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Lubin IM, Lockhart ER, Frank J, See VY, Vashist S, Greene C. Challenges and opportunities for integrating genetic testing into a diagnostic workflow: heritable long QT syndrome as a model. Diagnosis (Berl) 2021; 8:17-26. [PMID: 31287796 DOI: 10.1515/dx-2019-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/18/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND An increasing number of diagnostic evaluations incorporate genetic testing to facilitate accurate and timely diagnoses. The increasing number and complexity of genetic tests continue to pose challenges in deciding when to test, selecting the correct test(s), and using results to inform medical diagnoses, especially for medical professionals lacking genetic expertise. Careful consideration of a diagnostic workflow can be helpful in understanding the appropriate uses of genetic testing within a broader diagnostic workup. CONTENT The diagnosis of long QT syndrome (LQTS), a life-threatening cardiac arrhythmia, provides an example for this approach. Electrocardiography is the preferred means for diagnosing LQTS but can be uninformative for some patients due to the variable presentation of the condition. Family history and genetic testing can augment physiological testing to inform a diagnosis and subsequent therapy. Clinical and laboratory professionals informed by peer- reviewed literature and professional recommendations constructed a generalized LQTS diagnostic workflow. This workflow served to explore decisions regarding the use of genetic testing for diagnosing LQTS. SUMMARY AND OUTLOOK Understanding the complexities and approaches to integrating genetic testing into a broader diagnostic evaluation is anticipated to support appropriate test utilization, optimize diagnostic evaluation, and facilitate a multidisciplinary approach essential for achieving accurate and timely diagnoses.
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Affiliation(s)
- Ira M Lubin
- Division of Laboratory Systems, Centers for Disease Control and Prevention, Atlanta, USA
| | - Edward R Lockhart
- Division of Laboratory Systems, Centers for Disease Control and Prevention, Atlanta, USA
| | - Julie Frank
- Division of Genetics and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vincent Y See
- Cardiovascular Medicine Division and Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sudhir Vashist
- Division of Cardiology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carol Greene
- Division of Genetics and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
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Scheuner MT, Myrie K, Peredo J, Hoffman-Hogg L, Lundquist M, Guerra SL, Ball D. Integrating Germline Genetics Into Precision Oncology Practice in the Veterans Health Administration: Challenges and Opportunities. Fed Pract 2020; 37:S82-S88. [PMID: 32908356 DOI: 10.12788/fp.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objectives The advent of germline testing as a standard-of-care practice for certain tumor types and patients presents unique opportunities and challenges for the field of precision oncology. This article describes strategies to address workforce capacity, organizational structure, and genetics education needs within the US Department of Veterans Affairs (VA) with the expectation that these approaches may be applicable to other health care systems. Observations Germline information can have health, reproductive, and psychosocial implications for veterans and their family members, which can pose challenges when delivering germline information in the setting of cancer care. Additional challenges include the complexity inherent in the interpretation of germline information, the national shortage of genetics professionals, limited awareness and knowledge about genetic principles among many clinicians, and organizational barriers, such as the inability to order genetic tests and receive results in the electronic health record. These challenges demand thoughtful implementation planning at the health care system level to develop sustainable strategies for the delivery of high-quality genetic services in precision oncology practice. Conclusions The VA is uniquely positioned to address the integration of germline genetic testing into precision oncology practice due to its outsized role in treating veterans with cancer, training the health care workforce, and developing, testing, and implementing innovative models of clinical care.
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Affiliation(s)
- Maren T Scheuner
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
| | - Kenute Myrie
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
| | - Jane Peredo
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
| | - Lori Hoffman-Hogg
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
| | - Margaret Lundquist
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
| | - Stephanie L Guerra
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
| | - Douglas Ball
- is a Professor in Medicine and Pediatrics at the University of California, San Francisco School of Medicine and the Director of the Clinical Genetics Program, San Francisco US Department of Veteran Affairs (VA) Health Care System. is a Portfolio Manager for Oncology and Lead for Precision Oncology, Clinical Science Research and Development Service, VA Office of Research and Development is a Genetic Counselor at the Greater Los Angeles VA Healthcare System in California. is Program Manager for the Veterans Health Administration (VHA), National Center for Health Promotion and Disease Prevention in Durham, North Carolina, and National Oncology Clinical Advisor for the Office of Nurses Services in Washington, DC. is a Nurse Practitioner and is a Staff Physician with the Genomic Medicine Service, VHA Central Office. is an American Association for the Advancement of Science (AAAS) and Science and Technology Policy Fellow, VA Office of Research and Development
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Huang H, Cunningham AM, Harrington AM. Simple Laboratory Test Utilization Interventions to Reduce Inappropriate Specialty Coagulation Testing. Am J Clin Pathol 2020; 153:181-189. [PMID: 31602457 DOI: 10.1093/ajcp/aqz147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The naming convention in coagulation may cause confusion in electronic ordering systems, leading to inappropriate test orders. We implemented test utilization efforts and studied utilization before and after interventions for two specialty coagulation assays. METHODS Two interventions were implemented: test names were changed from factor assay to activity, and residents reviewed all factor V and X requests. A retrospective review of factor V and X activity orders was performed for the period 1 year before and after interventions. RESULTS After interventions, factor V and X activity orders decreased by approximately 40%. Resulted tests decreased by 53.8% and 47.8%, corresponding to reductions of $2,493.05 and $1,867.80 per year in laboratory charges for factor V and factor X activity, respectively. Abnormal factor V activity results increased from 45% to 59%. Factor V activity orders from outpatient clinics decreased by 21.6%. CONCLUSIONS Simple interventions can reduce inappropriate specialty coagulation test orders and unnecessary costs.
