Counseling Appointment Research Articles

A smartphone-smartcard platform for contingency management in an inner-city substance use disorder outpatient program

Contingency management (CM) is an efficacious incentive-based intervention for promoting drug abstinence, but treatment providers have not widely adopted it. Smartphone and smart debit card technologies can deliver automated, patient-centered, high-fidelity CM and related services, including cognitive behavioral therapy and appointment reminders. This study evaluated clinical outcomes associated with an integrated smartphone-smartcard platform in an inner-city outpatient clinic. We enrolled adults with opioid use disorder (n = 85) over nine weeks, and they received CM services for four months. We retrospectively compared them to matched controls who received services at the same time, from the same provider at a similar, nearby clinic in the same city. The platform was associated with significantly higher rates of counseling appointment attendance in study months 2 to 4 (9.6%–18.0% increases) and an odds ratio of 4.84 for increased proportion of urine samples consistent with drug abstinence and adherence to prescribed medication, compared to controls at 120 days (P < 0.05). Overwhelmingly, participants reported that they found the platform acceptable. These results suggest that the platform is an effective method for remote delivery of CM services that could overcome key logistical barriers to widespread adoption of CM among treatment providers.

Prenatal tests for chromosomal abnormalities detection (PTCAD): pregnant women's knowledge in an Italian Population.

Nowadays several Prenatal Tests for Chromosomal Abnormalities Detection (PTCAD) are available. In those cases in which there is not an Institutional protocol to advise women about the available PTCAD, the choice of which one to undergo is up to the woman and largely depends on her knowledge about them. Therefore, we decided to evaluate, as a primary outcome, knowledge about PTCAD among pregnant women attending our Term Clinic. As a secondary outcome we evaluated the relationship between the patient's knowledge and the subsequently chosen PTCAD. From August 2017 to August 2018 an anonymous questionnaire with multiple-choice answers was administered to all pregnant women attending our Term antenatal Clinic, a tertiary obstetric unit in Catanzaro (Italy). Three hundred and twenty-five pregnant women were enrolled in the study. We observed that 28.8% of the pregnant women that chose one of the PTCAD, avoided the first trimester combined screening test; among these, 11.4% were in favour of the cell-free foetal DNA test. The latter was erroneously considered diagnostic by 34.3% of the women that had chosen it. This study demonstrated that women's knowledge about PTCAD is poor and that there is a potentially dangerous confusion between the words 'screening' and 'diagnostic'. Informative campaigns about PTCAD and the application of dedicated antenatal counselling appointments should be a health-care priority to avoid unnecessary risks and costs for pregnant women and possible legal issues.

Impact of increased understanding of personal and family health history on patients.

256 Background: The InheRET personal and family health history survey was administered to 384 patients at three Michigan Medicine Clinics (2 primary care (11% of patients) and one breast and ovarian cancer risk clinic (89% of patients)) between October 1, 2018 and May 31, 2019. Since family history alone misses ~30% of those with deleterious germline mutations, this study follows these patients to determine what, if any, impact completion of the histories had on patients’ lifestyle choices, cancer prevention screenings, and risk-reducing therapies adopted based on perceived risk status: Meeting or not meeting NCCN Guidelines for referral to genetics for further evaluation. Methods: One year after patients completed their health histories, a follow-up survey was emailed to patients inquiring into actions taken following completion of the InheRET health history form. Anonymous responses were automatically collected into a Google Datasheet and analyzed. Results: As of June 16, 2020, 61 patients had returned their surveys; 37 (60.7%) reported being referred to a genetics specialist, of whom 92% kept their counseling appointments and 100% of these were recommended to be tested. At the time of survey completion, 29 patients had been tested and 32 patients had not been tested. We analyzed the actions taken between these two groups and discovered that 75% of patients who did not meet NCCN Guidelines and were not recommended for counseling and testing (population risk patients) still made lifestyle changes to improve their health and engaged in at least one cancer screening activity in the past year to reduce their cancer risk. The only preventive medical treatments received by this group were Tamoxifen (12.9%) and Hormone Replacement Therapy (3.2%). Among patients meeting NCCN Guidelines and tested (4 positive, 17 negative, 8 inconclusive/VUS/unknown results), 58.6% made positive lifestyle choices, 86.5% engaged in one or more cancer screening activities, and 34.5% sought additional medical interventions such as chemoprevention, hormone replacement and/or prophylactic surgery. Conclusions: By learning more about their personal and family health histories, patients who did not meet referral guidelines and were not referred for counseling and testing were proactive in taking actions to improve their overall health and reduce their cancer risk. This demonstrates the importance of knowing and understanding one’s family health history, even for those not meeting NCCN referral guidelines.

