Core Competencies in Cancer Genomics for Healthcare Professionals: Results From a Systematic Literature Review and a Delphi Process

The continuous development and use of genomic sequencing requires healthcare professionals to constantly integrate these advancements into their clinical practice. There is a documented lack of cancer genomics contents in the teaching and learning programs. We aimed to identify the core competencies in cancer genomics for non-genetic healthcare professionals. We performed a literature review in PubMed, SCOPUS, and Web of Science databases to retrieve articles published from 2000 to 2018, in English or Italian language. We included articles that reported the competencies for non-genetic healthcare professionals in cancer genomics. A web-based modified Delphi survey was conducted, aiming to define, through consensus, a set of core competencies that should be covered in the curricula. The international expert panel included specialists in genetics, genomics, oncology, and medical specialists. In the literature review, we retrieved nine articles, from which we identified core competencies for general physicians and nurses. The competencies were organized in three main domains: knowledge, attitudes, and practical abilities. In the second round of Delphi survey, consensus of 83.3% was reached for the definition of the core competencies. Thirty-seven items were defined as the competencies required for physicians and forty-two items for nurses. Through a consensus-based approach, a set of core competencies in cancer genomics for non-genetic healthcare professionals has been identified. Our findings could benchmark standards for curriculum development and future educational strategies.

The Value(s) of Vaccination: Building the Scientific Evidence According to a Value-Based Healthcare Approach

Objectives

To provide a new value-based immunization approach collating the available scientific evidence on the topic.

Methods

Four value pillars (personal, allocative, technical, and societal) applied to vaccination field were investigated. A systematic literature review was performed querying three database from December 24th, 2010 to May 27th, 2020. It included studies on vaccine-preventable diseases (VPDs) that mentioned the term value in any part and which were conducted in advanced economies. An in-depth analysis was performed on studies addressing value as key element.

Results

Overall, 107 studies were considered. Approximately half of the studies addressed value as a key element but in most of cases (83.3%) only a single pillar was assessed. Furthermore, the majority of papers addressed the technical value by looking only at classical methods for economic assessment of vaccinations whereas very few dealt with societal and allocative pillars.

Conclusions

Estimating the vaccinations value is very complex, even though their usefulness is certain. The assessment of the whole value of vaccines and vaccinations is still limited to some domains and should encompass the wider impact on economic growth and societies.

Evidence and recommendations for a value-based decision making on vaccinations

Issue/problem

Vaccinations are one of the most successful public health measures and contribute to the achievement of Sustainable Development Goals. Despite this, there are still several challenges, such as poor resources, unequal access, and vaccine hesitancy. An exploitation of the full value of vaccinations could help contrasting them.

Description of the problem

A dual approach was followed to exploit full value of vaccinations. First, the four pillars of value pinpointed by the Expert Panel on Effective Ways of Investing in Health of the European Commission, namely personal, societal, allocative, and technical value, were considered to carry out a systematic review of available papers addressing the value of vaccinations. The synthesis of data was the submitted to a panel of international experts in vaccinations who gave inputs on recommendations to drive a value-based decision-making.

Results

Overall, 54 papers published from 2010 onwards addressed at least one pillar of value with most of them (83.3%) assessing a single one. Two-thirds of papers addressed the technical pillar, namely the economic value, in most cases without catching the broad economic implications. Very few studies addressed allocative and societal value highlighting the need to generate evidence to support the application of these pillars. Furthermore, some aspects of the allocative pillar, such as equity, accessibility, and appropriate use, were not addressed so far. Recommendations on research on full value of vaccinations, decision-making process and public engagement were eventually issued.

Lessons

The project allowed to apply for the first the value-based approach to vaccinations. This led to the identification of current gaps in the assessment of full value of vaccinations and to recommendations to foster a value-based decision-making. These results have international relevance because of the growing attention to the value-based approach for sustainable health systems.

Key messages

The full value of vaccinations need to be further investigated according to the four pillars pinpointed by the Expert Panel on Effective Ways of Investing in Health. Different actions could be promoted with respect to research, decision-making process and public engagement in order to exploit the full value of vaccination and drive a value-based decision-making.

