Article Text
PDF
Abstract
Background Population-based genetic screening and testing programmes have substantial potential to improve cancer-related outcomes through early detection and cancer prevention. Yet, genetic testing for cancer risk remains largely underused. This study aimed to describe barriers and facilitators to patient engagement at each stage of a California-based genetic screening programme, from completing the electronic screener to receiving the test and to identify potential improvements that could support precision medicine-based approaches to patient care.
Methods We conducted 26 semistructured interviews among programme participants who did not complete the screener (n=9), those who did not receive the recommended test (n=7) and those who received a genetic test (n=10). Interviewees were selected from patients who recently received a mammogram through one of the participating Southern California clinics. Interviews were transcribed and coded using Atlas.ti. The study used a qualitative descriptive approach to identify similar and contrasting themes among the participant groups.
Results This study found that barriers and facilitators to engagement were largely the same regardless of how far participants had moved through the process towards getting a genetic test. We identified four overarching themes: participants wanted clear communication of personal benefits at each stage; participants needed additional information and knowledge to navigate genetic screening and testing; a trusted provider could be instrumental in participants following a recommendation; and repetition and timing strongly impacted participants’ likelihood to engage.
Conclusions Providing education about the benefits of genetic screening and testing to patients and their families, as well as clear communication about what each step entails may help patients engage with similar programmes. Strategies aimed at increasing coordination among a patient’s healthcare team can also help ensure information reaches patients in multiple ways, from multiple providers, to increase the likelihood that recommendations for testing come from trusted sources, which supports the uptake of genetic testing.
- cancer genetics
- patient satisfaction
- quality improvement
- mass screening
Data availability statement
No data are available. The data generated and analysed in this study were derived from in-depth interviews and are not publicly available due to restrictions, namely the data contain information that could compromise the privacy of research participants.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
STRENGTHS AND LIMITATIONS OF THIS STUDY
In-depth interviews with patients expand our understanding of patients’ experiences and preferences for a population-based genetic screening programme.
This study offers insights on how to promote engagement at multiple stages of a genetic screening and testing pathway.
The majority of interviewees identified as white, women, with English as a preferred language, which limits generalisability.
The study was limited to participants already engaged in healthcare and did not address overall barriers and access to care.
Introduction
A growing number of genetic screening programmes have been implemented across various settings, such as primary care and specialty ambulatory care (eg, cardiology), to identify high-risk patients who may benefit from additional preventive treatment and ensure they receive appropriate follow-up care.1 2 Programmes that offer population genetic screening to assess cancer risk are increasingly viewed as a key means for supporting population health overall because of their potential to identify patients in need of enhanced monitoring or who could benefit from risk-reducing treatments to prevent or mitigate symptoms.3 4 Indeed, conducting additional cancer-risk assessment during routine screening appointments such as mammograms has become a recommended standard of care,5 which creates a critical need for these centres to implement efficient, scalable tools and workflows to support the risk assessment and genetic screening of their entire served population. Population-based genetic screening programmes can also help mitigate some of the barriers that have been identified in more standard genetic service delivery models, such as long wait times, limited genetic counsellors and overall accessibility. However, genetic screening and testing for cancer risk remain largely underused among patients,6 7 raising questions about patient perceptions of these programmes, including benefits and barriers, to understand how to encourage participation.
Leveraging genetic testing to assess cancer risk has substantial potential to improve cancer-related outcomes through early detection and cancer prevention.8–10 Yet, for these programmes to be effective, patients must be actively engaged through a multistep process. This includes the completion of a personal and family history screener to qualify for testing, the completion of a genetic test if they meet the recommended risk threshold and connection to appropriate cancer screening and prevention care if patients are identified to have elevated cancer risk.
Despite population-based cancer risk genetic testing programmes requiring multiple steps, previous studies tend to assess general perceptions of genetic testing from individuals who were not being offered a genetic test11–13 or post-test reactions of participants who completed the genetic testing.1 14–16 Few studies have focused on learning about the barriers and facilitators to engagement from patients who drop out of the programme at each stage—including those who do not complete the risk assessment and those who do not receive a recommended genetic test. For these programmes to be ultimately successful, it is essential to understand the factors that shape patients’ uptake and engagement in genetic testing at each stage of the process.
