San Francisco Veterans Affairs Health Care System, San Francisco, California.
University of California, San Francisco, School of Medicine, San Francisco.
JAMA Netw Open. 2022 Apr 1;5(4):e226687. doi: 10.1001/jamanetworkopen.2022.6687.
Telehealth enables access to genetics clinicians, but impact on care coordination is unknown.
To assess care coordination and equity of genetic care delivered by centralized telehealth and traditional genetic care models.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included patients referred for genetic consultation from 2010 to 2017 with 2 years of follow-up in the US Department of Veterans Affairs (VA) health care system. Patients were excluded if they were referred for research, cytogenetic, or infectious disease testing, or if their care model could not be determined.
Genetic care models, which included VA-telehealth (ie, a centralized team of genetic counselors serving VA facilities nationwide), VA-traditional (ie, a regional service by clinical geneticists and genetic counselors), and non-VA care (ie, community care purchased by the VA).
Multivariate regression models were used to assess associations between patient and consultation characteristics and the type of genetic care model referral; consultation completion; and having 0, 1, or 2 or more cancer surveillance (eg, colonoscopy) and risk-reducing procedures (eg, bilateral mastectomy) within 2 years following referral.
In this study, 24 778 patients with genetics referrals were identified, including 12 671 women (51.1%), 13 193 patients aged 50 years or older (53.2%), 15 639 White patients (63.1%), and 15 438 patients with cancer-related referrals (62.3%). The VA-telehealth model received 14 580 of the 24 778 consultations (58.8%). Asian patients, American Indian or Alaskan Native patients, and Hawaiian or Pacific Islander patients were less likely to be referred to VA-telehealth than White patients (OR, 0.54; 95% CI, 0.35-0.84) compared with the VA-traditional model. Completing consultations was less likely with non-VA care than the VA-traditional model (OR, 0.45; 95% CI, 0.35-0.57); there were no differences in completing consultations between the VA models. Black patients were less likely to complete consultations than White patients (OR, 0.84; 95% CI, 0.76-0.93), but only if referred to the VA-telehealth model. Patients were more likely to have multiple cancer preventive procedures if they completed their consultations (OR, 1.55; 95% CI, 1.40-1.72) but only if their consultations were completed with the VA-traditional model.
In this cross-sectional study, the VA-telehealth model was associated with improved access to genetics clinicians but also with exacerbated health care disparities and hindered care coordination. Addressing structural barriers and the needs and preferences of vulnerable subpopulations may complement the centralized telehealth approach, improve care coordination, and help mitigate health care disparities.
远程医疗使人们能够获得遗传临床医生的服务，但尚不清楚其对医疗协调的影响。
评估集中式远程医疗和传统遗传护理模式提供的遗传护理的协调性和公平性。
设计、地点和参与者：这项横断面研究纳入了 2010 年至 2017 年期间因遗传咨询而转诊至美国退伍军人事务部（VA）医疗保健系统的患者，并在该系统中随访了 2 年。如果患者是为了研究、细胞遗传学或传染病检测而转诊，或者无法确定其护理模式，则将其排除在外。
遗传护理模式，包括 VA-远程医疗（即，为全美 VA 设施提供服务的集中式遗传咨询师团队）、VA-传统医疗（即，由临床遗传学家和遗传咨询师提供的区域性服务）和非 VA 护理（即，VA 购买的社区护理）。
使用多变量回归模型评估患者和咨询特征与遗传护理模式转诊之间的关联；咨询完成情况；以及在转诊后 2 年内是否进行了 0、1 或 2 次或更多次癌症监测（例如结肠镜检查）和降低风险的程序（例如双侧乳房切除术）。
在这项研究中，确定了 24778 名接受遗传学转诊的患者，其中包括 12671 名女性（51.1%）、13193 名 50 岁或以上的患者（53.2%）、15639 名白人患者（63.1%）和 15438 名癌症相关转诊患者（62.3%）。24778 次咨询中有 14580 次是由 VA-远程医疗模式接收的（58.8%）。与传统的 VA 模式相比，亚裔患者、美国印第安人或阿拉斯加原住民患者和夏威夷或太平洋岛民患者被转诊至 VA-远程医疗模式的可能性较小（OR，0.54；95%CI，0.35-0.84）。与传统的 VA 模式相比，非 VA 护理完成咨询的可能性较低（OR，0.45；95%CI，0.35-0.57）；VA 模式之间咨询完成情况无差异。与白人患者相比，黑人患者完成咨询的可能性较小（OR，0.84；95%CI，0.76-0.93），但前提是他们被转诊至 VA-远程医疗模式。如果完成咨询，患者更有可能进行多次癌症预防程序（OR，1.55；95%CI，1.40-1.72），但前提是咨询是通过 VA-传统模式完成的。
在这项横断面研究中，VA-远程医疗模式与更容易获得遗传临床医生的服务相关，但也与加剧的医疗保健差距和阻碍医疗协调相关。解决结构性障碍以及脆弱人群的需求和偏好可能会补充集中式远程医疗方法，改善医疗协调，并有助于减轻医疗保健差距。