Increased Protein Density During Weight Loss Is Correlated with Reduced Abdominal Obesity and Body Mass Index and Improved Body Composition

Abstract Objectives There is a clear link between abdominal obesity and chronic diseases. Dietary changes leading to substantial weight loss reduce obesity and improve health; however, no viable dietary treatment program exists that produces clinically significant, cost-effective, and sustainable weight loss. To test the hypothesis that a diet dense in lean proteins and fiber is inversely associated with abdominal obesity while maintaining skeletal muscle mass (SMM), we evaluated the correlation between mean protein and fiber density and changes in BMI, waist circumference and SMM during weight loss. Methods Thirty adult males and females participated in this ongoing, 2-year dietary weight loss program. The Individualized Dietary Improvement Program focused on reducing caloric intake and increasing protein (7–11 g/100 kcal) and fiber (1.8–3.2 g/100 kcal) density to desired ranges. Participants attended 19 group educational sessions, 3 individual counseling appointments, self-weighed daily, and submitted monthly 24-hour dietary recalls. BMI, waist circumference and body composition (InBody) measurements were collected at baseline and after 6 months. Results At 6 months, 25 participants (24–70y) remained in the study with 18 completing all body measurements. Mean weight loss (n = 25) was −2.2 ± 0.5 BMI points (–5.2 ± 1.3% of initial body weight) and mean waist circumference reduction (n = 18) was −6.5 ± 1.3 cm from baseline. Significant increases in protein and fiber density were seen from baseline to month 2 (P &amp;lt; 0.05). There were direct inverse associations between mean protein density and both reduced waist circumference (P &amp;lt; 0.01) and reduced BMI (P &amp;lt; 0.01). Fiber intake had no significant impact on weight loss, and maintenance of SMM did not significantly correlate with mean protein density. However, only 11.0 ± 3.2% of weight lost was due to the loss of SMM, supporting the efficacy of the program. A significant positive correlation (P &amp;lt; 0.01) existed between fat mass loss and protein density, with 74.3 ± 4.7% of excess body fat accounting for total weight lost. Conclusions Increased protein density correlates with accelerated loss of fat mass, greater reductions in abdominal adiposity, and may protect SMM from degradation during weight loss. Funding Sources This research is supported by the NIBIB of the NIH and the USDA NIFA.

Genetic Counseling Referrals for Gynecologic Oncology, Are We Missing Opportunities? [29H

INTRODUCTION: NCCN and SGO recommend genetic evaluation for women with epithelial ovarian cancer (EOC) and certain endometrial cancer (EC) patients. Despite guidelines, patients are not consistently receiving referrals. Our primary aim was to evaluate if patients at a tertiary care center were being referred per recommendations. Secondary aims were to determine demographic, socioeconomic or pathologic differences associated with referrals. METHODS: This is a retrospective cohort study of all patients diagnosed with EOC, EC before age 50, or EC with mismatch repair deficiency on tumor testing at a tertiary referral center between 2009 and 2018. Rates of referrals were calculated. Descriptive statistics compared patients who were and were not referred to genetics. A multivariable model was fit to identify potential predictive variables. RESULTS: 275 women were included (58 EC 217 EOC); per guidelines, 100% should have received referrals. Overall, 34.5% of the population were referred. 15.5% EC vs 39.6% EOC patients received referrals. On univariate analyses, family history, EOC diagnosis, grade and histology were the only variables that differed between those who were and weren't referred. Race, ethnicity, age, BMI, language spoken, insurance status, and stage were not associated with referral rates. EOC diagnosis and family history were the only independently associated variables on multivariable regression. Of referred patients, 73.8% attended genetic counseling appointments. CONCLUSION: Patients with epithelial ovarian and endometrial cancers are referred to genetics less frequently than recommended. The majority of patients who were referred attended the appointment. Family history was the only variable independently associated with referral.