As genetic screening programmes become more common, it is important to understand patient experiences of these programmes, and what may motivate patients to complete the full genetic screening and testing process. This qualitative study used interviews with patients who had engaged to various degrees with a cancer screening programme in a clinical setting to identify barriers and facilitators to patient engagement at each stage in the process, patient perspectives on the programme and what could be improved to support precision medicine-based approaches to patient care.
Materials & methods
Setting
In 2020, the Providence Clinical Genetics and Genomics team in Southern California launched the Comprehensive Assessment, Risk, Education developed by Ambry Genetics (The Ambry CARE Program), a population-based approach designed to increase cancer-related genetic testing for preventive purposes.17 The programme uses a text or email-based link that directs patients to an electronic screener to gather information about personal and family cancer history from patients who are due to receive a mammogram through one of six participating clinics (see figure 1). Patients are sent the screener 1 week prior to their scheduled mammogram and reminders 1–3 days prior. Patients who meet the National Comprehensive Cancer Network (NCCN) criteria of ‘high risk’18 are recommended to receive a multigene ‘panel’ genetic testing for alterations in more than 80 genes associated with hereditary cancer risks across a broad spectrum of tumour sites in addition to breast (uterine, ovarian, colorectal, pancreatic, etc). After being identified as meeting NCCN criteria, the electronic platform provides patients with their recommendations for genetic testing and a pretest educational video. Patients receive the screening and/or genetic testing recommendation at their mammogram appointment and have the opportunity to ask questions, provide consent for testing and collect their sample on the same day of their visit; they may also elect to schedule a traditional pretest genetic counselling appointment with a genetic counsellor if they wish. For eligible patients who do not present for genetic testing on the day of their mammogram, the genetics clinic follows up to offer sample collection through alternate means, such as returning to a testing centre on a different day, sending a kit to the patient’s home or scheduling a genetic counselling appointment to discuss further. Patients who undergo genetic testing and test positive for a pathogenic variant in any of the genes are offered genetic counselling and receive detailed risk reduction, prevention and management recommendations. Programme data on which patients completed the screener, who received the testing recommendation but did not receive genetic testing and who completed the full process are collected as part of routine care and programme oversight.
CARE Program workflow. *National Comprehensive Cancer Network. CARE, Comprehensive Assessment, Risk, Education.
At the time of the study, around 150 000 electronic screeners had been sent to patients, with an approximately 70% completion rate. A little less than 30% of these patients met NCCN criteria and received a testing recommendation. Of these, about 15% of patients eligible to receive testing go on to complete genetic testing.
Participant selection
In May–June 2023, we conducted qualitative interviews with patients who had recently received or were due to receive a mammogram through one of the participating clinics. We used programme data to identify potential interviewees and to classify them according to where they were along the workflow of receiving the electronic screener, completing the information, receiving the recommendation that they meet guidelines for hereditary risk assessment and receiving the genetic test. Of note, these classifications were based on the patient’s point along the workflow for their current appointment rather than any past appointments in which they may have been exposed to the electronic screener. As described in more detail in the limitations, a greater proportion of participants had previously received genetic testing than anticipated during recruitment. Email invitations were sent to all patients who met the study criteria; outreach materials and patient interviews were conducted in English. Participants reviewed consent forms with the interviewer and gave verbal consent separately to the interview procedure and to electronic health records (EHR) release.
Patient and public involvement
Patients or the public were not involved in the design, conduct, analysis or dissemination of the research study. However, patients were central to the study in determining the relevant barriers and facilitators of genetic testing. In addition, based on the results of patient interviews and what we learnt about patient misconceptions and areas of interest, we provided feedback to programme staff, who updated a frequently asked questions document that was distributed to all participants in the study.
Data collection
Three semistructured interview guides were developed for the groups: (1) those who had received the screener but had declined to fill out the information or had not yet completed it, (2) those who met NCCN criteria for high risk but declined testing or had not yet decided to receive testing and (3) those who received a positive genetic test result (ie, pathogenic variant(s) detected). While patients who tested negative would have insight into what encouraged them to take the genetic test, our study was limited to patients who tested positive for a variant so that interviews could explore patients’ experiences receiving genetic counselling and risk reduction recommendations. In addition, the experiences of patients who had a variant were of the most interest to the programme team to help ensure quality improvement across all stages as individuals who test negative for a variant are standardly offered genetic counselling as part of the programme for tailored empiric risk assessment, whereas it is a requirement for individuals who test positive.
