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Raper AC, Weathers BL, Drivas TG, Ellis CA, Kripke CM, Oyer RA, Owens AT, Verma A, Wileyto PE, Wollack CC, Zhou W, Ritchie MD, Schnoll RA, Nathanson KL. Protocol for a type 3 hybrid implementation cluster randomized clinical trial to evaluate the effect of patient and clinician nudges to advance the use of genomic medicine across a diverse health system. Implement Sci 2024; 19:61. [PMID: 39160614 PMCID: PMC11331805 DOI: 10.1186/s13012-024-01385-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 07/14/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND Germline genetic testing is recommended for an increasing number of conditions with underlying genetic etiologies, the results of which impact medical management. However, genetic testing is underutilized in clinics due to system, clinician, and patient level barriers. Behavioral economics provides a framework to create implementation strategies, such as nudges, to address these multi-level barriers and increase the uptake of genetic testing for conditions where the results impact medical management. METHODS Patients meeting eligibility for germline genetic testing for a group of conditions will be identified using electronic phenotyping algorithms. A pragmatic, type 3 hybrid cluster randomization study will test nudges to patients and/or clinicians, or neither. Clinicians who receive nudges will be prompted to either refer their patient to genetics or order genetic testing themselves. We will use rapid cycle approaches informed by clinician and patient experiences, health equity, and behavioral economics to optimize these nudges before trial initiation. The primary implementation outcome is uptake of germline genetic testing for the pre-selected health conditions. Patient data collected through the electronic health record (e.g. demographics, geocoded address) will be examined as moderators of the effect of nudges. DISCUSSION This study will be one of the first randomized trials to examine the effects of patient- and clinician-directed nudges informed by behavioral economics on uptake of genetic testing. The pragmatic design will facilitate a large and diverse patient sample, allow for the assessment of genetic testing uptake, and provide comparison of the effect of different nudge combinations. This trial also involves optimization of patient identification, test selection, ordering, and result reporting in an electronic health record-based infrastructure to further address clinician-level barriers to utilizing genomic medicine. The findings may help determine the impact of low-cost, sustainable implementation strategies that can be integrated into health care systems to improve the use of genomic medicine. TRIAL REGISTRATION ClinicalTrials.gov. NCT06377033. Registered on March 31, 2024. https://clinicaltrials.gov/study/NCT06377033?term=NCT06377033&rank=1.
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Affiliation(s)
- Anna C Raper
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Benita L Weathers
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Theodore G Drivas
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Colin A Ellis
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen Morse Kripke
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Randall A Oyer
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anjali T Owens
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anurag Verma
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Paul E Wileyto
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Colin C Wollack
- Information Services Applications, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wenting Zhou
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Marylyn D Ritchie
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Schnoll
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research on Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine L Nathanson
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Ma A, O'Shea R, Wedd L, Wong C, Jamieson RV, Rankin N. What is the power of a genomic multidisciplinary team approach? A systematic review of implementation and sustainability. Eur J Hum Genet 2024; 32:381-391. [PMID: 38378794 PMCID: PMC10999446 DOI: 10.1038/s41431-024-01555-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 12/07/2023] [Accepted: 01/26/2024] [Indexed: 02/22/2024] Open
Abstract
Due to the increasing complexity of genomic data interpretation, and need for close collaboration with clinical, laboratory, and research expertise, genomics often requires a multidisciplinary team (MDT) approach. This systematic review aims to establish the evidence for effectiveness of the genomic multidisciplinary team, and the implementation components of this model that can inform precision care. MEDLINE, Embase and PsycINFO databases were searched in 2022 and 2023. We included qualitative and quantitative studies of the genomic MDT, including observational and cohort studies, for diagnosis and management, and implementation outcomes of effectiveness, adoption, efficiency, safety, and acceptability. A narrative synthesis was mapped against the Genomic Medicine Integrative Research framework. 1530 studies were screened, and 17 papers met selection criteria. All studies pointed towards the effectiveness of the genomic MDT approach, with 10-78% diagnostic yield depending on clinical context, and an increased yield of 6-25% attributed to the MDT. The genomic MDT was found to be highly efficient in interpretation of variants of uncertain significance, timeliness for a rapid result, made a significant impact on management, and was acceptable for adoption by a wide variety of subspecialists. Only one study utilized an implementation science based approach. The genomic MDT approach appears to be highly effective and efficient, facilitating higher diagnostic rates and improved patient management. However, key gaps remain in health systems readiness for this collaborative model, and there is a lack of implementation science based research especially addressing the cost, sustainability, scale up, and equity of access.