ON THE ROLE OF THE STATE IN ENSURING EFFECTIVE DEFENSE IN CRIMINAL PROCEEDINGS FOR THE PURPOSES OF THE PRACTICE OF THE EUROPEAN COURT OF HUMAN RIGHTS

The article presents the issues on ensuring effective defense in criminal proceedings. Analysis of international legal documents, generalization of the practice of the European Court of Human Rights give grounds to divide international legal standards, that have been formed to facilitate the enforcement of the right to defense, into the following groups: 1) standards designed to facilitate the effectiveness of the defense by the accused him- or herself; 2) standards facilitating effective defense by the defense counsel; 3) standards, the adoption of which contributes to the effective defense maintained by the defense (when the defense is conducted jointly by the accused and the defense counsel) 4) standards that contain requirements for the state or its bodies and compel them to ensure the possibility of effective defense. The latter group of standards is important among others because the conduct of defense seems impossible without imposing certain requirements on the state and its bodies, and fixed guarantees of effective defense will turn into a declaration. The study of the case law of the European Court of Human Rights on maintaining effective defense in criminal proceedings allows us to state the lack of unity in its legal positions, since the issue of the effectiveness of ensuring the human right to defense in criminal proceedings depends on the specific circumstances of the case. The court notes that, on the one hand, the state can only intervene in the activities of defense counsel within the limits of public interests, given the independent nature of the legal profession. On the other hand, it cannot stand aside in the event of the discovery of violations of the standards for the conduct of defense in criminal proceedings, which assigns it a special role in maintaining effective defense for the suspect, the accused in criminal proceedings. Based on the analysis of the decisions of the European Court of Human Rights, standards are identified that contain requirements for the state or its bodies and compel them to ensure the possibility of effective defense: 1) the obligation of the state to conduct real (not illusionary or formal) defense for the suspect, the accused, since the appointment of a defense counsel does not ensure maintaining effective legal services; 2) the obligation to provide the defense team with the time and opportunity to conduct effective defense.

Facilitated referral pathway for genetic testing at the time of ovarian cancer diagnosis: uptake of genetic counseling and testing and impact on patient-reported stress, anxiety and depression

BackgroundTimely genetic testing at ovarian cancer diagnosis is essential as results impact front line treatment decisions. Our objective was to determine rates of genetic counseling and testing with an expedited genetics referral pathway wherein women with newly-diagnosed ovarian cancer are contacted by a genetics navigator to facilitate genetic counseling. MethodsPatients were referred for genetic counseling by their gynecologic oncologist, contacted by a genetics navigator and offered appointments for genetic counseling. Patients completed quality of life (QoL) surveys immediately pre- and post-genetic assessment and 6 months later. The primary outcome was feasibility of this pathway defined by presentation for genetic counseling. ResultsFrom 2015 to 2018, 100 patients were enrolled. Seventy-eight had genetic counseling and 73 testing. Median time from diagnosis to genetic counseling was 34 days (range 10–189). Among patients who underwent testing, 12 (16%) had pathogenic germline mutations (BRCA1-7, BRCA2-4, MSH2-1). Sixty-five patients completed QoL assessments demonstrating stress and anxiety at time of testing, however, scores improved at 6 months. Despite the pathway leveling financial and logistical barriers, patients receiving care at a public hospital were less likely to present for genetic counseling compared to private hospital patients (56% versus 84%, P = 0.021). ConclusionsFacilitated referral to genetic counselors at time of ovarian cancer diagnosis is effective, resulting in high uptake of genetic counseling and testing, and does not demonstrate a long term psychologic toll. Concern about causing additional emotional distress should not deter clinicians from early genetics referral as genetic testing can yield important prognostic and therapeutic information.

