This study shows that a simple electronic reminder system for pathologists markedly increases adherence to the MIPA procedure, a multidisciplinary guideline for recognition of CRC patients at high risk for Lynch syndrome. With surprisingly little effort and at low costs, multidisciplinary implementation of an entirely novel practice role for pathologists was improved. The efficiency of counselling by a clinical geneticist is greatly enhanced when patients with an MSI-high CRC are being referred for Lynch syndrome. This is due to the fact that especially patients with a positive MSI test are at very high risk to be mutation carriers, whereas a clinical geneticist has little to offer to a young patient with an MSI-negative CRC, unless the presence of polyposis or a positive family history clearly points at a hereditary defect. Our results may have a larger impact on health care because use of an electronic reminder system can increase adherence to guidelines of other hereditary diseases too.
To our knowledge, this is the first study of an implementation strategy designed to improve the recognition of patients at risk for Lynch syndrome by tumour testing. One year before the introduction of the MIPA procedure, only 30% of the patients at risk for Lynch syndrome was recognised as such by the traditional procedure based on signalling familial occurrence of colorectal cancer [25
]. This low number is in line with other studies showing that family history is insufficient for recognising patients at risk for Lynch syndrome [11
]. After introduction of the MIPA procedure in multidisciplinary teams including surgeons and pathologists by written materials, the recognition of patients at risk for Lynch syndrome was substantially higher, namely 59%. In the tailored implementation group, this recognition was even 77%. This difference between control and intervention group is relatively large. In a review including 235 controlled studies, Grimshaw [2
] studied the effectiveness of strategies to implement clinical guidelines. Overall, the majority of studies observed modest improvements in care of only 5–10%.
In the present study, the pathologists in the intervention arm obtained an overview of eligible patients only once a month. It is expected that the MSI analysis would be applied even more often, when the pathologist would get a pop-up with the possibility to initiate MSI testing at the moment of authorising the pathology report.
The surgeon-directed intervention led to 74% referrals of patients with an MSI-positive tumour. This was not significantly larger than in the control group (64%) probably because of small numbers. It is plausible that a referral rate of 74% is fairly optimal because not all patients with an MSI-positive tumour are capable or willing to receive genetic counselling at the time colorectal cancer is diagnosed and treated. Our results are in line with previous data showing that 78% of patients with CRC would accept genetic counselling shortly after diagnosis [26
Based on the Bethesda criteria, originally four MIPA criteria have been defined. However, only two of these criteria appeared to be fulfilled within our study. Therefore, we suggest restricting the MIPA criteria to the following two criteria: (1) CRC diagnosed before age 50 and (2) second CRC before age 70.
A limitation of the study is that the patient’s visit to a cancer genetics clinic for genetic counselling was measured until 6 months after the CRC diagnosis of the last patient. It is possible that more patients will receive genetic counselling in the near future. However, as it is unlikely that this effect differs between the two groups, this will not affect the conclusion that the intervention leads to a higher rate of adherence to the guideline.
Our findings indicate that a surprisingly simple and cheap electronic patient inclusion reminder system for medical specialists is effective for adherence to a complex multidisciplinary procedure for recognition of Lynch syndrome. The implications for health care can be substantially and are of course not restricted to patients at risk for Lynch syndrome. Our approach can serve as a model for implementation of guidelines in other hereditary diseases.