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additional 20 % of cases are signifi cantly associated with multifactorial and rare
variant genetic lesions that are not always easily recognized. Identifi cation of such
genetic traits in the later group requires complex genotyping and mapping to both
patient and familial medical history as well as additional individual level clinical
phenotype-related measurements (e.g. laboratory measures, patient reported out-
comes, etc.). Individuals with both of the aforementioned genetic predispositions
for colon adenocarcinoma are both at higher risk of the disease and may present
with more aggressive cancers than other types of patients [
6
,
7
].
Building upon this overall clinical context, let us consider a prototypical environ-
ment in which cases of colon adenocarcinoma may occur. We will defi ne this environ-
ment in terms of the following axes: (1) evidence and/or policy generators; (2)
healthcare providers and healthcare delivery organizations; and (3) patients with the
disease or risk therein and their surrounding families and communities. Each axis is
explored below. At the outset, we will situate our example is a medium sized North
American city with a population of approximately one million people. In this city, there
is a higher-than normal rate of colon adenocarcinoma with an incidence of 80 cases per
100,000 people in the community, or twice the average for the United States. That is,
we can expect that at any given time, there may be up to 800 cases of colon adenocar-
cinoma; the exact number could be variable, depending on additional demographic and
environmental factors that we will not go into detail about in this discussion.
2.2.1
Evidence and Policy Generators
In our prototypical city, a variety of researchers and policymakers have taken note of
the increased incidence of colon adenocarcinoma and are investigating the basis for
this rate of cancer as well as policy or other measures that could be taken to enhance
or improve early detection and/or diagnosis of colon adenocarcinoma so as to
decrease costs and quality of life impact associated with the disease and its treatment.
Such measures could include but are not limited to: (1) funding research programs to
identify the genetic or other bases for the increased cancer incidence; (2) launching
a public education and awareness campaign concerning the importance of screening
and early detection of colon cancer; and (3) taking measures across and between
healthcare providers and delivery organizations to help primary and specialty care
providers to readily identify those patients at greatest risk for colon adenocarcinoma
(e.g., individuals with a high familial incidence and genetic predisposition).
2.2.2
Healthcare Providers and Organizations
In our same city, there are two to three integrated healthcare delivery organiza-
tions (e.g., combined inpatient and outpatient care providers, with associated sup-
porting services), where at least one of those organizations is also part of an
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