eight practices, using an electronic case-finding tool (FAMCAT) to identify patients with higher likelihood of having FH and who were then offered diagnostic genetic testing in primary care. Data were analysed thematically.

RESULTS

While prior awareness of FH was low, patients were unsurprised to be identified as being at risk, and positive about being offered genetic testing by their practice. Patients not found to have FH were relieved, although some felt frustrated that their high cholesterol lacked a clear cause. Those confirmed to have FH largely expected and accepted this outcome. Practitioners saw detection of FH as an important new opportunity for preventive care. They found the case-finding tool easy to apply and noted patients' high uptake of genetic testing. While they were comfortable referring appropriate patients for further specialist management, GPs sought clearer definition about responsibility for identification and long- term care of FH in future care pathways.

CONCLUSION

Introducing genetic testing with electronic case finding for FH in primary care was positively experienced by patients and practitioners. Further development of this approach could help improve detection of FH in the general population.

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.

Pharmacogenomic testing to support prescribing in primary care: a structured review of implementation models

The application of pharmacogenomics could meaningfully contribute toward medicines optimization within primary care. This review identified 13 studies describing eight implementation models utilizing a multi-gene pharmacogenomic panel within a primary care or community setting. These were small feasibility studies (n <200). They demonstrated importance and feasibility of pre-test counseling, the role of the pharmacist, data integration into the electronic medical record and point-of-care clinical decision support systems (CDSS). Findings were considered alongside existing primary care prescribing practices and implementation frameworks to demonstrate how issues may be addressed by existing nationalized healthcare and primary care infrastructure. Development of point-of-care CDSS should be prioritized; establishing clinical leadership, education programs, defining practitioner roles and responsibilities and addressing commissioning issues will also be crucial.

How practice setting affects family physicians' views on genetic screening: a qualitative study

BACKGROUND

Genetic screening (GS), defined as the clinical testing of a population to identify asymptomatic individuals with the aim of providing those identified as high risk with prevention, early treatment, or reproductive options. Genetic screening (GS) improves patient outcomes and is accessible to the community. Family physicians (FPs) are ideally placed to offer GS. There is a need for FPs to adopt GS to address anticipated genetic specialist shortages.

OBJECTIVE

To explore FP attitudes, perceived roles, motivators and barriers, towards GS; and explore similarities and differences between private and public sector FPs.

METHODS

We developed a semi-structured interview guide using existing literature. We interviewed private and public sector FPs recruited by purposive, convenience and snowballing strategies, by telephone or video to theme saturation. All sessions were audio-recorded, transcribed and coded for themes by two independent researchers with an adjudicator.

RESULTS

Thirty FPs were interviewed (15 private, 15 public). Theme saturation was reached for each group. A total of 12 themes (6 common, 3 from private-practice participants, 3 public-employed participants) emerged. Six common major themes emerged: personal lack of training and experience, roles and relevance of GS to family medicine, reluctance and resistance to adding GS to practice, FP motivations for adoption, patient factors as barrier, and potential solutions. Three themes (all facilitators) were unique to the private group: strong rapport with patients, high practice autonomy, and high patient literacy. Three themes (all barriers) were unique to the public group: lack of control, patients' lower socioeconomic status, and rigid administrative infrastructure.

CONCLUSION

FPs are motivated to incorporate GS but need support for implementation. Policy-makers should consider the practice setting when introducing new screening functions. Strategies to change FP behaviours should be sensitive to their sense of autonomy, and the external factors (either as facilitators or as barriers) shaping FP practices in a given clinical setting.

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.

How genomic information is accessed in clinical practice: an electronic survey of UK general practitioners

Genomic technologies are having an increasing impact across medicine, including primary care. To enable their wider adoption and realize their potential, education of primary health-care practitioners will be required. To enable the development of such resources, understanding where GPs currently access genomic information is needed. One-hundred fifty-nine UK GPs completed the survey in response to an open invitation, between September 2017 and September 2018. Questions were in response to 4 clinical genomic scenarios, with further questions exploring resources used for rare disease patients, direct-to-consumer genetic testing and collecting a family history. Respondents were most commonly GP principals (independent GPs who own their clinic) (64.8%), aged 35-49 years (54%), worked as a GP for more than 15 years (44%) and practiced within suburban locations (typically wealthier) (50.3%). The most popular 'just in time' education source for all clinical genomic scenarios were online primary care focussed resources with general Internet search engines also popular. For genomic continuous medical education, over 70% of respondents preferred online learning. Considering specific scenarios, local guidelines were a popular resource for the familial breast cancer scenario. A large proportion (41%) had not heard of Genomics England's 100,000 genome project. Few respondents (4%) would access rare disease specific Internet resources (Orphanet, OMIM). Twenty-five percent of respondents were unsure how to respond to a direct-to-consumer commercial genetic test query, with 41% forwarding such queries to local genetic services. GPs require concise, relevant, primary care focussed resources in trusted and familiar online repositories of information. Inadequate genetic education of GPs could increase burden on local genetic services.

