Achieving behaviour change for detection of Lynch syndrome using the Theoretical Domains Framework Implementation (TDFI) approach: A study protocol

© 2016 Taylor et al. Background: Lynch syndrome is an inherited disorder associated with a range of cancers, and found in 2-5 % of colorectal cancers. Lynch syndrome is diagnosed through a combination of significant family and clinical history and pathology. The definitive diagnostic germline test requires formal patient consent after genetic counselling. If diagnosed early, carriers of Lynch syndrome can undergo increased surveillance for cancers, which in turn can prevent late stage cancers, optimise treatment and decrease mortality for themselves and their relatives. However, over the past decade, international studies have reported that only a small proportion of individuals with suspected Lynch syndrome were referred for genetic consultation and possible genetic testing. The aim of this project is to use behaviour change theory and implementation science approaches to increase the number and speed of healthcare professional referrals of colorectal cancer patients with a high-likelihood risk of Lynch syndrome to appropriate genetic counselling services. Methods: The six-step Theoretical Domains Framework Implementation (TDFI) approach will be used at two large, metropolitan hospitals treating colorectal cancer patients. Steps are: 1) form local multidisciplinary teams to map current referral processes; 2) identify target behaviours that may lead to increased referrals using discussion supported by a retrospective audit; 3) identify barriers to those behaviours using the validated Influences on Patient Safety Behaviours Questionnaire and TDFI guided focus groups; 4) co-design interventions to address barriers using focus groups; 5) co-implement interventions; and 6) evaluate intervention impact. Chi square analysis will be used to test the difference in the proportion of high-likelihood risk Lynch syndrome patients being referred for genetic testing before and after intervention implementation. A paired t-test will be used to assess the mean time from the pathology test results to referral for high-likelihood Lynch syndrome patients pre-post intervention. Run charts will be used to continuously monitor change in referrals over time, based on scheduled monthly audits. Discussion: This project is based on a tested and refined implementation strategy (TDFI approach). Enhancing the process of identifying and referring people at high-likelihood risk of Lynch syndrome for genetic counselling will improve outcomes for patients and their relatives, and potentially save public money

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Referral as imagined versus referral as done: mapping the referral process for genetic counselling for Lynch syndrome patients

AuthorsDeborah Debono, Natalie Taylor, Janet Long, Jeffrey Braithwaite, Melvin Chin, Rachel Williams, Elizabeth Salisbury, Sharron O'Neill, Tracey Dunlop, Kim-Chi Phan-Thien, Elizabeth EykmanBackgroundCancer patients with a high risk of LS can take a genetic test, enabling carriers to undertake effective surveillance, detect and treat cancer early and educate relatives. Early diagnosis of LS can save lives. However, less than half of NSW CRC patients with high risk of LS are referred for genetic testing. Given the opportunity to improve the referral process for genetic testing for LS where would we begin? According to Deming (1900– to 93), "If people do not see the process, they cannot improve it. "Process mapping creates a visual representation of the actors, steps, and decisions involved in a process. To improve the referral process for genetic testing, we first need to identify and visualise the process.AimsTo co-develop at two hospitals a map of the current referral process for genetic counselling of CRC patients with a high likelihood of LS.MethodSix face-to-face process mapping sessions were conducted with key healthcare professionals involved in the referral process for genetic counselling for testing for LS. Initially the limits of the referral process were determined and a narrative outline of the steps illustrated using Visio software. During subsequent sessions exploratory questions (e.g. 'and then what happens?') were used to co-develop the process map. Information was gathered on the sequence of activities, actors, artefacts and decision points. Feedback on process map iterations also contributed to its development.ResultsTo date there have been eight iterations of the process map. Co-mapping the referral process has: highlighted steps of the process at which data can be collected to validate the process map and to measure the effect of improvement strategies; highlighted work as imagined versus work as done; helped to create a shared understanding of the current process; and illuminated potential barriers for further exploration. The process map and associated data will be presented.ImplicationsCo-developing a process map provides a powerful tool to increase a shared understanding of the current referral process and to highlight potential targets for improvement

Using behaviour change and implementation science to address low referral rates in oncology 11 Medical and Health Sciences 1117 Public Health and Health Services

© 2018 The Author(s). Background: Patients undergoing surgery for bowel cancer now have a routine screening test to assess their genetic predisposition to this and other cancers (Lynch syndrome). A result indicating a high risk should trigger referral to a genetic clinic for diagnostic testing, information, and management. Appropriate management of Lynch syndrome lowers morbidity and mortality from cancer for patients and their family, but referral rates are low. The aim of this project was to increase referral rates for patients at high risk of Lynch syndrome at two Australian hospitals, using the Theoretical Domains Framework (TDF) Implementation approach. Methods: Multidisciplinary teams at each hospital mapped the referral process and discussed barriers to referral. A 12-month retrospective audit measured baseline referral rates. The validated Influences on Patient Safety Behaviours Questionnaire was administered to evaluate barriers using the TDF. Results were discussed in focus groups and interviews, and interventions co-designed, guided by theory. Continuous monitoring audits assessed change in referral rates. Results: Teams (n = 8, 11) at each hospital mapped referral processes. Baseline referral rates were 80% (4/5) from 71 screened patients and 8% (1/14) from 113 patients respectively. The questionnaire response rate was 51% (36/71). Most significant barrier domains were: 'environmental context;' 'memory and decision making;' 'skills;' and 'beliefs about capabilities.' Focus groups and interviews with 19 healthcare professionals confirmed these domains as significant. Fifteen interventions were proposed considering both emerging and theory-based results. Interventions included: clarification of pathology reports, education, introduction of e-referrals, and inclusion of genetic status in documentation. Audits continued to December 2016 showing a change in pathology processes which increased the accuracy of screening. The referral rate remained low: 46% at Hospital A and 9% Hospital B. Results suggest patients who have their referral deferred for some reason are not referred later. Conclusion: Lynch syndrome is typical of low incidence problems likely to overwhelm the system as genomic testing becomes mainstream. It is crucial for health researchers to test methods and define generalizable solutions to address this problem. Whilst our approach did not improve referrals, we have deepened our understanding of barriers to referral and approaches to low frequency conditions