Participants were asked open-ended questions about their views on genetic testing, what could or did motivate them to receive a genetic test (including their history of prior testing) and any barriers or facilitators they encountered during the process. Interview domains were developed after a literature search on barriers and facilitators of genetic testing and review with the Providence Clinical Genetics and Genomics team (see online supplemental table 1). Participant experiences with genetic testing did not always align with data captured by the programme data; interview questions were adjusted based on this information.
Supplemental material
We aimed to contact patients in the first two groups who had completed their mammograms within a month of study outreach. For patients in the tested-positive group, we conducted outreach with those who had tested positive at least 5 months prior. Interviews were between 30 and 60 min and were conducted either virtually or via the phone, based on participant preference. Interviews were recorded and transcribed verbatim by a transcription service and reviewed for accuracy by the research team.
Data analysis
Interview data were analysed using a qualitative descriptive approach, which stays closer to the data than other qualitative approaches, provides in-depth content from the participants’ perspective and is well suited to healthcare research.19 Initial codebooks were developed from the interview guide and revised iteratively when emergent codes were identified. To maintain methodological rigour, three of the interviews were double-coded. After each double-coded interview, the coding team met to discuss codes until a consensus was reached. The team reviewed the content of the codes to develop a set of central themes. Illustrative quotes are presented in the results section to support the themes and recommendations. All analyses were completed in Atlas.ti V.23. Additionally, information from EHR data was pulled to demographically describe the sample.
Results
A total of 26 interviews were conducted. Participants were primarily white and preferred English as their language (table 1).
Participant demographics
Four themes emerged from interviews with all participants, regardless of how far they had moved through the process towards completing a genetic test. These included (1) the desire for clear communication of benefits, (2) the need for more information and knowledge, (3) the importance of a trusted provider and (4) the advantages of repetition and timing. Additional exemplar quotes are found in table 2.
Themes and exemplar quotations
Communication of benefits
At each stage of the CARE program pathway, from filling out the electronic screener to receiving the genetic test, participants were motivated to complete the tasks based on their understanding of the importance of the steps. Many of the participants did not understand the purpose of the screener when they received it; nearly all of participants who did not complete the screener mentioned that they would have been more likely to complete it or find the task important had they known that it would be used to determine if they should receive a genetic test or otherwise inform the type of healthcare they would receive. Participants did not differentiate the electronic screener from other preappointment paperwork and forms; to most, it appeared to be the same as many of the other family history questionnaires that they were asked to fill out for other medical visits. Participants often expressed frustration at completing a seemingly redundant form.
Sometimes I think ‘I just did this last week,’ or ‘Do you have to know this again?’ That’s the thing I can say about it that’s a negative…It’s not difficult [but] it takes time. — Participant who did not complete the screener
In terms of receiving the genetic test, participants did not always realise that the recommendation was tied to their family history and an increased personal risk for certain cancers; participants suggested that understanding this link may have increased their motivation to receive the test.
I think that [knowing the connection between the screener and a genetic test recommendation] would change [my willingness to complete the screener] tremendously because it’s like you’re using your family history to figure out if it’s a possibility that that relates to you. — Participant who did not complete the screener
You know, when I did the genetic testing, it was basically like, ‘Do you wanna do it?’ …There wasn't, you know, ‘This is gonna be very helpful.’ Of course, it’s helpful, but the bottom line was, ‘You can do genetic testing if you're interested.’ So I was, because of all that history that I had on my dad’s side, thinking, you know, that has to be it. — Participant who received test
Many of the interviewees who engaged in the testing were motivated by being able to share their results with their family members. This benefit was not always clearly understood by interviewees who did not complete the screener or take the test; a better understanding of the connection may have increased engagement.
Although, you know, I was thinking too, it’s like I just had a grandchild born, so I think probably genetics is like more important to me now, now that there’s, you know, another generation that’s maybe a motivation as well. — Participant who did not complete the screener
Information and knowledge
A large proportion of interviewees had prior exposure to some kind of genetic testing through genetic testing associated with pregnancy, direct-to-consumer genetic testing or genetic testing after a personal cancer diagnosis. Despite this previous exposure, some participants were still unsure what the recommended genetic test entailed, including whether it involved a blood test or biopsy or required a hospital stay.