Developing an Evidence-Based Tool for Planning and Evaluating Vaccination Strategies Aimed at Improving Coverage in Elderly and At-Risk Adult Population

Background: Vaccination coverages need to be constantly maintained and improved with the implementation of vaccination strategies. This paper describes the development of an evidence-based tool to guide their planning and evaluation.

Methods: A scoping review was performed in MEDLINE and institutional websites to search for similar available tools. A first version of the tool was developed considering review results and a four-step method used for the control and continuous improvement of processes and products, namely the Deming cycle. A panel of eight experts was then involved in a Delphi study for the finalization of the tool that was eventually discussed in a face-to-face meeting.

Results: The scoping review found only one document and the first version of the tool was composed of 30 items. After the Delphi first round, 11 additional items were suggested and 5 original items amended. After the Delphi second round 41 items were eventually included. During the face-to-face meeting, 7 items were recognized as requisites for setting vaccination strategies, whereas 17 as relevant ones.

Conclusions: Current public health challenges impose the need for evidence-based tools to organize effective vaccination strategies. Our tool is a first proposal which aims to reflect this focus.

Capacity Building of Health Professionals on Genetics and Genomics Practice: Evaluation of the Effectiveness of a Distance Learning Training Course for Italian Physicians

BACKGROUND

The rapid spread of personalized medicine requires professionals to manage the "omics revolution." Therefore, the genetics/genomics literacy of healthcare professionals should be in line with the continuous advances in this field, in order to implement its potential implications for diagnosis, control and treatment of diseases. The present study investigates the effectiveness of a distance learning course on genetics and genomics targeted at medical doctors.

METHODS

In the context of a project funded by the Italian Ministry of Health, we developed a distance learning course, entitled Genetics and Genomics practice. The course focused on genetic/genomics testing, pharmacogenetics and oncogenomics and was developed according to andragogical training methods (Problem-based Learning and Case-based Learning). We used a pre-test vs. post-test study design to assess knowledge improvement on a set of 10 Multiple Choice Questions (MCQs). We analyzed the proportion of correct answers for each question pre and post-test and the mean score difference stratified by gender, age, professional status and medical discipline. Moreover, the test was submitted to the participants 8 months after the conclusion of the course (follow-up), in order to assess the retained knowledge.

RESULTS

The course was completed by 1,637 Italian physicians, most of which were primary care physicians (20.8%), public health professionals (11.5%) and specialist pediatricians (10.6%). The proportion of correct answers increased in the post-test for all the MCQs. The overall mean score significantly increased, from 59.46 in the pre-test to 71.42 in the post-test (p < 0.0001). The comparison in test performance between follow-up and pre-test demonstrated an overall knowledge improvement.

CONCLUSION

Genomics literacy among healthcare professionals is essential to ensure optimal translation to healthcare delivery of research. The results of this course suggest that distance-learning training in genetic/genomics practice represents an effective method to improve physicians' knowledge in the immediate and mid-term time scale. A preprint version of this paper is available at: https://www.researchsquare.com/article/rs-10083/v1.

Citizens' Attitudes, Knowledge, and Educational Needs in the Field of Omics Sciences: A Systematic Literature Review

Background: The huge development of omics sciences is changing the classical medical approach and making new technologies available. In this context, education of citizens is essential to allow appropriate decisions about their own health. Hence, we aimed to summarize existing literature regarding citizens' knowledge, attitudes, and educational needs on omics sciences. Methods: We performed a systematic literature review (SLR) using Pubmed, ISI Web of Science, and Embase databases. The eligibility criteria for inclusion in this review required that the studies investigated knowledge, attitudes, or educational needs regarding omics sciences among the general population. Results: We included 54 studies, published between 2006 and 2020. Most of the included studies (72%) investigated citizens' knowledge, half of them (56%) attitudes, and 20% educational needs in the field of omics sciences, while 52% investigated attitudes and perceptions about genetic and/or omics tests. Most studies (64%) reported a limited knowledge level among citizens, even though most (59%) reported participants understood the benefits of the use of omics sciences into medicine. As for omics tests, a controversial opinion toward their use into practice was reported among citizens. Most of the studies (82%) investigating citizens' educational needs highlighted a clear gap to be filled. Conclusions: Our SLR summarizes current knowledge on citizens' literacy, attitudes, and educational needs on omics science, underlining the need for strengthening public engagement on this topic. Further research is needed, however, to identify appropriate methods and models to achieve such an improvement.

