ÌÇÐÄvlog

It is critical to develop targeted interventions to address barriers that impede appropriate BRCA1/2 referrals to genetic counselors from primary care clinicians following US Preventive Services Task Force (USPSTF) guidelines.¹ We conducted a cluster randomized clinical trial (Genomics for Breast Cancer in Primary Care [BEATRICE]) of patient and clinician decision support to increase BRCA1/2 genetic referrals based on USPSTF guidelines. The study design, patient-level characteristics, and results have been published previously.^2,3 Here, we report the effectiveness of the intervention on clinician outcomes.

The Columbia University Irving Medical Center Institutional Review Board approved this secondary analysis of BEATRICE (); the trial protocol is provided in Supplement 1. Participants provided electronic informed consent. We followed the reporting guideline.

Data were obtained from clinicians who completed baseline and 6-month surveys (eMethods in Supplement 2). Surveys assessed demographics, practice characteristics, and predictors of genetic counseling referral behavior (attitudes, subjective norms, and perceived behavior control), informed by the theory of planned behavior.⁴ Baseline surveys of clinicians who did not complete the 6-month survey were compared with those who did, with no significant differences. We examined frequency distributions of clinician baseline and 6-month survey outcomes and participant demographic characteristics. We compared both groups using χ² tests for categorical variables and t tests (or Wilcoxon rank-sum tests when nonparametric) for continuous variables; 2-sided P < .05 was statistically significant. Analyses were performed using SAS, version 9.4 (SAS Institute).

Of 85 clinicians enrolled, 74 (87.0%) completed baseline and 6-month surveys and were included in this analysis. Clinicians (mean [SD] age, 43.1 [12.4] years) were diverse in terms of specialty and race and ethnicity (Table 1). Most were women (67 [90.5%] vs 7 men [9.5%]), and most (53 [71.6%]) practiced in community clinics serving predominantly Medicaid or Medicare patients. At baseline, 33 clinicians (44.6%) reported being moderately or very confident in counseling patients regarding inherited risk; 23 (31.1%) reported being moderately or very confident in discussing possible management options according to risk. With respect to subjective norms, having assessed patient risk for hereditary breast and ovarian cancer (HBOC), 52 clinicians (70.3%) reported that most other clinicians would expect them to make a referral to genetic testing services; 32 (43.2%) reported that patients would expect them to make a referral. Regarding perceived behavioral control, 24 clinicians (32.4%) reported that it would be very or somewhat difficult to refer patients to genetic testing services after assessing patient risk for HBOC (mean [SD] score, 4.4 [1.5]).

At 6 months, we found significant differences in clinician confidence in discussing possible management options according to patient risk (Table 2). Confidence was higher among the intervention vs control groups (13 [34.2%] vs 5 [13.9%] were moderately or very confident; P = .04). We also observed significant differences in subjective norms, with intervention clinicians more likely than control clinicians to agree or strongly agree with the patient’s expectation of making a referral to genetic testing services (mean [SD] score, 5.2 [1.1] vs 4.7 [1.1]; P = .02). We observed significant differences between the intervention vs control groups in perceived behavioral control to make a referral to genetic testing services after assessing patient risk for HBOC (mean [SD] score, 5.3 [1.5] vs 4.6 [4.6]; P = .02).

These findings suggest that patient and clinician decision support could affect clinician outcomes (including confidence, perceived behavioral control, and subjective norms) that are associated with behavioral intention and enactment.⁴ The implications of these findings for designing interventions support the need to target theoretically informed barriers, moving beyond clinician education alone, which has been shown to have minimal effect on clinician adoption of clinical genetic practices.⁵ Study limitations include recruitment from a single institution and the moderate sample size; additionally, larger system-level barriers were not examined, and the self-reported data may be limited by response options. Additional studies are needed to examine the effectiveness of theoretically informed decision support interventions in the context of referral decision-making to genetic counseling services.

Accepted for Publication: August 29, 2024.

Published: October 24, 2024. doi:10.1001/jamanetworkopen.2024.41175

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Kukafka R et al. ÌÇÐÄvlog Open.

Corresponding Author: Rita Kukafka, DrPH, MA, Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, 622 W 168th St, New York, NY 10032 (rk326@cumc.columbia.edu).

Author Contributions: Dr Kukafka had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kukafka, Silverman, Terry, Fleck, Dimond, Crew.

Acquisition, analysis, or interpretation of data: Kukafka, Pan, Chung, Younge, Dimond, Crew.

Drafting of the manuscript: Kukafka, Pan.

Critical review of the manuscript for important intellectual content: Kukafka, Silverman, Chung, Terry, Fleck, Younge, Dimond, Crew.

Statistical analysis: Kukafka, Pan, Silverman.

Obtained funding: Kukafka, Crew.

Administrative, technical, or material support: Kukafka, Silverman, Terry, Dimond.

Supervision: Kukafka, Silverman.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by grant RSG-17-103-01-CPPB from the American Cancer Society.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.