Table 1 Genetic referral barriers.
Barrier (coded to TDF domain) | Barrier descriptions |
|---|---|
Knowledge | Provider lack of knowledge about genetics and/or referral criteria [3, 33, 35,36,37,38, 42,43,44, 48, 55, 58, 60, 61, 73] |
Provider lack of knowledge about the genetic counseling referral process [3, 34] | |
Patient lack of knowledge about the availability of genetic services [35] | |
Provider lack of knowledge about the availability of genetic services [34, 37, 73] | |
Patient lack of knowledge about genetic testing and potential benefits [37] | |
Provider lack of knowledge about criteria for pathology tests to guide genetic risk assessment [3] | |
Lack of provider knowledge about the genetic counseling referral process [3, 34] | |
Skills | Difficulties communicating genetic information to patient [35] |
Limited exploration and/or documentation of patient family history [36, 44, 48, 54, 58] | |
Incomplete ordering of pathology tests (e.g., mismatch repair immunohistochemistry) [3] | |
Difficulties applying referral guidelines/criteria to identify patients at increased genetic risk [3, 55, 58] | |
Training provided on an ad hoc basis, resulting in unfamiliarity with referral processes [3] | |
Environmental context & resources | |
Limited availability of genetic counselors (due to clinical demands, limited resources) and subsequent long waitlists [34, 49, 56, 57] | |
Lack of geographical access to genetic services [42, 49, 50] | |
Patient financial constraints preventing access to genetic counseling and testing [50] | |
Time required to collect a complete family history to assess genetic risk [51] | |
Administrative referral barriers (e.g., referral forms not always available in clinic, faxing process can be fraught; multiple electronic management systems and departments with limited connectivity) [3] | |
Delayed implementation of genetic screening tests (e.g., mismatch repair immunohistochemistry) [3] | |
Lack of availability among genetic staff to attend multidisciplinary team meetings [3] | |
Genetic risk assessment guidelines may be complex to interpret and unsuited to occasional use in a busy setting [38] | |
Limited access to genetic services (reason not specified) [55] | |
Time constraints and absence of primarily responsible pathologist act as a barrier to appropriate ordering of genetic screening tests [62] | |
Limited integration of genetic testing into the cancer treatment workflow [56] | |
Memory, attention, & decision processes | Inconsistent documentation of referral recommendations [34] |
Difficulty deciding which patients were eligible for genetic screening tests (e.g., mismatch repair immunohistochemistry) [33] | |
Difficulty deciding which patients warrant genetic referral [36, 43, 48, 55] | |
Genetic risk assessment guidelines may be complex to interpret and unsuited to occasional use in a busy setting [38] | |
Clinicians can easily forget to refer cases for genetic screening tests (e.g., microsatellite instability testing) [62] | |
Interpreting pathology results can be difficult, making the decision-making process more difficult and less routine [3] | |
Genetic referrals can be overlooked due to competing clinical priorities [3] | |
Clinicians may not have the necessary information (e.g., immunohistochemistry reports) to make a decision about genetic referral [3] | |
Beliefs about consequences | Perception of limited clinical utility of genetic testing among providers [50] |
Lack of patient awareness about the potential benefits of genetic testing [37] | |
Beliefs about capabilities | Lack of confidence in ability to assess patients’ genetic risk or in providing genetic services [38, 42, 46] |
Terminology in the pathology reports can be confusing, generating the perception that it is hard to make an appropriate referral [3] | |
Emotion | Patient fear about the potential outcomes of genetic testing [37] |
Social/professional role & identity | Lack of clarity about clinician roles in the genetic risk assessment process [33, 34] |