Systematic review on citizens’ literacy in omic sciences and web search of initiatives to improve it

Introduction

We are assisting to a progressive change in the classical approach to patient care toward so-called personalized medicine, mainly driven by the development of omic sciences. To implement omic sciences into practice it is important to address healthcare professionals', policy makers', leaders', and citizens' literacy

Methods

As part of a project funded by the Italian Centre for Disease Prevention and Control (CCM), we carried out a systematic review (SR) on citizens' attitude, knowledge, and educational needs in omic sciences. The search was carried out on Pubmed, Web of Science, and Embase. We also conducted a separate web search on Google, Yahoo, and Bing on initiatives published in Italian and English aimed at improving citizens' literacy in the same field. Websites of retrieved initiatives were examined to identify additional resources

Results

Forty-nine studies were included in the SR. Most studies (n = 26, 66.7%) reported low levels of knowledge in omic sciences among citizens, and conflicting attitudes related to potential risks and benefits of omic sciences. Eleven studies (22%) evaluated citizens' educational needs, and most (n = 9, 82%) reported a clear knowledge gap. As for the web search, 13 initiatives were identified in Italy, 4 in Europe, and 22 in non-European Countries. Overall, 33% of them required in-person attendance, while 67% were web-based resources. The former included exhibitions, seminars, courses, symposia, information stands in public places, guided visits at research laboratories, and interactive laboratories; the latter included web-pages for reading, online lessons and courses, web portals for information, videos and short movies, animations, apps for mobile devices

Conclusions

Results show a clear need to improve citizens' literacy. To achieve this goal, the implementation of effective strategies and initiatives is crucial, hence this effort to summarize the existing ones will be essential for future plan developments.

Key messages

The current challenge is to identify effective methods of improving citizens' literacy and implementing them. Only through citizens’ empowerment the implementation of omic sciences in the Health System will be possible, since citizens are increasingly active in the health context.

BRaVE Project: processing an evidence-based tool to develop and evaluate vaccination strategies

Introduction

Deaths and epidemics due to vaccine-preventable diseases still occur even though there are effective vaccines available. Albeit recommendations released by the Italian Ministry of Health, vaccination coverages remain unsatisfactory. An improvement is therefore needed and new strategies are deserved in order to increase coverage. Nevertheless, neither a validated tool nor an institutional guideline to plan and/or evaluate vaccination strategies are available. The aim of BRaVE project was to build an evidence-based tool to develop and assess them.

Methods

In May 2019, a scoping review in MEDLINE and a search of ECDC and WHO websites were performed to look for validated tools to plan and/or evaluate vaccination strategies. The results of the search and the four phases of the Deming cycle (Plan, Do, Check, Act) were used to develop a grid. A multiprofessional panel of 7 experts validated the items included in the grid through a Delphi process followed by a face-to-face meeting.

Results

The original grid submitted to the panel of experts included 30 items (13 planning, 7 implementation, 4 check, 4 act, 2 other). The first round of Delphi led to the suggestion of 11 additional items and to the amendment of 4 out of 30 original items. During the second round of the Delphi the 41 items proposed were approved. At the end of the face-to-face meeting, 1 item was split. Seven items belonging to “Planning” (Plan) and “Implementation” (Do) were labelled as requisites for launching a vaccination strategy and the remaining 35 as items to be considered in their evaluation (15 planning, 11 implementation, 8 check, 4 act, 4 other).

Conclusions

Despite its importance, vaccination coverage is low. Evidence shows possible improvement in coverage, if innovative vaccination strategies are put in place. The developed grid is proposed as an organizational instrument which could improve and standardize vaccination strategies fostering their success and transferability.

Key messages

Novel organizational strategies could be a useful answer to improve vaccination coverage. The proposed grid could be used for the development and assessment of vaccination strategies.

