title: Reported referral for genetic counseling or BRCA 1/2 testing among United States physicians: a vignette-based study.
abstract: BACKGROUND
  Genetic counseling and testing is recommended for women at high but not average risk of ovarian cancer. National estimates of physician adherence to genetic counseling and testing recommendations are lacking.
  
  
  METHODS
  Using a vignette-based study, we surveyed 3200 United States family physicians, general internists, and obstetrician/gynecologists and received 1878 (62%) responses. The questionnaire included an annual examination vignette asking about genetic counseling and testing. The vignette varied patient age, race, insurance status, and ovarian cancer risk. Estimates of physician adherence to genetic counseling and testing recommendations were weighted to the United States primary care physician population. Multivariable logistic regression identified independent patient and physician predictors of adherence.
  
  
  RESULTS
  For average-risk women, 71% of physicians self-reported adhering to recommendations against genetic counseling or testing. In multivariable modeling, predictors of adherence against referral/testing included black versus white race (relative risk [RR], 1.16; 95% confidence interval [CI], 1.03-1.31), Medicaid versus private insurance (RR, 1.15; 95% CI, 1.02-1.29), and rural versus urban location. Among high-risk women, 41% of physicians self-reported adhering to recommendations to refer for genetic counseling or testing. Predictors of adherence for referral/testing were younger patient age [35 vs 51 years [RR, 1.78; 95% CI, 1.41-2.24]), physician sex (female vs male [RR, 1.30; 95% CI, 1.07-1.64]), and obstetrician/gynecologist versus family medicine specialty (RR, 1.64; 95% CI, 1.31-2.05). For both average-risk and high-risk women, physician-estimated ovarian cancer risk was the most powerful predictor of recommendation adherence.
  
  
  CONCLUSIONS
  Physicians reported that they would refer many average-risk women and would not refer many high-risk women for genetic counseling/testing. Intervention efforts, including promotion of accurate risk assessment, are needed.
authors.affiliation: Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. ktrivers@cdc.gov
authors.forename: Katrina F
authors.initials: KF
authors.lastname: Trivers
authors.forename: Laura-Mae
authors.initials: LM
authors.lastname: Baldwin
authors.forename: Jacqueline W
authors.initials: JW
authors.lastname: Miller
authors.forename: Barbara
authors.initials: B
authors.lastname: Matthews
authors.forename: C Holly A
authors.initials: CH
authors.lastname: Andrilla
authors.forename: Denise M
authors.initials: DM
authors.lastname: Lishner
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Goff
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000209:etiology / Q000235:genetics; D005260:Female; D019398:Genes, BRCA1; D024522:Genes, BRCA2; D005817:Genetic Counseling; D005820:Genetic Testing; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D010051:Ovarian Neoplasms / Q000209:etiology / Q000235:genetics; D010818:Practice Patterns, Physicians'; D012017:Referral and Consultation; D014481:United States