I’m not even sure what entails genetic testing. Is it a blood test? Is it, you know, a biopsy kind of thing? — Participant who did not receive the recommended test
One person who chose not to get the genetic test expressed confusion between the genetic tumour testing the participant had already received when diagnosed with breast cancer, and the recommendation to undergo genetic testing to assess cancer risk. Participants who had not completed the screener gave similar responses. Some indicated that they would want more information about the specifics around the test, if it were recommended, including both general information about the test (eg, how the test is done and how long it takes) and whether there were any medical risks (eg, one participant who was concerned because they were ‘allergic to everything’).
I thought it was saying that if you have cancer, you know, if I’m already sick, would I be interested in it. And that was probably in my mind, too. Like ‘No, I’m fine, I don’t need this’ …So I just didn’t understand it. — Participant who did not receive the recommended test
None of the participants (either those who had not received the screener or who did not receive the test) were fully opposed to the idea of genetic testing for cancer risk. Participants who were more hesitant about genetic testing wanted to know the personal benefit and expressed concerns about cost, but none of the interviewees had overriding objections to knowing about their genetic cancer predisposition because they felt that knowledge was power (‘ignorance is bliss, right? But I feel like I’d rather in control of some risks as opposed to it surprising me’). A few interviewees mentioned that they had encountered people (including family members they reached out to after receiving a test) who ‘put their head in the sand…like an ostrich, they just don’t want to know’ but most of the participants who received the testing recommendation already had a heightened awareness of their risk given their family and sometimes personal history with cancer.
That website form it said something about genetic testing and have I had it? No. Would you be interested? Yes. And the reason why I wanted to do it was because my father, mother, brother, and sister have all had cancer. I have not, and three of those have passed away due to cancer. And my sister had breast cancer…So I was just interested in how their cancer…pertained to me. — Participant who received the testing recommendation but was unable to complete the test
Importance of a trusted provider
The provider making the recommendation also mattered to some participants. A number of participants expressed confusion based on their providers’ level of emphasis on the testing recommendation, as well. Interviewees described the recommendation as a ‘suggestion’ from their mammogram technicians that was not accompanied by a sense of urgency, which made it difficult for them to judge the importance of the recommendation for testing. One participant who eventually received genetic testing did so because when their primary care provider recommended the test, they emphasised how important it was for the participant to be tested given their family history. Interviewees felt that the recommendation from the CARE program could be communicated more strongly, and one interviewee suggested that receiving the recommendation from their doctor (as opposed to a technician or other staff) would make it appear more important.
It wasn't like, ‘Oh, we think this would be good for you.’ […] vs, ‘If you wanna do it, you can, it doesn't matter.’ You know, it was just a matter of fact, ‘You can have it done if you want. — Participant who received the genetic test
I'm not sure that coming from a tech, it would carry a lot of weight…if [my oncologist] suggested it to me, I would probably do it. — Participant who did not receive the genetic test
Many participants across the CARE program pathway described strong, trusting relationships with at least one provider—usually a primary care provider or oncologist—whose recommendations they were most likely to follow; none identified mammography staff as that trusted source of information. Participants who received a genetic test and tested positive for at least one genetic marker typically communicated a positive relationship with the genetic counsellor.
[The genetic counselor] was very thorough. It went really well. She was very, um, kind and understanding and you know, I'm sure she gets various reactions of people when they go in there. So, she was very comforting and very reassuring. — Patient who tested positive
Participants were given the option to see the counsellor before receiving the test, however, most opted to take the test first, for some because of the convenience of taking the test quickly. Some participants who later tested positive wished that they had been directed more strongly towards the option of meeting the genetic counsellor prior to testing, so that they could receive more information about possible life insurance effects or additional explanation around possible test results.
I didn't know what was going on…so I think it was just like a big surprise. And I mean granted part of it is I chose not to meet with the genetic counselor first. And looking back I think I would've, but I just didn't know and I was going with whatever seemed easiest.