Informing Integration of Genomic Medicine Into Primary Care: An Assessment of Current Practice, Attitudes, and Desired Resources

Introduction: Preparing primary care providers for genomic medicine (GM) first requires assessment of their educational needs in order to provide clear, purposeful direction and justify educational activities. More understanding is needed about primary care providers’ perspectives on their role in newer areas of GM and what resources would be helpful in practice. Our objective was to determine family physicians’ (FP) current involvement and confidence in GM, attitudes regarding its clinical value, suggestions for integration of GM into practice, and resources and education required.

Methods: A self-complete anonymous questionnaire was mailed to a random sample of 2,000 FPs in Ontario, Canada in September 2012.

Results: Adjusted response rate was 26% (361/1,365), mean age was 51, and 53% were male. FPs reported many aspects of traditional GM as part of current practice (eliciting family history: 93%; deciding who to refer to genetics: 94%; but few reported confidence (44%, 32% respectively). Newer areas of GM were not part of most FPs’ current practice and confidence was low (pharmacogenetics: 28% part of practice, 5% confident; direct-to-consumer genetic testing: 14%/2%; whole genome sequencing: 8%/2%). Attitudes were mixed with 59% agreeing that GM would improve patient health outcomes, 41% seeing benefits to genetic testing, but only 36% agreeing it was their responsibility to incorporate GM into practice. Few could identify useful sources of genetic information (22%) or find information about genetic tests (21%). Educational resources participants anticipated would be useful included contact information for local genetics clinics (89%), summaries of genetic disorders (86%), and genetic referral (85%) and testing (86%) criteria. About 58% were interested in learning about new genetic technologies. Most (76%) wanted to learn through in-person teaching (lectures, seminars etc.), 66% wanted contact with a local genetic counselor to answer questions, and 59% were interested in a genetics education website.

Conclusion: FPs lack confidence in GM skills needed for practice, particularly in emerging areas of GM. They see their role as making appropriate referrals, are somewhat optimistic about the contribution GM may make to patient care, but express caution about its current clinical benefits. There is a need for evidence-based educational resources integrated into primary care and improved communication with genetic specialists.

Bridging the gap in genetics: a progressive model for primary to specialist care

BACKGROUND

The rapid expansion of genetic knowledge, and the implications for healthcare has resulted in an increased role for Primary Care Providers (PCPs) to incorporate genetics into their daily practice. The objective of this study was to explore the self-identified needs, including educational needs, of both urban and rural Primary Care Providers (PCPs) in order to provide genetic care to their patients.

METHODS

Using a qualitative grounded theory approach, ten key informant interviews, and one urban and two rural PCP focus groups (FGs) (n = 19) were conducted. All PCPs practiced in Southeastern Ontario. Data was analyzed using a constant comparative method and thematic design. The data reported here represent a subset of a larger study.

RESULTS

Participants reported that PCPs have a responsibility to ensure patients receive genetic care. However, specific roles and responsibilities for that care were poorly defined. PCPs identified a need for further education and resources to enable them to provide care for individuals with genetic conditions. Based on the findings, a progressive stepped model that bridges primary and specialty genetic care was developed; the model ranged from PCPs identifying patients with genetic conditions that they could manage alone, to patients who they could manage with informal or electronic consultation to those who clearly required specialist referral.

CONCLUSIONS

PCPs identified a need to integrate genetics into primary care practice but they perceived barriers including a lack of knowledge and confidence, access to timely formal and informal consultation and clearly defined roles for themselves and specialists. To address gaps in PCP confidence in providing genetic care, interventions that are directed at accessible just-in-time support and consultation have the potential to empower PCPs to manage patients' genetic conditions. Specific attention to content, timing, and accessibility of educational interventions is critical to address the needs of both urban and rural PCPs. A progressive framework for bridging primary to specialty care through a 'stepped' model for providing continuing medical education, and genetic care can was developed and can be used to guide future design and delivery of educational interventions and resources.

