Innovative Family History Strategy: A Multi-Method Study

Problem

A complete, up-to-date family history (FH) is imperative in primary care (PC). Identification of high-risk individuals may enable appropriate follow-up including personalized screening and management and possibly genetic testing. Complete FH is rarely documented in the electronic medical record (EMR).

Our study aim was to evaluate an innovative strategy to collect FH, explore patients’ and family physicians’ (FP) views of this strategy and its potential implementation in Canadian family Practice .

Approach

Mixed-methods study within a matched-paired randomized controlled trial in family practices affiliated with the University of Toronto Practice-Based Research Network (UTOPIAN). Intervention group: FPs from randomly selected practices using OCEAN emailing platform with PSS EMR, randomly selected patients aged 30-69y (4/week/FP) seen in clinic over 6 months. Matched control physicians (1:1) and patients (5:1) from UTOPIAN database. Intervention consisted of patient and FP education, emailed patient invitation to complete validated FH questionnaire, automatic FH EMR upload, FP notification of completed FH and links to clinical support tools. Intervention patients were emailed follow-up questionnaires 3 days following their clinic visit. Participating FPs were invited for telephone interviews. Outcome measures: New documentation of FH in EMR within 30 days of clinic visit using mixed effects logistic regression; descriptive statistics for patient attitudes and FP follow-up actions; descriptive thematic analysis of FP interviews.

Findings

15 FPs and 576 patients recruited from 3 practices to intervention group, matched to 15 FPs and 2203 patients in the control group. Within 30 days of clinic visit, new FH was documented in EMR for 16.1% (93/576) of intervention patients compared to 0.2% (5/2203) control patients (OR=94.2; 95% CI 36.8, 240.8). New documentation of cancer FH was higher in the intervention group (7.8% vs 0.1%, OR=85.3, 95% CI 20.5, 354.4). Of patients who discussed FH at the visit (n=296), 25% reported screening test recommended, 8% referral to non-genetics specialist and 2% referral to genetics. Most patients (61%) found this FH strategy helpful. Six major themes were identified in FP interviews: 1) Clinical value of FH; 2) A new way to opportunistically collect FH by leveraging technology; 3) Facilitated rich FH discussions; 4) Increased awareness, knowledge and confidence regarding management of positive FH; 5) Led to clinically relevant management; 6) Implementation needs to be tailored to practice context.

Consequences

This study demonstrated significant improvement in collection/documentation of FH. Patients welcomed the opportunity to provide FH information prior to appointments. FPs expressed the importance of routine FH collection and its implications for clinical management. Factors contributing to the intervention’s success included being patient-completed and seamless EMR integration with a reminder. The intervention needs tailoring to different contexts.