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Baker EK, Shikany A, Winlaw DS, Weaver KN. Phenotypes and genotypes in a cohort of children with single-ventricle CHD. Cardiol Young 2024; 34:815-821. [PMID: 37850440 DOI: 10.1017/s1047951123003505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE CHD is known to be associated with increased risk for neurodevelopmental disorders. The combination of CHD with neurodevelopmental disorders and/or extra-cardiac anomalies increases the chance for an underlying genetic diagnosis. Over the last 15 years, there has been a dramatic increase in the use of broad-scale genetic testing. We sought to determine if neurodevelopmental disorders in children with single-ventricle CHD born prior to the genetic testing revolution are associated with genetic diagnosis. METHODS We identified 74 5-12-year-old patients with single-ventricle CHD post-Fontan procedure. We retrospectively evaluated genetic testing performed and neurodevelopmental status of these patients. RESULTS In this cohort, there was an overall higher rate of neurodevelopmental disorders (80%) compared to the literature (50%). More of the younger (5-7-year-old) patients were seen by genetic counsellors compared to the older (8-12-year-old) cohort (46% versus 19% p value = 0.01). In the younger cohort, the average age of initial consultation was 7.7 days compared to 251 days in the older cohort. The overall rate of achieving a molecular diagnosis was 12% and 8% in the younger and older cohorts, respectively; however, the vast majority of did not have broad genetic testing. CONCLUSION The minority of patients in our cohort achieved a genetic diagnosis. Given a large increase in the number of genes associated with monogenic CHD and neurodevelopmental disorders in the last decade, comprehensive testing and consultation with clinical genetics should be considered in this age range, since current testing standards did not exist during their infancy.
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Affiliation(s)
- Elizabeth K Baker
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Amy Shikany
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David S Winlaw
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Heart Institute, Cardiothoracic Surgery, Cincinnati Children's Hospital Medicine, Cincinnati, OH, USA
| | - K Nicole Weaver
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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2
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Ji J, Leung ML. Clinical Utility and Long-Term Feasibility of Exome and Genome Reanalysis: From the Perspectives of a Clinical Laboratory. J Appl Lab Med 2024; 9:162-167. [PMID: 38167756 DOI: 10.1093/jalm/jfad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/28/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Jianling Ji
- Center for Personalized Medicine, Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA, United States
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Marco L Leung
- Department of Pathology and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, United States
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3
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D'Gama AM, Agrawal PB. Genomic medicine in neonatal care: progress and challenges. Eur J Hum Genet 2023; 31:1357-1363. [PMID: 37789085 PMCID: PMC10689757 DOI: 10.1038/s41431-023-01464-z] [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: 05/24/2023] [Revised: 09/01/2023] [Accepted: 09/13/2023] [Indexed: 10/05/2023] Open
Abstract
During the neonatal period, many genetic disorders present and contribute to neonatal morbidity and mortality. Genomic medicine-the use of genomic information in clinical care- has the potential to significantly reduce morbidity and mortality in the neonatal period and improve outcomes for this population. Diagnostic genomic testing for symptomatic newborns, especially rapid testing, has been shown to be feasible and have diagnostic and clinical utility, particularly in the short-term. Ongoing studies are assessing the feasibility and utility, including personal utility, of implementation in diverse populations. Genomic screening for asymptomatic newborns has also been studied, and the acceptability and feasibility of such an approach remains an active area of investigation. Emerging precision therapies, with examples even at the "n-of-1" level, highlight the promise of precision diagnostics to lead to early intervention and improve outcomes. To sustainably implement genomic medicine in neonatal care in an ethical, effective, and equitable manner, we need to ensure access to genetics and genomics knowledge, access to genomic tests, which is currently limited by payors, feasible processes for ordering these tests, and access to follow up in the clinical and research realms. Future studies will provide further insight into enablers and barriers to optimize implementation strategies.
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Affiliation(s)
- Alissa M D'Gama
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA
| | - Pankaj B Agrawal
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA.
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, USA.
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Holtz Children's Hospital, Jackson Health System, Miami, FL, USA.