I wasn't aware that I should have life insurance before I do genetic testing in case something shows up…which is a huge factor…I think part of it is I didn't ask questions and I wasn't really proactive in this care. Because I honestly never believed I had a genetic mutation. — Patient who tested positive
Repetition and timing
Interviews with participants who did and did not receive the genetic test suggested that, while there may not be immediate uptake by those who receive the recommendation, hearing about genetic testing multiple times and in multiple ways has a long-term effect of encouraging appropriate patients to receive testing. Many of the participants who were eventually successful at moving through the CARE program pathway (ie, completed the screener and took the genetic test) had received genetic testing recommendations before. Their decision to receive the test at this point, rather than when it was suggested first, was based on a confluence of contextual factors, including changing family and personal cancer experiences and changes in the cost of the testing, etc. As mentioned previously, some participants received the test after getting the recommendation from multiple types of providers.
I was just worn out…and I'd been through so much. I think it was at one of those points where I just felt like I just needed to like curl up and lick my wounds and recover and kind of hide for a while. — Participant who did not receive genetic testing after initial recommendation but received it after a subsequent recommendation
Similarly, participants who did not complete the screener described being busy with family and work obligations, but none expressed a complete refusal to share the information or fill out the forms. They described generally completing documentation of information like family history prior to a medical appointment but were unable to do so for their most recent mammography appointment.
And then this year…I can't remember what was going on…I was like, I don't have time to do this, so I just didn't do it. I figured I'll do it next year. — Participant who did not complete the screener
Discussion
Population-based genetic screening and testing programmes can help identify patients at an increased risk of cancer and direct them towards enhanced cancer screening services (eg, mammograms, colonoscopies, ultrasounds, MRI) or other recommendations. However, for these programmes to be successful, patients must be effectively engaged at each step of the programme pathway. Although study participants had varying degrees of engagement in the CARE program pathway, four themes emerged highlighting barriers and facilitators to participation that cut across the different groups: the benefits around clarity of communication, the need for increased information and knowledge, the importance of a trusted provider and the effects of repetition and timing.
The themes we identified largely indicate that the reasons participants have for not engaging in testing are potentially mutable and that patients are willing to engage in genetic screening and testing when they have a clear understanding of the specific purpose and procedures at each point in the pathway. Similar to prior research, our study found that patients are open to hearing about their genetic risks11 but are most likely to support testing when there are clear medical benefits, and when testing is for specific diagnostic and predictive purposes.12 20 21 These findings reiterate that a genetic risk assessment programme, such as CARE, needs to clearly articulate to patients the diagnostic and predictive purposes of genetic screening and testing and how the testing would impact their future healthcare. Programmes could consider opportunities to integrate patient communication and education during appointments, such as when mammogram patients are waiting to be seen.
Interestingly, while a limited number of individuals suggested that ‘not wanting to know’ factored into their thoughts around receiving a genetic test, the fear of emotional and psychosocial effects from genetic testing results that have been cited in other literature20 22 23 was not frequently identified by participants in this study. In fact, most participants felt that ‘knowledge was power’ and having more information could help in their care. These findings may suggest a growing acceptance of genetic testing, with knowledge and provider relationships as the main factors affecting engagement.
Other barriers to genetic testing identified by patients in the study included effects on insurance and potential costs, which aligns with findings from previous studies.1 13 24 Interviewees also expressed being frustrated by redundant requests for information that did not feel relevant to a given appointment or were not addressed by their healthcare provider during appointments. This highlights a need for improved portability and visibility of patient-provided history, particularly for patients who return year over year to the same centre or see multiple providers within the same network. Moreover, patients at each stage in the pathway described their own limited capacity, in terms of time and attention, to prioritise, navigate and complete each request and recommendation offered by the healthcare system.
Communication from a trusted provider helped counteract barriers to genetic testing and was identified as a key facilitator to moving forward in the process for many participants. Previous research has also underscored the importance of hearing the recommendation for genetic testing from a trusted provider, especially among racially and ethnically diverse patients.25–27 In addition, patient navigators have been shown to improve patient follow-through on genetic testing.28 Despite patients’ desire to hear this information from a provider, few studies have evaluated the impact of educational training programmes designed to improve healthcare providers’ communication skills related to genetic testing and cancer risk on the uptake of genetic testing.29 30 This highlights the need for additional research to identify strategies to effective support non-genetic clinicians in the provision of this type of patient counselling. Our findings also suggest that patients who opt to get genetic testing do not always choose to talk to a genetic counsellor prior to testing; patient navigators may also be able to provide information about talking to a genetic counsellor before getting testing and help a patient determine if that is the best option for them.