GP attitudes to and expectations for providing personal genomic risk information to the public: a qualitative study

Background

As part of a pilot randomised controlled trial examining the impact of personal melanoma genomic risk information on behavioural and psychosocial outcomes, GPs were sent a booklet containing their patient’s genomic risk of melanoma.

Aim

Using this booklet as an example of genomic risk information that might be offered on a population-level in the future, this study explored GP attitudes towards communicating genomic risk information and resources needed to support this process.

Design & setting

Semi-structured interviews were conducted with 22 Australian GPs.

Method

The interviews were recorded and transcribed, and data were analysed thematically.

Results

GPs in this sample believed that communicating genomic risk may become a responsibility within primary care and they recommended a shared decisionmaking approach to guide the testing process. Factors were identified that may influence how and when GPs communicate genomic risk information. GPs view genomics-based risk as one of many disease risk factors and feel that this type of information could be applied in practice in the context of overall risk assessment for diseases for which prevention and early detection strategies are available. They believe it is important to ensure that patients understand their genomic risk and do not experience long-term adverse psychological responses. GPs desire clinical practice guidelines that specify recommendations for genomic risk assessment and patient management, point-of-care resources, and risk prediction tools that include genomic and traditional risk factors.

Conclusion

These findings will inform the development of resources for preparing GPs to manage and implement genomic risk information in practice.

Genetic cancer risk assessment in general practice: systematic review of tools available, clinician attitudes, and patient outcomes

BACKGROUND

A growing demand for cancer genetic services has led to suggestions for the involvement of GPs. How, and in which conditions, they can be involved, and whether there are important barriers to implementation should be ascertained.

AIM

To review the tools available, clinician attitudes and experiences, and the effects on patients of genetic cancer risk assessment in general practice.

DESIGN AND SETTING

Systematic review of papers published worldwide between 1996 and 2017.

METHOD

The MEDLINE (via Ovid), EMBASE, Cochrane Library, CINAHL, and PsycINFO databases and grey literature were searched for entries dating from January 1996 to December 2017. Study quality was assessed with relevant Critical Appraisal Skills Programme tool checklists and a narrative synthesis of findings was conducted.

RESULTS

In total, 40 studies were included in the review. A variety of testing and screening tools were available for genetic cancer risk assessment in general practice, principally for breast, breast-ovarian, and colorectal cancer risk. GPs often reported low knowledge and confidence to engage with genetic cancer risk assessment; however, despite time pressures and concerns about confidentiality and the impact of results on family members, some recognised the potential importance relating to such a development of the GP's role. Studies found few reported benefits for patients. Concerns about negative impacts on patient anxiety and cancer worries were largely not borne out.

CONCLUSION

GPs may have a potential role in identifying patients at risk of hereditary cancer that can be facilitated by family-history tools. There is currently insufficient evidence to support the implementation of population-wide screening for genetic cancer risk, especially given the competing demands of general practice.

Discussions about predictive genetic testing for Lynch syndrome: the role of health professionals and families in decisions to decline

Unaffected relatives of individuals with Lynch syndrome can be offered predictive genetic testing to guide surveillance recommendations. The decision-making process of those who decline testing, particularly those who do not attend a clinical genetics service, is poorly understood. We have addressed this gap by interviewing 33 individuals from Lynch syndrome mutation-carrying families, unaffected by cancer, who declined predictive genetic testing. Here, we analyse the data provided by 20 participants who unequivocally declined testing. Those who indicated they did not have enough information to make a decision or intended to undergo testing in the future were excluded. Analysis revealed that few decliners discussed their decision with general practitioners or genetic counsellors. Family members were commonly involved to varying degrees, with participants either (1) making group decisions with family members, (2) feeling persuaded by family members to either accept or decline testing, (3) discussing the test but making their own decision. A minority did not discuss testing with family members while making their decision. This research reveals the health communication activities of an understudied group, those declining predictive testing, and indicates that for many, health professionals play a minor role in the decision compared to family.