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Affiliation(s)
- Alan Ma
- Specialty of Genomic Medicine, University of Sydney, Sydney, NSW, Australia.
- Department of Clinical Genetics, Children's Hospital at Westmead, The Sydney Children's Hospitals Network, Sydney, NSW, Australia.
- Eye Genetics Research Unit, Children's Medical Research Institute, Sydney, NSW, Australia.
| | - Rosie O'Shea
- Specialty of Genomic Medicine, University of Sydney, Sydney, NSW, Australia
| | - Laura Wedd
- Department of Clinical Genetics, Children's Hospital at Westmead, The Sydney Children's Hospitals Network, Sydney, NSW, Australia
- Eye Genetics Research Unit, Children's Medical Research Institute, Sydney, NSW, Australia
| | - Claire Wong
- Specialty of Genomic Medicine, University of Sydney, Sydney, NSW, Australia
- Department of Clinical Genetics, Children's Hospital at Westmead, The Sydney Children's Hospitals Network, Sydney, NSW, Australia
| | - Robyn V Jamieson
- Specialty of Genomic Medicine, University of Sydney, Sydney, NSW, Australia
- Department of Clinical Genetics, Children's Hospital at Westmead, The Sydney Children's Hospitals Network, Sydney, NSW, Australia
- Eye Genetics Research Unit, Children's Medical Research Institute, Sydney, NSW, Australia
| | - Nicole Rankin
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
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Chambers DA, Emmons KM. Navigating the field of implementation science towards maturity: challenges and opportunities. Implement Sci 2024; 19:26. [PMID: 38481286 PMCID: PMC10936041 DOI: 10.1186/s13012-024-01352-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/09/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND The field of implementation science has significantly expanded in size and scope over the past two decades, although work related to understanding implementation processes have of course long preceded the more systematic efforts to improve integration of evidence-based interventions into practice settings. While this growth has had significant benefits to research, practice, and policy, there are some clear challenges that this period of adolescence has uncovered. MAIN BODY This invited commentary reflects on the development of implementation science, its rapid growth, and milestones in its establishment as a viable component of the biomedical research enterprise. The authors reflect on progress in research and training, and then unpack some of the consequences of rapid growth, as the field has grappled with the competing challenges of legitimacy among the research community set against the necessary integration and engagement with practice and policy partners. The article then enumerates a set of principles for the field's next developmental stage and espouses the aspirational goal of a "big tent" to support the next generation of impactful science. CONCLUSION For implementation science to expand its relevance and impact to practice and policy, researchers must not lose sight of the original purpose of the field-to support improvements in health and health care at scale, the importance of building a community of research and practice among key partners, and the balance of rigor, relevance, and societal benefit.
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Affiliation(s)
- David A Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Room 3E-414, Rockville, Bethesda, MD, 20850, USA.
| | - Karen M Emmons
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Okuyama S, White LL, Anderson KP, Medina E, Deutsch S, Ransom C, Jackson P, Kauffman TL, Mittendorf KF, Leo MC, Bulkley JE, Wilfond BS, Goddard KA, Feigelson HS. Evaluating cancer genetic services in a safety net system: overcoming barriers for a lasting impact beyond the CHARM research project. J Community Genet 2023:10.1007/s12687-023-00647-x. [PMID: 37126135 DOI: 10.1007/s12687-023-00647-x] [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: 11/08/2022] [Accepted: 04/14/2023] [Indexed: 05/02/2023] Open
Abstract
Underserved patients face substantial barriers to receiving cancer genetic services. The Cancer Health Assessments Reaching Many (CHARM) study evaluated ways to increase access to genetic testing for individuals in underserved populations at risk for hereditary cancer syndromes (HCS). Here, we report the successful implementation of CHARM in a low-resource environment and the development of sustainable processes to continue genetic risk assessment in this setting. The research team involved key clinical personnel and patient advisors at Denver Health to provide input on study methods and materials. Through iterative and collaborative stakeholder engagement, the team identified barriers and developed solutions that would both facilitate participation in CHARM and be feasible to implement and sustain long term in clinical care. With a focus on infrastructure building, educational modules were developed to increase awareness among referring providers, and standard methods of identifying and managing HCS patients were implemented in the electronic medical record. Three hundred sixty-four DH patients successfully completed the risk assessment tool within the study, and we observed a sustained increase in referrals to genetics for HCS (from 179 in 2017 to 427 in 2021 post-intervention). Implementation of the CHARM study at a low-resourced safety net health system resulted in sustainable improvements in access to cancer genetic risk assessment and services that continue even after the study ended.Trial registration NCT03426878.