Housing Defense as the New Gideon

New York City has become the first jurisdiction in the United States to create a right to appointed counsel for poor people facing eviction. This Article draws on NYC’s housing defense statute to highlight three ways in which the creation of a civil right to counsel has the potential to build on and expand beyond the Gideon v. Wainwright model. The right to appointment of criminal defense counsel, as recognized in Gideon, was part of the Supreme Court’s indirect response to the Civil Rights Movement. In contrast, the NYC legislature openly promotes substantive outcomes, explicitly targeting eviction and its secondary effects. Additionally, the legislature’s focus on housing recognizes concerns that disproportionately impact Black women; this echoes the racial equality goal underlying Gideon and promotes gender equality. Finally, while the criminal defense model defends individuals against only state power, NYC’s right to housing defense counsel includes tenants of private landlords and thereby checks private power. All three of these features are worth attention from legislatures considering expansion of the right to civil counsel. The Article also identifies one important way in which the new model of appointment of housing counsel is like the criminal model for appointment: NYC’s legislation addresses appointment of defense lawyers, as opposed to lawyers for plaintiffs, potential plaintiffs, or people engaged in non-litigation matters. This Article argues that the focus on defense lawyering limits the impact of appointment of counsel. Defense lawyering suffers from systemic limitations that influence litigation strategy and the potential to collaborate with social movements. With respect to the substantive goal of housing preservation, problems like discrimination, harassment, and dangerous conditions also pose significant threats and could be more robustly addressed through affirmative suits. In spite of recognizing the limits of defense lawyering, this Article concludes that the availability of counterclaims in civil litigation makes civil defense more flexible than criminal defense. As a result, civil defense might be able to do more than criminal defense to challenge the status quo and advance substantive improvements for poor litigants.

Meeting the Mandates of Gault: Automatic Appointment of Counsel in Juvenile Delinquency Proceedings

AbstractIn 1967, the United States Supreme Court ruled that children facing delinquency charges have a constitutional right to defense counsel. Despite that mandate, state assessments of juvenile defense systems have consistently found high rates of waiver of counsel. Children are facing harsh punishments with potentially lifelong consequences without the benefit of a trained defense attorney at their side. Given the severity of the consequences of juvenile court involvement and society’s understanding of the developmental science behind adolescence, this article argues that to meet constitutional requirements, juvenile courts must automatically appoint defense counsel for all children facing delinquency charges.

Health disparities between genderqueer, transgender, and cisgender individuals: An extension of minority stress theory.

Interpersonal, social, and structural stressors have been identified as key elements that explain health disparities between transgender and cisgender individuals. However, most of this research has focused on binary transgender individuals or has not differentiated between binary and nonbinary individuals; little research has examined the experiences of minority stress or health of those identifying outside the gender binary. Guided by intersectionality and drawing on a sample of 3,568 college students from the Center for Collegiate Mental Health's 2012-2016 database-of whom 892 identified outside the gender binary-we conducted analyses of demographic and outcome measures administered in participants' 1st counseling appointment, examining differences between cisgender, transgender, and genderqueer individuals. We found that genderqueer individuals were harassed, sexually abused, and subjected to traumatic events at higher rates than were either cisgender or binary transgender individuals, with approximately 50% of genderqueer individuals reporting one of these experiences. We found that genderqueer individuals experienced more anxiety, depression, psychological distress, and eating concerns than did binary transgender and cisgender individuals and more social anxiety than did cisgender individuals. Genderqueer individuals more frequently reported self-harm and suicidality than did any other group, with approximately 2/3 of participants' having contemplated and nearly 50% making a suicide attempt. We extend current theorizing about minority stress (Hendricks & Testa, 2012; Meyer, 2003) to include genderqueer individuals and delineate several structural aspects of genderqueer experiences that may be responsible for these trends, including others' lack of knowledge about genderqueer experiences and pronouns, poor access to legal and medical resources, and systemic discrimination. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Case of Colonel Abel

In June 2010, journalists for the Associated Press reported the arrest of ten Russian spies, all suspected of being “deep-cover” illegal agents in the United States. Seeking to convey the magnitude of this event, the journalists wrote in the first paragraphs of their article that this “blockbuster series of arrests” might even be as significant as the FBI’s “famous capture of Soviet Col. Rudolf Abel in 1957 in New York.” Colonel Abel’s story of American justice at a time of acute anxiety about the nation’s security is one that continues to resonate today. The honor, and error, that is contained in that story offer lessons worth remembering as the American and Russian systems of justice struggle with a new common enemy, international terrorists. This paper examines three topics: (1) the appointment of counsel for Abel, (2) the pretrial investigation and trial work conducted by his defense counsel, and (3) the defense’s motion to suppress evidence, a motion that led to two separate oral arguments before the United States Supreme Court. Comparisons are made between the American and Russian systems of criminal procedure. Similarities and differences are also explored between the treatment in the United States of a suspected Soviet spy in 1957 and suspected terrorists fifty years later.