Primary care providers' lived experiences of genetics in practice

To effectively translate genetic advances into practice, engagement of primary care providers (PCPs) is essential. Using a qualitative, phenomenological methodology, we analyzed key informant interviews and focus groups designed to explore perspectives of urban and rural PCPs. PCPs endorsed a responsibility to integrate genetics into their practices and expected advances in genetic medicine to expand. However, PCPs reported limited knowledge and difficulties accessing resources, experts, and continuing education. Rural practitioners’ additional concerns included cost, distance, and poor patient engagement. PCPs’ perspectives are crucial to develop relevant educational and systems-based interventions to further expand genetic medicine in primary care.

Family history-taking practices and genetic confidence in primary and tertiary care providers for childhood cancer survivors

BACKGROUND

There is growing impetus for increased genetic screening in childhood cancer survivors. Family history-taking is a critical first step in determining survivors' suitability. However, the family history-taking practices of providers of pediatric oncology survivorship care and the confidence of these providers to discuss cancer risks to relatives are unknown.

PROCEDURE

Fifty-four providers completed semistructured interviews in total, which included eight tertiary providers representing nine hospitals across two countries (63% male, 63% oncologists, 37% nurses) and 46 primary care providers (PCPs) nominated by a survivor (59% male, 35% regional practice). We used content analysis and descriptive statistics/regression to analyze the data.

RESULTS

Few tertiary (38%) or primary (35%) providers regularly collected survivors' family histories, often relying on survivors/parents to initiate discussions. Providers mostly took two-generation pedigrees (63% tertiary and 81% primary). Primary providers focused on adult cancers. Lack of time, alternative priorities, and perceived lack of relevance were common barriers. Half of all tertiary providers felt moderately comfortable discussing genetic cancer risk to children of survivors (88% felt similarly discussing risks to other relatives). Most primary providers lacked confidence: 41% felt confident regarding risks to survivors' children and 48% regarding risks to other relatives.

CONCLUSIONS

While family history-taking will not identify all survivors suitable for genetics assessment, recommendations for regular history-taking are not being implemented in tertiary or primary care. Additional PCP-targeted genetic education is warranted given that they are well placed to review family histories of pediatric cancer survivors.

Primary care professionals' perceptions of using a short family history questionnaire

BACKGROUND

Improving access for relatives at-risk of genetic conditions by building referral systems from primary care to genetic services is well recognised.

OBJECTIVES

This study aimed to explore primary care professionals' (PCPs) views about using a short, seven-item family history questionnaire (S-FHQ) as an intervention for identifying at-risk relatives of patients with a genetic condition in routine primary care for referral to genetic services.

METHOD

This qualitative study was conducted in the UK in 2013-14. Focus groups were held with 21 PCPs. The normalisation process theory (NPT) was used during analysis as the theoretical lens for exploring potential implementation and sustainability of the intervention.

RESULTS

In principle, participants were supportive of the S-FHQ. They initially expressed enthusiasm for the S-FHQ and identified benefits of its use. However, in discussions about its use in practice, they raised concerns about their expertise to deliver the intervention, implications for their workload, potential duplication with existing roles and services in secondary care, the ethical implications of its use in routine care and its acceptability to patients.

CONCLUSION

This study shows why even a short family history questionnaire, as an intervention for identifying at-risk relatives, is unlikely to be implemented by primary care professionals.

Family physicians' management of genetic aspects of a cardiac disease: a scenario-based study from slovenia

The aim of this study was to find out how Slovenian family physicians (FPs) would manage a hypothetical clinical case, to explore their views about possible ethical dilemmas associated with this clinical case and to determine possible associations with demographic and other characteristics of FPs. This was an observational cross-sectional postal study in the Slovenian FPs' surgeries. The study population consisted of the whole population of Slovenian FPs (n = 950). The main outcome measures were the percentages of the answers of FPs on different questions about the clinical case on the management of patient and his relative with hereditary cardiomyopathy. There were 271 FPs who answered the questionnaire (response rate was 27.1%). A sample included 66 (24.4%) men and the mean age of all respondents was 45.5 ± 10.6 years. When dealing with the clinical case, most FPs expressed willingness to take the patient's family history. Only 34.2% FPs did not believe that ordering genetic tests was part of their job. Additionally, only 50.0% of them felt competent to interpret the genetic risk, 25.0% of them would give information about genetic testing and only 6.0% would interpret the results of the genetic testing. Family physicians in Slovenia were willing to include genetic tasks into routine management of their patients, but they do not feel competent enough to interpret the genetic risks and the results of genetic testing. However, an important part of FPs would not refer patients at risk to genetic counseling. The inclusion of genetic topics to family medicine specialization curriculum is needed.

