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J Gen Intern Med. 2018 Jun;33(6):877-885. doi: 10.1007/s11606-017-4295-4. Epub 2018 Jan 26.

How Primary Care Providers Talk to Patients about Genome Sequencing Results: Risk, Rationale, and Recommendation.

Author information

1
Section of General Internal Medicine, VA Boston Healthcare System, Boston, MA, USA. jvassy@partners.org.
2
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA. jvassy@partners.org.
3
Department of Medicine, Harvard Medical School, Boston, MA, USA. jvassy@partners.org.
4
Margolis Center for Health Policy, Duke University, Durham, NC, USA.
5
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
6
Department of Medicine, Harvard Medical School, Boston, MA, USA.
7
Division of Genetics, Brigham and Women's Hospital, Boston, MA, USA.
8
Broad Institute of MIT and Harvard, Cambridge, MA, USA.
9
Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA.
10
Fuqua School of Business, Sanford School of Public Policy, School of Medicine, Duke University, Durham, NC, USA.

Abstract

BACKGROUND:

Genomics will play an increasingly prominent role in clinical medicine.

OBJECTIVE:

To describe how primary care physicians (PCPs) discuss and make clinical recommendations about genome sequencing results.

DESIGN:

Qualitative analysis.

PARTICIPANTS:

PCPs and their generally healthy patients undergoing genome sequencing.

APPROACH:

Patients received clinical genome reports that included four categories of results: monogenic disease risk variants (if present), carrier status, five pharmacogenetics results, and polygenic risk estimates for eight cardiometabolic traits. Patients' office visits with their PCPs were audio-recorded, and summative content analysis was used to describe how PCPs discussed genomic results.

KEY RESULTS:

For each genomic result discussed in 48 PCP-patient visits, we identified a "take-home" message (recommendation), categorized as continuing current management, further treatment, further evaluation, behavior change, remembering for future care, or sharing with family members. We analyzed how PCPs came to each recommendation by identifying 1) how they described the risk or importance of the given result and 2) the rationale they gave for translating that risk into a specific recommendation. Quantitative analysis showed that continuing current management was the most commonly coded recommendation across results overall (492/749, 66%) and for each individual result type except monogenic disease risk results. Pharmacogenetics was the most common result type to prompt a recommendation to remember for future care (94/119, 79%); carrier status was the most common type prompting a recommendation to share with family members (45/54, 83%); and polygenic results were the most common type prompting a behavior change recommendation (55/58, 95%). One-fifth of recommendation codes associated with monogenic results were for further evaluation (6/24, 25%). Rationales for these recommendations included patient context, family context, and scientific/clinical limitations of sequencing.

CONCLUSIONS:

PCPs distinguish substantive differences among categories of genome sequencing results and use clinical judgment to justify continuing current management in generally healthy patients with genomic results.

KEYWORDS:

genome sequencing; medical decision-making; physician communication

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