Impact of Implementing B-RSTTM to Screen for Hereditary Breast and Ovarian Cancer on Risk Perception and Genetic Counseling Uptake Among Women in an Academic Safety Net Hospital

BackgroundLower socioeconomic status is strongly associated with decreased perception of cancer risk. Fewer low socioeconomic status women than expected currently access cancer genetic services from which they may benefit. Patients and MethodsWe screened women presenting for a screening mammogram at a safety net academic hospital using the Breast Cancer Genetics Referral Screening Tool Version 3.0 (B-RSTTM), an online tool designed to identify individuals potentially at risk for hereditary breast and ovarian cancer. Participants screening either positive (high risk) or negative (moderate risk) were offered genetic counseling appointments. We used a brief survey to evaluate change in risk perception before and after using B-RSTTM, and after a genetic counseling appointment, if applicable. Barriers to accepting appointments were assessed when participants declined. ResultsOf the 126 participants, 91 (72.2%) screened negative-average risk, 13 (10.3%) screened negative-moderate risk, and 22 (17.5%) screened positive. Of those who screened positive or negative-moderate, 24 (68.6%) expressed interested in a genetic counseling appointment, of which 19 (79.2%) scheduled. Four of the 19 scheduled (21.1%) completed the appointment. We found a significant difference in the number who rated their breast cancer risk correctly on the post-test between the groups who self-rated as low, moderate, or high risk. Those who perceived themselves as high risk were the most likely to rate their risk correctly on the post-test (P < .001). ConclusionWe showed that using B-RSTTM in a safety net academic hospital was effective at identifying women at increased risk for hereditary breast and ovarian cancer.

A novel approach to offering additional genomic findings—A protocol to test a two‐step approach in the healthcare system

Internationally, the practice of offering additional findings (AFs) when undertaking a clinically indicated genomic test differs. In the USA, the recommendation is to include analysis for AFs alongside diagnostic analysis, unless a patient opts-out, whereas European and Canadian guidelines recommend opt-in models. These guidelines all consider the offer of AFs as an activity concurrent with the offer of diagnostic testing. This paper describes a novel two-step model for managing AFs within the healthcare system in Victoria, Australia and presents the study protocol for its evaluation. Adults who have received results of diagnostic whole exome sequencing undertaken within the healthcare system are invited to attend a genetic counseling appointment to consider reanalysis of their stored genomic data for AFs. The evaluation protocol addresses uptake, decision-making, understanding, counseling challenges, and explores preferences for future models of care. Recruitment commenced in November 2017 and will cease when 200 participants have been approached. When the study is concluded, the evaluation results will contribute to the evidence base guiding approaches to counseling and models of care for AFs.

Abstract P5-09-20: Improved patient compliance and genetic screening efficiency following implementation of an electronic pedigree survey (PROGENY)

Abstract Introduction Patients referred for genetic counseling do not consistently complete a family history questionnaires (FHQ), which is required before scheduling a genetic counseling appointment (GCA). A paper survey has traditionally been used to collect this FHQ data. This requires the genetic counselor to manually input the patient's FHQ information into a pedigree generator prior to scheduling their GCA, thereby delaying the genetic screening process. Some genetic counseling centers have switched from using this paper survey to a web-based pedigree-generator, like PROGENY, for collecting patient's FHQ data. No literature to date has evaluated the impact of this change on patient compliance with completing the required FHQ, the genetic screening process, or patient outcomes. This study assesses changes in patient compliance and genetic screening efficiency with the implementation of PROGENY compared to traditional surveying as a means of collecting FHQ data. Hypothesis More patients will complete the FHQ and GCA and there will be reduced time between patient referral and completion of the FHQ and GCA with the use of PROGENY compared to the traditional paper survey. Methods This is a retrospective chart review of patients referred for genetic counseling six months before and after implementation of PROGENY. Independent t-tests assuming unequal variances were conducted using JMP to compare genetic screening efficiency with and without the use of PROGENY. Results This study found that 41% more patients completed the FHQ and 25% more patients completed a GCA when using PROGENY. Further, there was a statistically significant reduction in the time between referral and completion of the FHQ (t(311)=9.14, p&amp;lt;.0001) as well as the GCA (t(280)=3.04, p&amp;lt;.0001). Specifically, the average time for patients to complete the FHQ was 84.45 days faster with PROGENY and the time for patients to complete a GCA was 34.83 days faster with PROGENY than without PROGENY. Conclusions These results support our hypothesis and suggest that utilizing PROGENY in collecting patient FHQ data correlates with improved patient compliance and genetic screening efficiency. Future work should investigate how quality improvement such as this impacts patient outcomes, such as the timeliness of finding an actionable genetic mutation and detecting cancerous and precancerous lesions. Some limitations of this study include high variability. This is likely due to factors such as appointment cancellations, geneticist availability and workload, and patient age, ethnicity, gender, and socioeconomic status. Future work should assess the impact of these factors on variables such as patient compliance and efficiency of the genetic screening process. Citation Format: Hennick TM, Khan T, Moroose R, Bisson R. Improved patient compliance and genetic screening efficiency following implementation of an electronic pedigree survey (PROGENY) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-09-20.