Primary-care providers' perceived barriers to integration of genetics services: a systematic review of the literature

PURPOSE

We aimed to systematically review the literature to identify primary-care providers' perceived barriers against provision of genetics services.

METHODS

We systematically searched PubMed and ERIC using key and Boolean term combinations for articles published from 2001 to 2012 that met inclusion/exclusion criteria. Specific barriers were identified and aggregated into categories based on topic similarity. These categories were then grouped into themes.

RESULTS

Of the 4,174 citations identified by the search, 38 publications met inclusion criteria. There were 311 unique barriers that were classified into 38 categories across 4 themes: knowledge and skills; ethical, legal, and social implications; health-care systems; and scientific evidence. Barriers most frequently mentioned by primary-care providers included a lack of knowledge about genetics and genetic risk assessment, concern for patient anxiety, a lack of access to genetics, and a lack of time.

CONCLUSION

Although studies reported that primary-care providers perceive genetics as being important, barriers to the integration of genetics medicine into routine patient care were identified. The promotion of practical guidelines, point-of-care risk assessment tools, tailored educational tools, and other systems-level strategies will assist primary-care providers in providing genetics services for their patients.

Family physicians' self-perceived importance of providing genetic test information to patients: a cross-sectional study from Slovenia

BACKGROUND

Management of patients with genetic problems, including provision of genetic testing, is increasingly becoming a part of primary health care. The aim of this study was to determine the family physicians' (FPs) self-perceived importance of providing genetic test information to their patients.

MATERIAL AND METHODS

This was an observational cross-sectional postal study in the whole population of Slovenian family physicians (N=950). Its main outcome measure was the perceived importance of providing genetic test information on each of 10 items on a 5-point Likert scale.

RESULTS

There were 271 (27.1% response rate) FPs that completed the questionnaire, out of which 205 (75.6%) were women. Mean age of the sample was 45.5 ± 10.6 years. More than 90% of Slovene FPs felt that it was their professional duty to discuss genetic testing issues with their patients. They were particularly prone to discuss clinical implications of positive and negative test results, as well as giving the patients information about the risk of passing a mutation onto children.

CONCLUSIONS

Most Slovene family physicians feel responsible and willing to offer and discuss genetic testing and implications with their patients. Additional education should be provided to empower them for this task.

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

The aim of this study is to describe how Belgian family physicians register and use the family history data of their patients in daily practice. Qualitative in-depth semistructured one-to-one interviews were conducted including 16 family physicians in Belgium. These interviews were recorded, transcribed, and analysed. Recurring themes were identified and compared with findings from the existing literature. All interviewed family physicians considered the family history as an important part of the medical records. Half of the surveyed physicians confirmed knowing the family history of at least 50% of their patients. The data on family history were mainly collected during the first consultations with the patient. The majority of physicians did not use a standardised questionnaire or form to collect and to record the family history. To estimate the impact of a family history, physicians seldom use official guidance or resources. Physicians perceived a lack of time and unreliable information provided by their patients as obstacles to collect and interpret the family history. Solutions that foster the use of family history data were identified at the level of the physician and also included the development of specific instruments integrated within the electronic medical record.

Development and evaluation of a brief self-completed family history screening tool for common chronic disease prevention in primary care

BACKGROUND

Family history is an important risk factor for many common chronic diseases, but it remains underutilised for diagnostic assessment and disease prevention in routine primary care.

AIM

To develop and validate a brief self-completed family history questionnaire (FHQ) for systematic primary care assessment for family history of diabetes, ischaemic heart disease, breast cancer, and colorectal cancer.

DESIGN AND SETTING

Two-stage diagnostic validation study in 10 general practices in eastern England. Method Participants aged 18-50 years were identified via random sampling from electronic searches of general practice records. Participants completed a FHQ then had a three-generational 'gold standard' pedigree taken, to determine disease risk category. In stage 1, the FHQ comprised 12 items; in stage 2 the shorter 6-item FHQ was validated against the same 'gold standard'.