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Affiliation(s)
- Sonia Okuyama
- Division of Oncology, Denver Health and Hospital Authority, Denver, CO, USA.
| | - Larissa L White
- Institute for Health Research, Kaiser Permanente, Aurora, CO, USA
| | | | - Elizabeth Medina
- Ambulatory Care Services, Denver Health and Hospital Authority, Denver, CO, USA
| | - Sonia Deutsch
- Ambulatory Care Services, Denver Health and Hospital Authority, Denver, CO, USA
| | | | - Paige Jackson
- Denver Health and Hospital Authority, Denver, CO, USA
| | - Tia L Kauffman
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | | | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Joanna E Bulkley
- Department of Translational and Applied Genomics, Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute and Hospital, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Katrina Ab Goddard
- Department of Translational and Applied Genomics, Kaiser Permanente Center for Health Research, Portland, OR, USA
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
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O'Shea R, Ma AS, Jamieson RV, Rankin NM. Precision medicine in Australia: now is the time to get it right. Med J Aust 2022; 217:559-563. [PMID: 36436133 PMCID: PMC10100177 DOI: 10.5694/mja2.51777] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 08/01/2022] [Accepted: 08/08/2022] [Indexed: 11/29/2022]
Affiliation(s)
| | - Alan S Ma
- University of Sydney, Sydney, NSW.,Western Sydney Genetics Program, Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, NSW
| | - Robyn V Jamieson
- University of Sydney, Sydney, NSW.,Western Sydney Genetics Program, Children's Hospital at Westmead, Sydney Children's Hospitals Network, Sydney, NSW
| | - Nicole M Rankin
- University of Sydney, Sydney, NSW.,Centre for Health Policy, University of Melbourne, Melbourne, VIC
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Roberts MC, Mader JM, Turbitt E, Smit AK, Landry L, Olstad DL, Passero LE, Allen CG. Using a Participatory Approach to Develop Research Priorities for Future Leaders in Cancer-Related Precision Public Health. Front Genet 2022; 13:881527. [PMID: 35754808 PMCID: PMC9218810 DOI: 10.3389/fgene.2022.881527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/02/2022] [Indexed: 11/21/2022] Open
Abstract
Precision public health is an emerging discipline combining principles and frameworks of precision health with the goal of improving population health. The development of research priorities drawing on the strengths of precision and public health is critical to facilitate the growth of the discipline to improve health outcomes. We held an interactive workshop during a virtual conference bringing together early-career researchers across public health disciplines to identify research priorities in precision public health. The workshop participants discussed and voted to identify three priority areas for future research and capacity building including 1) enhancing equity and access to precision public health research and resources, 2) improving tools and metrics for evaluation and 3) applying principles of implementation science to support sustainable practices. Participants also developed future objectives for achieving each priority. Future efforts by working groups will continue the process of identifying, revising, and advancing critical research priorities to grow the impact of precision public health.