Rethinking the Role of Lawyers for Children : Child Representation in Canadian Family Relationship Cases

This article examines various methods for involving children in family and child welfare proceedings, surveys varying approaches in different Canadian jurisdictions to the appointment of counsel for children in these cases, and explores the controversies about the role of counsel for children. While child representation is becoming common, in most provinces it is usually limited to welfare proceedings involving older children. All jurisdictions, however, have some provisions to allow for child participation in family relationship cases. Governments and law societies in Canada should develop more coherent and comprehensive programs and policies to ensure that the views of children are considered in the family justice process in a child-focused and cost-efficient manner. There needs to be more recognition of the role of lawyers in facilitating settlement. Appointment of counsel is, however, not always the best way to involve children ; if the child is willing to share views, in some cases this may be better done by a judicial interview, a Views of the Child Report or an assessment. There should be a presumption that counsel will be an instructional advocate, but if a child lacks the capacity or willingness to instruct counsel, counsel should be an advocate for the rights and interests of the child. Regardless of the role adopted, counsel for a child also has responsibility for introducing significant evidence not otherwise before the court.

Using Engeström’s Activity Triangle Model to Design and Develop a Technology-based HIV Intervention for the Youth

Recent reports claim there is a significant decline in terms of new HIV infections recorded among adults and children. In spite of this global decline, the Philippines continue to face an increased number of new HIV cases, especially among the youth. HIV testing, an important step towards HIV detection and medication, can be aided with mobile technology specifically smartphones. Given the advanced capabilities of smartphones and its wide reach among the youth, it can be a potential tool for delivering HIV health care intervention. This paper outlines how TimesApp - an Android-based prototype for anonymously scheduling an HIV counseling and testing appointment was developed using Engestrom’s second generation activity triangle model.

Assessing Shared Decision-Making Clinical Behaviors Among Genetic Counsellors.

Shared decision-making (SDM) is a collaborative approach in which clinicians educate, support, and guide patients as they make informed, value-congruent decisions. SDM improves patients' health-related outcomes through increasing knowledge, reducing decisional conflict, and enhancing experience of care. We measured SDM in genetic counselling appointments with 27 pregnant women who were at increased risk to have a baby with a genetic abnormality. The eight experienced genetic counsellors who participated had no specific SDM training and were unaware that SDM was being assessed. Audio transcripts of appointments were scored using 'Observing Patient Involvement in Decision Making' (OPTION12). Patients' anxiety and decisional conflict were also assessed. The genetic counsellors' mean OPTION12 score was 42.4% (SD 9.0%; possible range 0-100%). Specific SDM behaviours that scored highest included introducing the concept of equipoise and listing all options with their pros and cons. Behaviours that scored lowest included eliciting patients' preferred approach to receiving information and desired degree of involvement in decision-making. Patients' levels of anxiety and decisional conflict were unassociated with genetic counsellors' OPTION12 scores. Some SDM behaviours were better demonstrated in this prenatal genetic counselling study than others. Formal training of genetic counsellors in SDM may enhance use of this approach in their professional practice.

An invitation to complete: Making advance directives part of the new patient process.