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Affiliation(s)
- Huiya Huang
- Department of Pathology, Medical College of Wisconsin, Milwaukee
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Santoro JD, Sandoval Karamian AG, Ruzhnikov M, Brimble E, Chadwick W, Wusthoff CJ. Use of electronic medical record templates improves quality of care for patients with infantile spasms. HEALTH INF MANAG J 2018; 50:47-54. [PMID: 30124080 DOI: 10.1177/1833358318794501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Infantile spasms (IS) is a neurologic disorder of childhood where time to treatment may affect long-term outcomes. Due to the clinical complexity of IS, care can be delayed. OBJECTIVE To determine if the use of electronic medical record templates (EMRTs) improved care quality in patients treated for IS. METHOD Records of patients newly diagnosed with IS were retrospectively reviewed both before and after creation of an EMRT for the workup and treatment of IS. Quality of care measures reviewed included delays in treatment plan, medication administration, obtaining neurodiagnostic studies and discharge. The need for repeat neurodiagnostic studies was also assessed. Resident physicians were surveyed regarding template ease of use and functionality. RESULTS Of 17 patients with IS, 7 received template-based care and 10 did not. Patients in the non-template group had more delays in treatment (p = 0.010), delay in medication administration (p = 0.10), delay in diagnostic studies (p = 0.01) and delay in discharge (p = 0.39). Neurodiagnostic studies needed to be repeated in 5 out of 10 patients in the non-template group and none of the 7 patients in the template group (p = 0.04). Surveyed resident physicians reported improved coordination in care, avoidance of delays in discharge and improved ability to predict side effects of treatment with template use. CONCLUSION In a single centre, the use of protocolised EMRTs decreased treatment delays and the need for repeated invasive procedures in patients with newly diagnosed IS and was reported as easy to use by resident physicians. IMPLICATIONS The use of protocolised EMRTs may improve the quality of patient care in IS and other rare diseases.
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Khoury MJ, Bowen MS, Clyne M, Dotson WD, Gwinn ML, Green RF, Kolor K, Rodriguez JL, Wulf A, Yu W. From public health genomics to precision public health: a 20-year journey. Genet Med 2017; 20:574-582. [PMID: 29240076 DOI: 10.1038/gim.2017.211] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 10/20/2017] [Indexed: 12/20/2022] Open
Abstract
In this paper, we review the evolution of the field of public health genomics in the United States in the past two decades. Public health genomics focuses on effective and responsible translation of genomic science into population health benefits. We discuss the relationship of the field to the core public health functions and essential services, review its evidentiary foundation, and provide examples of current US public health priorities and applications. We cite examples of publications to illustrate how Genetics in Medicine reflected the evolution of the field. We also reflect on how public-health genomics is contributing to the emergence of "precision public health" with near-term opportunities offered by the US Precision Medicine (AllofUs) Initiative.
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Affiliation(s)
- Muin J Khoury
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - M Scott Bowen
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mindy Clyne
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - W David Dotson
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Marta L Gwinn
- Office of Advanced Molecular Detection, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ridgely Fisk Green
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katherine Kolor
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Juan L Rodriguez
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anja Wulf
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Wei Yu
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Zhou Y, Procop GW, Riley JD. A Novel Approach to Improving Utilization of Laboratory Testing. Arch Pathol Lab Med 2017; 142:243-247. [DOI: 10.5858/arpa.2017-0031-oa] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
The incorporation of best practice guidelines into one's institution is a challenging goal of utilization management, and the successful adoption of such guidelines depends on institutional context. Laboratorians who have access to key clinical data are well positioned to understand existing local practices and promote more appropriate laboratory testing.
Objective.—
To apply a novel approach to utilization management by reviewing international clinical guidelines and current institutional practices to create a reliable mechanism to improve detection and reduce unnecessary tests in our patient population.
Design.—
We targeted a frequently ordered genetic test for HFE-related hereditary hemochromatosis, a disorder of low penetrance. After reviewing international practice guidelines, we evaluated 918 HFE tests and found that all patients with new diagnoses had transferrin saturation levels that were significantly higher than those of patients with nonrisk genotypes (72% versus 42%; P < .001).
Results.—
Our “one-button” order that restricts HFE genetic tests to patients with transferrin saturation greater than 45% is consistent with published practice guidelines and detected 100% of new patients with HFE-related hereditary hemochromatosis.
Conclusions.—
Our proposed algorithm differs from previously published approaches in that it incorporates both clinical practice guidelines and local physician practices, yet requires no additional hands-on effort from pathologists or clinicians. This novel approach to utilization management embraces the role of pathologists as leaders in promoting high-quality patient care in local health care systems.
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