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Affiliation(s)
- Megan C Roberts
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina, Chapel Hill, NC, United States
| | | | - Erin Turbitt
- Graduate School of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Amelia K Smit
- Daffodil Centre, A Joint Venture with Cancer Council NSW, The University of Sydney, Sydney, NSW, Australia.,Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - Latrice Landry
- Program for Cancer Care Equity, Dana Farber Cancer Institute, Boston, MA, United States
| | - Dana Lee Olstad
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lauren E Passero
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina, Chapel Hill, NC, United States
| | - Caitlin G Allen
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, United States
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Mittendorf KF, Knerr S, Kauffman TL, Lindberg NM, Anderson KP, Feigelson HS, Gilmore MJ, Hunter JE, Joseph G, Kraft SA, Zepp JM, Syngal S, Wilfond BS, Goddard KAB. Systemic Barriers to Risk-Reducing Interventions for Hereditary Cancer Syndromes: Implications for Health Care Inequities. JCO Precis Oncol 2021; 5:PO.21.00233. [PMID: 34778694 PMCID: PMC8585306 DOI: 10.1200/po.21.00233] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/21/2021] [Accepted: 09/28/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kathleen F. Mittendorf
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Sarah Knerr
- School of Public Health, University of Washington, Seattle, WA
| | - Tia L. Kauffman
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Nangel M. Lindberg
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | | | - Marian J. Gilmore
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Jessica Ezzell Hunter
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Galen Joseph
- Department of Humanities and Social Sciences, University of California, San Francisco, School of Medicine, San Francisco, CA
| | - Stephanie A. Kraft
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Jamilyn M. Zepp
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Sapna Syngal
- Dana Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Benjamin S. Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Katrina A. B. Goddard
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
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Oh A, Vinson CA, Chambers DA. Future directions for implementation science at the National Cancer Institute: Implementation Science Centers in Cancer Control. Transl Behav Med 2021; 11:669-675. [PMID: 32145023 DOI: 10.1093/tbm/ibaa018] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The National Cancer Institute (NCI) Cancer Moonshot initiative seeks to accelerate cancer research for the USA. One of the scientific priorities identified by the Moonshot's Blue Ribbon Panel (BRP) of scientific experts was the implementation of evidence-based approaches. In September 2019, the NCI launched the Implementation Science Centers in Cancer Control (ISC3 or "Centers") initiative to advance this Moonshot priority. The vision of the ISC3 is to promote the development of research centers to build capacity and research in high-priority areas of cancer control implementation science (e.g., scale-up and spread, sustainability and adaptation, and precision implementation), build implementation laboratories within community and clinical settings, improve the state of measurement and methods, and improve the adoption, implementation, and sustainment of evidence-based cancer control interventions. This paper highlights the research agenda, vision, and strategic direction for these Centers and encourages transdisciplinary scientists to learn more about opportunities to collaborate with these Centers.
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Affiliation(s)
- April Oh
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Cynthia A Vinson
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - David A Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
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Behavioral and Psychological Outcomes Associated with Skin Cancer Genetic Testing in Albuquerque Primary Care. Cancers (Basel) 2021; 13:cancers13164053. [PMID: 34439206 PMCID: PMC8394482 DOI: 10.3390/cancers13164053] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/28/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Genetic information is publicly available but research examining the best use of such information has not engaged diverse members of the public. We examined public reactions to melanoma genetic testing (using the melanocortin-1 receptor [MC1R] gene) in a study randomizing (like the flip of a coin) 600 diverse primary care patients to a MC1R test offer or usual care. We found that testing did not improve sun protection and skin cancer screening, nor did it lead worry to increase. However, groups less aware of their skin cancer risk, including those who thought their risk was “unlikely” at the start of the study, showed significant improvements in sun protection at three months. In conclusion, testing might be very helpful for certain people who have the most to learn about their risk, who may become motivated to protect themselves from the damaging effects of the sun as a result of skin cancer genetic testing. Abstract Public availability of genetic information is increasing; thus, efforts to improve diversity in basic and translational research in genomics is a top priority. Given the increasing U.S. incidence and mortality of melanoma, and the prevalence of common melanocortin-1 receptor (MC1R) gene melanoma risk variants in the general population, we examined genomic testing of MC1R for skin cancer risk in a randomized controlled trial in Albuquerque, New Mexico primary care. Participants were 48% Hispanic and were randomized 5:1 to a MC1R test invitation or usual care. We assessed 3 month sun protection, skin cancer screening, and skin cancer worry outcomes associated with testing, and key effect moderators (e.g., cancer risk perceptions, and skin cancer risk factors). Our findings indicate that the primary outcomes were unchanged by the MC1R test offer, test acceptance, and level of risk feedback. Moderator analyses showed that those with lower risk perception, and those with skin that readily tans, significantly increased their sun protection in response to higher than average risk feedback. Risk feedback did not prompt cancer worry, and average risk feedback did not erode existing sun protection. This study paves the way for the development of tailored strategies to address low skin cancer risk awareness in this understudied context of public health genomics.