Strategies to Improve Vaccination among At-Risk Adults and the Elderly in Italy

The World Health Organization (WHO), the United States (US) Centers for Disease Control and Prevention (CDC), the European Center for Disease Control (ECDC), and the immunization guidelines of many countries issue vaccination recommendations for adults and the elderly. However, the uptake of vaccination in these groups is generally low due to several reasons. The present study aimed to identify strategies implemented in Italy in unconventional settings to promote vaccination against influenza, pneumococcal, and herpes zoster virus (HZV) infections among these subjects, i.e., the at-risk adult population and the elderly. We conducted a literature review and a survey of experts. The literature search yielded seven strategies; all of these concerned influenza vaccination, while three also addressed pneumococcal and HZV vaccination. The survey of experts identified 15 strategies; 10 regarded influenza vaccination, while four regarded pneumococcal vaccination and one regarded HZV vaccination. Most of the strategies were implemented in hospital clinics and rest homes. Regarding influenza and pneumococcal vaccinations, the target population mainly comprised at-risk adults, while the elderly represented the main target population for HZV vaccination. Our results show that, in Italy, there are initiatives aimed at promoting vaccination in unconventional settings, but further efforts are required to assess their effectiveness and to further extend them.

Cost-effectiveness analysis of genetic diagnostic strategies for Lynch syndrome in Italy

Lynch syndrome (LS) is an autosomal dominant condition caused by pathogenic variants in mismatch repair (MMR) genes that predispose individuals to different malignancies, such as colorectal cancer (CRC) and endometrial cancer. Current guidelines recommended testing for LS in individuals with newly diagnosed CRC to reduce cancer morbidity and mortality in relatives. Economic evaluations in support of such approach, however, are not available in Italy. We developed a decision-analytic model to analyze the cost-effectiveness of LS screening from the perspective of the Italian National Health System. Three testing strategies: the sequencing of all MMR genes without prior tumor analysis (Strategy 1), a sequential IHC and MS-MLPA analysis (Strategy 2), and an age-targeted strategy with a revised Bethesda criteria assessment before IHC and methylation-specific MLPA for patients ≥ than 70 years old (Strategy 3) were analyzed and compared to the “no testing” strategy. Quality Adjusted Life Years (QALYs) in relatives after colonoscopy, aspirin prophylaxis and an intensive gynecological surveillance were estimated through a Markov model. Assuming a CRC incidence rate of 0.09% and a share of patients affected by LS equal to 2.81%, the number of detected pathogenic variants among CRC cases ranges, in a given year, between 910 and 1167 depending on the testing strategy employed. The testing strategies investigated, provided one-time to the entire eligible population (CRC patients), were associated with an overall cost ranging between €1,753,059.93-€10,388,000.00. The incremental cost-effectiveness ratios of the Markov model ranged from €941.24 /QALY to €1,681.93 /QALY, thus supporting that “universal testing” versus “no testing” is cost-effective, but not necessarily in comparison with age-targeted strategies. This is the first economic evaluation on different testing strategies for LS in Italy. The results might support the introduction of cost-effective recommendations for LS screening in Italy.

The Current Practice of Lynch Syndrome Diagnosis and Management in Italy: A Qualitative Assessment

BACKGROUND

Lynch syndrome (LS) is the most frequent form of hereditary colorectal cancer (CRC; up to 3-5% of the total CRC burden) and predisposes to the development of other cancers. Multidisciplinary diagnostic strategies are relevant both to the index cases and to their at-risk relatives, but their implementation is still limited. Our study aimed to explore LS testing practices in Italy.

METHODS

In order to ascertain the current practice of LS diagnosis and management, we conducted a qualitative assessment by sending a questionnaire to health care professionals at 4 Italian hospitals selected as "models" representing different hospital settings. Based on the surveys, we reconstructed the management pathways for CRC patients in terms of diagnostic strategies and health professionals involved.

RESULTS

Seven of the 8 invited professionals filled in the questionnaire. Noncompliance with the latest guidelines was reported, as no tumor "screening" was performed on CRC cases. The lack of a structured multidisciplinary team who manages CRC patients from risk assessment to diagnosis and follow-up was reported. The availability of professionals and laboratory technologies differ widely between hospitals. As for cascade testing of at-risk relatives, a systematic and active approach was absent in all the considered hospitals.

