Emery J, Morris H, Goodchild R, Fanshawe T, Prevost A T, Bobrow M, Kinmonth A L
General Practice, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, 328 Stirling Highway, Claremont, Western Australia 6010, Australia.
Br J Cancer. 2007 Aug 20;97(4):486-93. doi: 10.1038/sj.bjc.6603897. Epub 2007 Aug 14.
The objective was to evaluate the effect of an assessment strategy using the computer decision support system (the GRAIDS software), on the management of familial cancer risk in British general practice in comparison with best current practice. The design included cluster randomised controlled trial, and involved forty-five general practice teams in East Anglia, UK. Randomised to GRAIDS (Genetic Risk Assessment on the Internet with Decision Support) support (intervention n=23) or comparison (n=22). Training in the new assessment strategy and access to the GRAIDS software (GRAIDS arm) was conducted, compared with an educational session and guidelines about managing familial breast and colorectal cancer risk (comparison) were mailed. Outcomes were measured at practice, practitioner and patient levels. The primary outcome measure, at practice level, was the proportion of referrals made to the Regional Genetics Clinic for familial breast or colorectal cancer that were consistent with referral guidelines. Other measures included practitioner confidence in managing familial cancer (GRAIDS arm only) and, in patients: cancer worry, risk perception and knowledge about familial cancer. There were more referrals to the Regional Genetics Clinic from GRAIDS than comparison practices (mean 6.2 and 3.2 referrals per 10 000 registered patients per year; mean difference 3.0 referrals; 95% confidence interval (CI) 1.2-4.8; P=0.001); referrals from GRAIDS practices were more likely to be consistent with referral guidelines (odds ratio (OR)=5.2; 95% CI 1.7-15.8, P=0.006). Patients referred from GRAIDS practices had lower cancer worry scores at the point of referral (mean difference -1.44 95% CI -2.64 to -0.23, P=0.02). There were no differences in patient knowledge about familial cancer. The intervention increased GPs' confidence in managing familial cancer. Compared with education and mailed guidelines, assessment including computer decision support increased the number and quality of referrals to the Regional Genetics Clinic for familial cancer risk, improved practitioner confidence and had no adverse psychological effects in patients. Trials are registered under N0181144343 in the UK National Research Register.
目的是评估使用计算机决策支持系统（GRAIDS软件）的评估策略与当前最佳实践相比，对英国全科医疗中家族性癌症风险管理的效果。设计包括整群随机对照试验，涉及英国东安格利亚的45个全科医疗团队。随机分为GRAIDS（互联网遗传风险评估与决策支持）支持组（干预组n = 23）或对照组（n = 22）。对干预组进行新评估策略的培训并提供GRAIDS软件，对照组则邮寄关于家族性乳腺癌和结直肠癌风险管理的教育课程及指南。在医疗机构、从业者和患者层面进行结果测量。在医疗机构层面，主要结果指标是转诊至区域遗传学诊所的家族性乳腺癌或结直肠癌病例中符合转诊指南的比例。其他指标包括从业者对家族性癌症管理的信心（仅干预组），以及患者的癌症担忧、风险认知和对家族性癌症的了解。与对照组相比，GRAIDS组转诊至区域遗传学诊所的病例更多（每年每10000名注册患者的平均转诊数分别为6.2例和3.2例；平均差异3.0例；95%置信区间（CI）1.2 - 4.8；P = 0.001）；GRAIDS组的转诊更有可能符合转诊指南（优势比（OR）= 5.2；95% CI 1.7 - 15.8，P = 0.006）。GRAIDS组转诊的患者在转诊时的癌症担忧得分较低（平均差异 - 1.44，95% CI - 2.64至 - 0.23，P = 0.02）。患者对家族性癌症的了解没有差异。该干预提高了全科医生对家族性癌症管理的信心。与教育和邮寄指南相比，包括计算机决策支持的评估增加了转诊至区域遗传学诊所进行家族性癌症风险评估的数量和质量，提高了从业者的信心，且对患者没有不良心理影响。该试验在英国国家研究注册库中注册号为N0181144343。