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Sperber NR, Dong OM, Roberts MC, Dexter P, Elsey AR, Ginsburg GS, Horowitz CR, Johnson JA, Levy KD, Ong H, Peterson JF, Pollin TI, Rakhra-Burris T, Ramos MA, Skaar T, Orlando LA. Strategies to Integrate Genomic Medicine into Clinical Care: Evidence from the IGNITE Network. J Pers Med 2021; 11:647. [PMID: 34357114 PMCID: PMC8306482 DOI: 10.3390/jpm11070647] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/29/2021] [Accepted: 07/02/2021] [Indexed: 11/16/2022] Open
Abstract
The complexity of genomic medicine can be streamlined by implementing some form of clinical decision support (CDS) to guide clinicians in how to use and interpret personalized data; however, it is not yet clear which strategies are best suited for this purpose. In this study, we used implementation science to identify common strategies for applying provider-based CDS interventions across six genomic medicine clinical research projects funded by an NIH consortium. Each project's strategies were elicited via a structured survey derived from a typology of implementation strategies, the Expert Recommendations for Implementing Change (ERIC), and follow-up interviews guided by both implementation strategy reporting criteria and a planning framework, RE-AIM, to obtain more detail about implementation strategies and desired outcomes. We found that, on average, the three pharmacogenomics implementation projects used more strategies than the disease-focused projects. Overall, projects had four implementation strategies in common; however, operationalization of each differed in accordance with each study's implementation outcomes. These four common strategies may be important for precision medicine program implementation, and pharmacogenomics may require more integration into clinical care. Understanding how and why these strategies were successfully employed could be useful for others implementing genomic or precision medicine programs in different contexts.
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Affiliation(s)
- Nina R. Sperber
- Duke Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27701, USA
- Durham VA Health Care System, Durham, NC 27705, USA
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC 27708, USA; (O.M.D.); (G.S.G.); (T.R.-B.); (L.A.O.)
| | - Olivia M. Dong
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC 27708, USA; (O.M.D.); (G.S.G.); (T.R.-B.); (L.A.O.)
| | - Megan C. Roberts
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Paul Dexter
- Regenstrief Institute, Indianapolis, Indiana University School of Medicine and Clem McDonald Center for Biomedical Informatics, Indianapolis, IN 46202, USA;
| | - Amanda R. Elsey
- Center for Pharmacogenomics and Precision Medicine, Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL 32610, USA; (A.R.E.); (J.A.J.)
| | - Geoffrey S. Ginsburg
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC 27708, USA; (O.M.D.); (G.S.G.); (T.R.-B.); (L.A.O.)
| | - Carol R. Horowitz
- Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Julie A. Johnson
- Center for Pharmacogenomics and Precision Medicine, Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL 32610, USA; (A.R.E.); (J.A.J.)
| | - Kenneth D. Levy
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, 950 W. Walnut Street, Indianapolis, IN 46202, USA; (K.D.L.); (T.S.)
| | - Henry Ong
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (H.O.); (J.F.P.)
| | - Josh F. Peterson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37232, USA; (H.O.); (J.F.P.)
| | - Toni I. Pollin
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Tejinder Rakhra-Burris
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC 27708, USA; (O.M.D.); (G.S.G.); (T.R.-B.); (L.A.O.)
| | - Michelle A. Ramos
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Todd Skaar
- Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, 950 W. Walnut Street, Indianapolis, IN 46202, USA; (K.D.L.); (T.S.)
| | - Lori A. Orlando
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC 27708, USA; (O.M.D.); (G.S.G.); (T.R.-B.); (L.A.O.)
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Phillips KA, Douglas MP, Wordsworth S, Buchanan J, Marshall DA. Availability and funding of clinical genomic sequencing globally. BMJ Glob Health 2021; 6:bmjgh-2020-004415. [PMID: 33574068 PMCID: PMC7880109 DOI: 10.1136/bmjgh-2020-004415] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/06/2023] Open
Abstract
The emergence of next-generation genomic sequencing (NGS) tests for use in clinical care has generated widespread interest around the globe, but little is known about the availability and funding of these tests worldwide. We examined NGS availability across world regions and countries, with a particular focus on availability of three key NGS tests—Whole-Exome Sequencing or Whole-Genome Sequencing for diagnosis of suspected genetic diseases such as intellectual disability disorders or rare diseases, non-invasive prenatal testing for common genetic abnormalities in fetuses and tumor sequencing for therapy selection and monitoring of cancer treatment. We found that these NGS tests are available or becoming available in every major region of the world. This includes both high-income countries with robust genomic programmes such as the USA and the UK, and growing availability in countries with upper-middle-income economies. We used exploratory case studies across three diverse health care systems (publicly funded/national (UK), publicly funded/provincial (Canada) and mixed private/public system (USA)) to illustrate the funding challenges and approaches used to address those challenges that might be adopted by other countries. We conclude by assessing what type of data and initiatives will be needed to better track and understand the use of NGS around the world as such testing continues to expand.