CONCLUSIONS

Our study shows that no structured and standardized pathways for the diagnosis and management of LS patients are currently in place in Italy. We envisage that by extending our research to further experiences and countries, an increasing awareness of the topic can be translated into a health gain for hereditary CRC patients and their at-risk relatives.

Influenza vaccination campaigns targeted at healthcare workers:results of four hospitals in Rome

Background

Seasonal influenza vaccination (SIV) of health care workers (HCWs) is well recognized as a public health measure that can protect both HCWs from infection and patients from the risk of influenza complications. Nevertheless, vaccination coverage rates among this specific population result generally lower than the recommended target. With our study, we aimed to describe the activities and the outcomes of four different SIV campaigns targeted at HCWs and organized during the season 2018/2019 in four hospitals in Rome.

Methods

A cross-sectional study involving four teaching hospitals was performed. The collected data were synthetized into a set of descriptors and indicators, validated through a previous study that had involved the same Centers.

Results

The Medical Directorates, in collaboration with the University Hygiene and Public Health Units of the four hospitals organized different strategies: Hospital 1, 3 and 4 realized educational courses for HCWs and actively promoted the campaigns through e-mail invitations to all HCWs. As for the access to vaccination, all the hospitals provided a dedicated unit for SIV; Hospital 1 and Hospital 4 organized also on-site vaccination sessions in the hospital wards, that required a large number of staff. The vaccination coverage rates resulted: 22.37% in Hospital 1, 18.10% in Hospital 4, 9.28% in Hospital 2 and 8,51% in Hospital 3.

Conclusions

Our results demonstrate that multi-activity campaigns, involving education, promotion and easy access to vaccination constitute an effective approach to reinforce the value of SIV. Our findings suggest that on-site vaccination may play a key role in determining a higher vaccination coverage.

Key messages

Multi-activity vaccination campaigns, involving education, promotion and easy access to vaccination constitute an effective approach to reinforce the value of seasonal influenza vaccination for HCWs. On-site vaccination may play a key role in determining a higher vaccination coverage.

Seasonal influenza vaccination among health-care workers: the impact of different tailored programs in four University hospitals in Rome

Seasonal influenza vaccination (SIV) of health-care workers (HCWs) is recommended in most countries to protect them and their patients from infection. Although SIV can reduce the risk of influenza complications among vulnerable patients, vaccination uptake is generally unsatisfactory. The present study aimed to assess the impact of different programs in promoting SIV uptake among HCWs during the season 2017/2018 in four teaching hospitals in Rome. A multicentric cross-sectional study was carried out, in order to describe the four different campaigns and to assess their impact by identifying and developing a set of indicators that provide information about the vaccination services, the percentage of invited HCWs, the vaccinators' workforce and the vaccination coverage rates.The hospitals organized different strategies: Hospital 1, 3 and 4 organized educational courses for HCWs and actively invited every single HCW through e-mail. All the hospitals organized a dedicated unit for influenza vaccination, and Hospital 1 added on-site vaccination sessions that required a large number of staff. Hospital 1 and hospital 4 registered a comparable vaccination coverage rate, 12.97% and 12.76%, respectively, while it was 6.88% in Hospital 2 and 4.23% in Hospital 3. Our indicators demonstrated to be effective and useful for analyzing the different SIV campaigns. The results suggest that the best practice to promote SIV among HCWs should include multiple approaches. Among those, an easy access to the vaccination site seems to play a key role in determining a higher vaccination coverage.

[Omic sciences and capacity building of health professionals: a distance learning training course for Italian physicians, 2017-2018]

BACKGROUND

Nowadays, a strategy to manage the current "omic revolution" is needed in Italy. Actions aimed to improve genetic/omics &quot;literacy&quot; among health professionals and citizens are necessary, based on recommendations outlined in the Italian 2013 Guidelines on genomics in public health, and the 2018 National Plan for the innovation of the health system based on the omic sciences.