The findings highlight the importance of supporting the coordination of healthcare team around genetic testing and risk assessment. Improved coordination of the healthcare team may help ensure that multiple providers address the recommendation with patients at multiple time points and increase the feeling of importance around the test. Additionally, expanding the languages in which the screener is available is crucial for supporting equitable access to testing, particularly in linguistically diverse regions such as Southern California.
Limitations
As mentioned before, self-selection bias was a limitation in this study; participants who were completely opposed to genetic testing or had the largest concerns around privacy issues or distrust of the healthcare system may not have chosen to participate in the qualitative interviews. This limitation was mitigated by performing outreach in three separate categories—including those who did not fill out the family history screening and those who did not receive a test after a recommendation—which ensured that the study included patients who stopped engaging early in the pathway. Additionally, these participants likely reflect to some extent a patient population that would be willing to consider screening and testing, if aspects of the programme were improved; this study gives insight into what those considerations and changes might be.
Another limitation was in identifying participants from each of the three groups. The CARE patient portal was used for outreach; however, this portal was designed to support patient care rather than research purposes, and patient experiences and history with genetic testing were not always included. For example, of the seven interviews conducted with participants categorised in the programme data as group 2 (ie, did not receive genetic screening after the recommendation), only four had never actually received a genetic test for cancer risk in their lifetime. The other three had received genetic testing for cancer risk years prior to the CARE recommendation, received the genetic test in another country or received the test after the CARE recommendation when they were referred again by their primary care provider. We addressed this limitation by adjusting interview guides based on a participant’s actual experiences, rather than our initial categorisation.
There are also limitations around the number of participants who were interviewed for the study, which limits the generalisability of the findings. In addition, participants largely identified as white, and with English as a preferred language; the programme was implemented in a number of Southern California clinics, which also limits the geographical scope and relevance of the study. Participants also overwhelmingly identified as women, with an average age of 59 years. While this is expected, since the programme was implemented in a mammogram setting, it affects how much the findings can be generalised to other genders and age groups. Additionally, the study only included participants who were scheduled to receive or recently received a mammogram. Individuals who do not receive this kind of screening, including those who are generally not engaged with the healthcare system, are not represented in our findings. This population would likely face different barriers to receiving genetic screening or testing recommendations. Future research could focus on the equity considerations of engaging missing populations in these genetic risk programmes.
Conclusion
Interviews with participants at multiple stages of a genetic screening and testing programme pathway suggest that patients face similar barriers at each step in the programme, as they try to understand and prioritise the relative importance of screening and testing for their personal health and healthcare. Given the growth of genetic risk assessment in outpatient care settings, the results of study provide helpful insights to improve patient engagement with risk assessment and uptake of genetic testing. Patient education about the benefits of the programme to patients and their families, as well as clear communication about what testing entails, may help patients engage with the programme. Strategies aimed at increasing coordination among a patient’s healthcare team can help present information to patients in multiple ways, from multiple providers, to help ensure that recommendations come from trusted sources and support the uptake of genetic testing.
Data availability statement
No data are available. The data generated and analysed in this study were derived from in-depth interviews and are not publicly available due to restrictions, namely the data contain information that could compromise the privacy of research participants.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and the institutional review board of Providence Health & Services (Oregon) approved the study (#2023000128). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors would like to acknowledge and thank Providence St. Joseph Health and the Providence Foundation for funding this work. In addition, we thank Ambry Genetics and their development team for creating The Ambry CARE Program, which facilitated risk stratification in our population screening efforts. We would also like to acknowledge the support and insight from the programme staff at the Prevention4ME programme for their help identifying potential interviewees. Finally, we would like to thank the research staff who helped with this study including Abby Bush for their project support.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors All authors (CD, KRE, KKC, SB, OG and SER) contributed to the study conception and design. Material preparation, data collection and analysis were performed by CD and SER. KRE, KKC, SB and OG aided in the interpretation of results and implications for practice. The first draft of the manuscript was written by CD and SER and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. SER is responsible for the overall content as guarantor.
Funding This study was funded by Providence St. Joseph Health (PSJH) (grant number: N/A) and the Providence Foundation (grant number: N/A).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.