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Affiliation(s)
- Kathryn A Phillips
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS); Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Michael P Douglas
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS); Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - Deborah A Marshall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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12
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Allen CG, Peterson S, Khoury MJ, Brody LC, McBride CM. A scoping review of social and behavioral science research to translate genomic discoveries into population health impact. Transl Behav Med 2021; 11:901-911. [PMID: 32902617 PMCID: PMC8240657 DOI: 10.1093/tbm/ibaa076] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Since the completion of the Human Genome Project, progress toward translating genomic research discoveries to address population health issues has been limited. Several meetings of social and behavioral scientists have outlined priority research areas where advancement of translational research could increase population health benefits of genomic discoveries. In this review, we track the pace of progress, study size and design, and focus of genomics translational research from 2012 to 2018 and its concordance with five social and behavioral science recommended priorities. We conducted a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines for Scoping Reviews. Steps involved completing a search in five databases and a hand search of bibliographies of relevant literature. Our search (from 2012 to 2018) yielded 4,538 unique studies; 117 were included in the final analyses. Two coders extracted data including items from the PICOTS framework. Analysis included descriptive statistics to help identify trends in pace, study size and design, and translational priority area. Among the 117 studies included in our final sample, nearly half focused on genomics applications that have evidence to support translation or implementation into practice (Centers for Disease Control and Prevention Tier 1 applications). Common study designs were cross-sectional (40.2%) and qualitative (24.8%), with average sample sizes of 716 across all studies. Most often, studies addressed public understanding of genetics and genomics (33.3%), risk communication (29.1%), and intervention development and testing of interventions to promote behavior change (19.7%). The number of studies that address social and behavioral science priority areas is extremely limited and the pace of this research continues to lag behind basic science advances. Much of the research identified in this review is descriptive and related to public understanding, risk communication, and intervention development and testing of interventions to promote behavior change. The field has been slow to develop and evaluate public health-friendly interventions and test implementation approaches that could enable health benefits and equitable access to genomic discoveries. As the completion of the human genome approaches its 20th anniversary, full engagement of transdisciplinary efforts to address translation challenges will be required to close this gap.
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Affiliation(s)
- Caitlin G Allen
- Behavioral, Social and Health Education Sciences Department, Emory University, Atlanta, GA, USA
| | - Shenita Peterson
- Woodruff Health Science Center Library, Emory University, Atlanta, GA, USA
| | - Muin J Khoury
- Office of Genomics and Precision Public Health, Office of Science, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Lawrence C Brody
- Gene and Environment Interaction Section, National Human Genome Research Institute, Bethesda, MD, USA
| | - Colleen M McBride
- Behavioral, Social and Health Education Sciences Department, Emory University, Atlanta, GA, USA
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13
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Returning genomic results in a Federally Qualified Health Center: the intersection of precision medicine and social determinants of health. Genet Med 2020; 22:1552-1559. [PMID: 32371921 PMCID: PMC7483616 DOI: 10.1038/s41436-020-0806-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 03/05/2020] [Accepted: 04/01/2020] [Indexed: 12/16/2022] Open
Abstract
Purpose: This report describes the return of sequencing results to low-income Latino participants recruited through a Federally Qualified Health Center (FQHC). We describe challenges in returning research results secondary to social determinants of health and present lessons learned to guide future genomic medicine implementation studies in low resource settings. Methods: 500 Latino adults (76% women) consented to research sequencing for a predetermined panel of actionable genes. Providers and staff from the FQHC were engaged to align processes with the practice and a Community Advisory Board grounded the project in the local community. Results: A pathogenic/likely pathogenic variant was present in 10 participants (2%). Challenges in return of results included the time lag (582±53 days) between enrollment and returning actionable results, difficulty reaching participants, missed appointments, low health literacy, lack of health insurance, and reconciling results with limited information on family history. Return of one actionable result was deferred due to acute emotional distress secondary to recent traumatic life events. Conclusion: The social determinants of health influence the implementation of genomic medicine in low-income populations in low-resource settings. Considering non-biological factors that contribute to disparities will be necessary to better appreciate how genomic medicine may fit within the context of health equity.