MATERIALS AND METHODS

In the context of a project funded by the Italian Ministry of Health, a distance-learning course entitled "Genetic and Genomic practices" was developed, targeted at medical professionals (mainly general practitioners). The main objective of the course was to train physicians in the responsible use of omic technologies. The course was structured according to the main models of adult learning theory (Problem-based-learning and case studies) and delivered on the institutional platform of the Italian National Institute of Health for one year, from February 2017 to February 2018, with the endorsement of the Italian Society of Hygiene and Preventive Medicine and the Italian Society of Human Genetics.

RESULTS

In one year, 3,054 participants registered for the course and 53% completed it. About 21% of participants were primary care physicians, 12% were public health physicians and 11% were hospital paediatricians. The most represented age group of participants was 51-65 years and their geographical distribution was 38.5% southern Italy/islands, 36.3% northern Italy and 25.2% central Italy. Pre-test data showed that training needs of primary care physicians was very high.

CONCLUSIONS

In the current context, characterized by the &quot;omic revolution&quot;, physicians must be able to understand its potential implications for the diagnosis, control and treatment of diseases. It is therefore necessary to work on capacity building of all health professionals involved in various ways in the use of the "omic sciences". Distance-learning training in genetic/genomic practices represents a low-cost, satisfactory and clinically applicable method to improve physicians' knowledge.

Core competencies in genetics for healthcare professionals: results from a literature review and a Delphi method

BACKGROUND

Advances in genetics and genomics require that healthcare professionals manage and incorporate new technologies into the appropriate clinical practice. The aim of this study was to identify core competencies in genetics for non-geneticists, both physicians and non-physicians.

METHODS

We performed a literature review by searching MEDLINE, SCOPUS, and ISI Web of Science databases to identify studies reporting competencies in genetics in terms of knowledge, attitudes and abilities for non-genetic healthcare professionals. Furthermore, we conducted a survey according to a modified Delphi method, involving genetics experts to evaluate the competencies to be included as items of the curricula.

RESULTS

Three eligible documents were identified and 3 Delphi rounds were carried out to reach a consensus on the competencies to be incorporated in the curricula. With reference to the curriculum for physicians, 19 items were included in the knowledge domain, 3 in the attitudes and 10 in the abilities domain. We developed two different curricula for non-physicians: one specific for those working in genetic services (20 items in the knowledge domain, 3 in the attitudes and 12 in the abilities) and one for those not working in genetic services (10 items in the knowledge domain, 3 in the attitudes and 2 in the abilities).

CONCLUSIONS

We developed 3 curricula in genetics addressed to non-genetic healthcare professionals. They differ in the "knowledge" and "abilities", while the "attitudes" are the same for all the healthcare professionals. Although some concerns about the generalizability of the findings could arise due to the Italian perspective, we envisage the curricula can be used for genetics educational programs in several contexts.

A Systematic Review on the Existing Screening Pathways for Lynch Syndrome Identification

Background

Lynch syndrome (LS) is the most common hereditary colon cancer syndrome, accounting for 3–5% of colorectal cancer (CRC) cases, and it is associated with the development of other cancers. Early detection of individuals with LS is relevant, since they can take advantage of life-saving intensive care surveillance. The debate regarding the best screening policy, however, is far from being concluded. This prompted us to conduct a systematic review of the existing screening pathways for LS.

Methods

We performed a systematic search of MEDLINE, ISI Web of Science, and SCOPUS online databases for the existing screening pathways for LS. The eligibility criteria for inclusion in this review required that the studies evaluated a structured and permanent screening pathway for the identification of LS carriers. The effectiveness of the pathways was analyzed in terms of LS detection rate.

Results

We identified five eligible studies. All the LS screening pathways started from CRC cases, of which three followed a universal screening approach. Concerning the laboratory procedures, the pathways used immunohistochemistry and/or microsatellite instability testing. If the responses of the tests indicated a risk for LS, the genetic counseling, performed by a geneticist or a genetic counselor, was mandatory to undergo DNA genetic testing. The overall LS detection rate ranged from 0 to 5.2%.

Conclusion

This systematic review reported different existing pathways for the identification of LS patients. Although current clinical guidelines suggest to test all the CRC cases to identify LS cases, the actual implementation of pathways for LS identification has not been realized. Large-scale screening programs for LS have the potential to reduce morbidity and mortality for CRC, but coordinated efforts in educating all key stakeholders and addressing public needs are still required.