RESULTS

There were 1147 participants (stage 1: 618; stage 2: 529). Overall, 32% were at increased risk of one or more marker conditions (diabetes 18.9%, ischaemic heart disease 13.3%, breast cancer 6.2%, colorectal cancer 2.2%). The shorter 6-item FHQ performed very well for all four conditions: pooled data from both stages show diabetes, sensitivity = 98%, specificity = 94%; ischaemic heart disease, sensitivity = 93%, specificity = 81%; breast cancer, sensitivity = 81%, specificity = 83%; colorectal cancer, sensitivity = 96%, specificity = 88%, with an area under the receiver operating characteristic curve of 0.90 for males and 0.89 for females.

CONCLUSION

This brief self-completed FHQ shows good diagnostic accuracy for identifying people at higher risk of four common chronic diseases. It could be used in routine primary care to identify patients who would be most likely to benefit from a more detailed pedigree and risk assessment, and consequent management strategies.

A primary care specialist genetics service: a cluster-randomised factorial trial

BACKGROUND

GPs do not have the confidence to identify patients at increased genetic risk. A specialist primary care clinical genetics service could support GPs with referral and provide local clinics for their patients.

AIM

To test whether primary care genetic-led genetics education improves both non-cancer and cancer referral rates, and primary care-led genetics clinics improve the patient pathway.

DESIGN AND SETTING

Cluster-randomised factorial trial in 73 general practices in the south of England.

METHOD

Practices randomised to receive case scenario based seminar (intervention) or not (control), and referred patients a primary (intervention) or secondary (control) care genetic counsellor (GC)-led appointment.

OUTCOME MEASURES

GP referral and clinic attendance rates (primary), appropriate cancer and case scenario referral rates, patient satisfaction, clinic costs, and case management (secondary).

RESULTS

Eighty-nine and 68 referrals made by 36 intervention and 37 control practices respectively. There was a trend towards an overall higher referral rate among educated GPs (referral rate ratio [RRR] 1.34, 95% confidence interval [CI] = 0.89 to 2.02; P = 0.161), and they made more appropriate cancer referrals (RRR 2.36, 95% CI = 1.07 to 5.24; P = 0.035). No indication of difference in clinic attendance rates (odds ratio 0.91, 95% CI = 0.43 to 1.95; P = 0.802) or patient satisfaction (P = 0.189). Patients spent 49% less travelling (£3.60 versus £6.62; P<0.001) and took 33% less time (39.7 versus 57.7 minutes; P<0.001) to attend a primary than secondary care appointment; 83% of GC-managed appointments met the 18-week referral to treatment, NHS target.

CONCLUSION

An integrated primary care genetics service both supports GPs in appropriate cancer referral and provides care in the right place by the right person.

Is patient-centered care the same as person-focused care?

Both patient-centered and person-focused care are important, but they are different. In contrast to patient-centered care (at least as described in the current literature with assessments that are visit-based), person-focused care is based on accumulated knowledge of people, which provides the basis for better recognition of health problems and needs over time and facilitates appropriate care for these needs in the context of other needs. That is, it specifically focuses on the whole person. Proposed enhancements and innovations to primary care do not appear to address person-focused care. Tools to assess person-focused care are available and deserve more widespread use in primary care.

Offering antenatal sickle cell and thalassaemia screening to pregnant women in primary care: a qualitative study of GPs' experiences

BACKGROUND

Timely antenatal sickle cell and thalassaemia (SC&T) screening for all women in primary care facilitates informed decision making, but little is known about its implementation.

AIM

To assess the feasibility of offering antenatal SC&T screening in primary care at the time of pregnancy confirmation.

DESIGN OF STUDY

Cross-sectional investigation of GPs' beliefs and perceived practices.

METHOD

Informal face-to-face interviews with 34 GPs.

SETTING

Seventeen inner-city general practices that offered antenatal SC&T screening as part of a trial.

RESULTS

GPs identified both barriers and facilitators. Organisational barriers included inflexible appointment systems and lack of interpreters for women whose first language was not English. Professional barriers included concerns about raising possible adverse outcomes in the first antenatal visit. Perceived patient barriers included women's lack of awareness of SC&T. Hence, GPs presented the test to women as routine, rather than as a choice. Organisational facilitators included simple and flexible systems for offering screening in primary care, practice cohesion, and training. Professional facilitators included positive attitudes to screening for SC&T. Perceived patient facilitators included women's desire for healthy children.

CONCLUSION

GPs reported barriers, as well as facilitators, to successful implementation but the extent to which screening could be regarded as offering 'informed choice' remained fundamental when making sense of these barriers and facilitators.