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14
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Allen CG, Duquette D, Guan Y, McBride CM. Applying theory to characterize impediments to dissemination of community-facing family health history tools: a review of the literature. J Community Genet 2020; 11:147-159. [PMID: 31267271 PMCID: PMC7062972 DOI: 10.1007/s12687-019-00424-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/30/2019] [Indexed: 10/26/2022] Open
Abstract
Uptake of community-facing family health history (FHH) tools to identify those at highest risk of disease and target prevention efforts has been consistently low. This review uses the diffusion of innovations (DOI) as a framework to organize the FHH evidence base and identify potential strategies to improve uptake of community-facing FHH tools. Methods for this literature review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We completed systematic searches in PubMed, Embase, and Web of Science databases for studies from 2009 to 2017 and hand searched bibliographies of relevant literature to identify additional articles. We abstracted and synthesized results, which were then organized by the DOI including the innovation-decision making process and characteristics of the innovation likely to influence diffusion (e.g., compatibility, relative advantage, complexity, trialability, observa/bility). Of the 290 unique articles identified, 65 were eligible for full-text review after title and abstract screening; a total of 27 were included in the final abstraction. Eleven unique tools were identified. The most commonly used tool was the Surgeon General's My Family Health Portrait (n =9/27). Only six studies directly evaluated participant perceptions shown to be associated with tool uptake. Studies tended to focus on improving compatibility by customizing tools to the target population's needs and use of educational interventions. Results from this review suggest the need to evaluate strategies to increase the pace of uptake of community-facing FHH tools. These include pragmatic trials that compare different approaches to engage and evaluate participant perceptions of the relative advantage and complexity of tools. Ancillary support strategies may include collaborations with community networks to facilitate use and implementation study designs for rigorous evaluation.
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Affiliation(s)
- Caitlin G Allen
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30308, USA.
| | - Debra Duquette
- Feinberg School of Medicine, Northwestern University, 420 East Superior Street, Chicago, IL, 60611, USA
| | - Yue Guan
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30308, USA
| | - Colleen M McBride
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30308, USA
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15
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O'Donnell CJ. Opportunities, challenges and expectations management for translating biobank research to precision medicine. Eur J Epidemiol 2020; 35:1-4. [PMID: 32107740 DOI: 10.1007/s10654-020-00616-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 01/30/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Christopher J O'Donnell
- VA Boston Healthcare System, West Roxbury VA Medical Center, Cardiology Section, 5B-113, 1400 VFW Parkway, Boston, MA, 02132, USA. .,Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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16
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Boyce CA, Barfield W, Curry J, Shero S, Green Parker M, Cox H, Bustillo J, Price LN. Building the Next Generation of Implementation Science Careers to Advance Health Equity. Ethn Dis 2019; 29:77-82. [PMID: 30906153 DOI: 10.18865/ed.29.s1.77] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Rapid advancements in translational research have produced innovative clinical discoveries and evidence-based interventions that are ready for uptake in real-world settings, creating vast opportunities and challenges for implementation science. However, there is an inadequate research workforce to study effective strategies and delivery of implementation to advance the field. Novel career development initiatives will build scholars for the next generation of implementation science to bridge research to practice for diverse populations to advance health equity, specifically with a strategic focus on heart, lung, blood and sleep diseases and conditions. Along with traditional mentoring and curricula, research training includes state-of-the-art approaches using complex methods and multi-disciplinary collaborations between researchers, practice settings, and diverse communities. Implementation science scholars strive not only to decrease the lag time between the discovery of evidence-based interventions and successful implementation but also how to advance health equity and to reduce disparities for underserved populations that suffer disproportionally.
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Affiliation(s)
- Cheryl Anne Boyce
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - Whitney Barfield
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - Jennifer Curry
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - Susan Shero
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - Melissa Green Parker
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - Helen Cox
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - Jazmin Bustillo
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - LeShawndra N Price
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
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