7 Background: In Colorado, there is no legal designation as to who is authorized to make healthcare decisions for an adult unable to make decisions for themselves. Completing an advance directive is increasingly associated with better end-of-life outcomes. Failure to complete an advance directive leads to fewer days on hospice and expensive, end-of-life care. It was hypothesized that patients who completed a Medical Durable Power of Attorney (MDPOA) document early may have higher adoption of advance care planning and earlier hospice at end-of-life. Methods: The Rocky Mountain Cancer Centers (RMCC) is the largest private oncology group in Colorado with multiple offices across the state. The RMCC-Pueblo clinic developed and piloted a new patient process where, at registration, all new patients were invited to complete a MDPOA while also completing other new patient forms. The Medical Durable Power of Attorney (MDPOA) is a document that appoints a healthcare decision maker (“healthcare agent”). Data on 4,441 patients from Nov. 1, 2017, to June 30, 2018, were extracted from the electronic health record (EHR), including code status, advance care planning counseling appointment, advance directive completion, and outcomes. Results: During this pilot, advance directive capture within the EHR rose from 15.4% to 21.4%. While the number of patients who elected hospice enrollment at the end of life was about the same, the length of hospice stay increased from an average of 14 to over 20 days, a 50% improvement. Conclusions: A MDPOA as a routine part of the new patient intake process is feasible and scalable. It opens the door to future ACP discussions and improved hospice utilization. Because of these findings, we are currently expanding this process to all RMCC practice sites. The results suggest that early completion of an Advance Directive lead to ongoing and healthy discussions about the patient’s end-of-life preferences for care, including appropriate hospice enrollment.

Health beliefs associated with readiness for genetic counseling among high risk breast cancer survivors.

We used the Health Belief Model (HBM) to explore factors associated with readiness for genetic counseling among breast cancer survivors. Breast cancer survivors meeting NCCN genetic counseling referral criteria completed questionnaires capturing demographic and clinical information and factors guided by the HBM, including health beliefs, psychosocial variables, and cues to action. Using logistic regression, we examined whether the above variables differed based on readiness group (pre-contemplators, who did not plan to make a genetic counseling appointment, and contemplators, who planned to make a genetic counseling appointment in the next 1-6months). Of 111 participants, 57% were pre-contemplators and 43% were contemplators. Higher cancer worry was associated with increased odds of being a contemplator (OR=2.99; 95% CI=1.37-6.54) and higher perceived barriers to genetic counseling were associated with decreased odds of being a contemplator (OR=0.31; 95% CI=0.11-0.85). Those who reported a family member encouraged them to get tested were more likely to be contemplators (OR=3.57; 95% CI=1.19-10.70). Our results suggest key factors for predicting genetic counseling readiness include cancer worry, perceived barriers, and family influence. There is need for increased genetic counseling awareness. Better understanding of factors related to survivors' decisions about counseling can inform tailored interventions to improve uptake and ultimately reduce cancer recurrence risk.

High patient satisfaction with a simplified BRCA1/2 testing procedure: long-term results of a prospective study

PurposeIn the BRCAsearch study, unselected breast cancer patients were prospectively offered germline BRCA1/2 mutation testing through a simplified testing procedure. The purpose of the present study was to evaluate satisfaction with the BRCAsearch testing procedure and, furthermore, to report on uptake rates of prophylactic surgeries among mutation carriers.MethodsPre-test information was provided by a standardized invitation letter instead of in-person genetic counseling. The patients were offered contact with a genetic counselor for telephone genetic counseling if they felt a need for that. Mutation carriers were telephoned and given a time for a face-to-face post-test genetic counseling appointment. Non-carriers were informed about the test result through a letter. One year after the test results were delivered, a study-specific questionnaire was mailed to the study participants who had consented to testing. The response rate was 83.1% (448 of 539).ResultsA great majority (96.0%) of the responders were content with the method used for providing information within the study, and 98.7% were content with having pursued genetic testing. 11.1% answered that they would have liked to receive more oral information. In an adjusted logistic regression model, patients with somatic comorbidity (OR 2.56; P = 0.02) and patients born outside of Sweden (OR 3.54; P = 0.01) were more likely, and patients with occupations requiring at least 3 years of university or college education (OR 0.37; P = 0.06) were less likely to wanting to receive more oral information. All 11 mutation carriers attended post-test genetic counseling. At a median follow-up of 2 years, the uptake of prophylactic salpingo-oophorectomy was 100%, and the uptake of prophylactic mastectomy was 55%.ConclusionsSatisfaction with a simplified BRCA1/2 testing procedure was very high. Written pre-test information has now replaced in-person pre-test counseling for breast cancer patients in our health care region.