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4
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Rosenberg A, Tian C, He H, Ulm E, Collins Ruff K, B Nagaraj C. An evaluation of clinical presentation and genetic testing approaches for patients with neuromuscular disorders. Am J Med Genet A 2023; 191:2679-2692. [PMID: 37503964 DOI: 10.1002/ajmg.a.63356] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/20/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023]
Abstract
Inherited neuromuscular disorders (NMDs) are a large group of genetic conditions characterized by impaired peripheral nerve, motor neuron, neuromuscular junction, or skeletal muscle function. These conditions are also known to have clinical and genetic heterogeneity and variable ages of onset. Clinical evaluation for NMDs has increasingly incorporated molecular genetics. However, genetic testing is complicated by the variety of testing options and the ambiguity of NMD phenotypes. Examining test selection and yield may elucidate testing recommendations and improve the diagnostic journey for these patients. This retrospective chart review evaluated the clinical presentations, genetic testing approaches, and diagnostic outcomes of 155 patients with suspected NMDs at Cincinnati Children's Hospital Medical Center. A total of 262 individual tests were ordered, averaging 1.7 tests per patient. The clinic utilized 26 separate genetic tests, with test yields ranging from 0% to 66%. Overall, 21% of patients received a genetic diagnosis. Of all the clinical findings evaluated, elevated CPK levels with or without muscle weakness were the most informative symptoms correlated with a diagnostic result. This study highlights several genetic testing considerations for NMDs, including the variability of diagnostic outcomes. This knowledge is relevant to clinicians and patients, especially during the pretest counseling and consenting process.
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Affiliation(s)
- Amanda Rosenberg
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Cuixia Tian
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Hua He
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Elizabeth Ulm
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Chinmayee B Nagaraj
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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5
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Douglas MP, Ragavan MV, Chen C, Kumar A, Gray SW, Blakely CM, Phillips KA. Private Payer and Medicare Coverage Policies for Use of Circulating Tumor DNA Tests in Cancer Diagnostics and Treatment. J Natl Compr Canc Netw 2023; 21:609-616.e4. [PMID: 37308126 PMCID: PMC10846388 DOI: 10.6004/jnccn.2023.7011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 02/07/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Circulating tumor DNA (ctDNA) is used to select initial targeted therapy, identify mechanisms of therapeutic resistance, and measure minimal residual disease (MRD) after treatment. Our objective was to review private and Medicare coverage policies for ctDNA testing. METHODS Policy Reporter was used to identify coverage policies (as of February 2022) from private payers and Medicare Local Coverage Determinations (LCDs) for ctDNA tests. We abstracted data regarding policy existence, ctDNA test coverage, cancer types covered, and clinical indications. Descriptive analyses were performed by payer, clinical indication, and cancer type. RESULTS A total of 71 of 1,066 total policies met study inclusion criteria, of which 57 were private policies and 14 were Medicare LCDs; 70% of private policies and 100% of Medicare LCDs covered at least one indication. Among 57 private policies, 89% specified a policy for at least 1 clinical indication, with coverage for ctDNA for initial treatment selection most common (69%). Of 40 policies addressing progression, coverage was provided 28% of the time, and of 20 policies addressing MRD, coverage was provided 65% of the time. Non-small cell lung cancer (NSCLC) was the cancer type most frequently covered for initial treatment (47%) and progression (60%). Among policies with ctDNA coverage, coverage was restricted to patients without available tissue or in whom biopsy was contraindicated in 91% of policies. MRD was commonly covered for hematologic malignancies (30%) and NSCLC (25%). Of the 14 Medicare LCD policies, 64% provided coverage for initial treatment selection and progression, and 36% for MRD. CONCLUSIONS Some private payers and Medicare LCDs provide coverage for ctDNA testing. Private payers frequently cover testing for initial treatment, especially for NSCLC, when tissue is insufficient or biopsy is contraindicated. Coverage remains variable across payers, clinical indications, and cancer types despite inclusion in clinical guidelines, which could impact delivery of effective cancer care.
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Affiliation(s)
- Michael P. Douglas
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California
| | - Meera V. Ragavan
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California
| | - Cheng Chen
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California
- Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, California
| | - Anika Kumar
- UCSF School of Medicine, San Francisco, California
| | - Stacy W. Gray
- Department of Population Science, City of Hope, Duarte, California
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California
| | - Collin M. Blakely
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California
- UCSF Thoracic Oncology Program, University of California San Francisco, San Francisco, California
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Kathryn A. Phillips
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California
- Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, California
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
- UCSF Philip R. Lee Institute for Health Policy, San Francisco, California
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6
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Streff H, Uhles CL, Fisher H, Franciskovich R, Littlejohn RO, Gerard A, Hudnall J, Smith HS. Access to clinically indicated genetic tests for pediatric patients with Medicaid: Evidence from outpatient genetics clinics in Texas. Genet Med 2023; 25:100350. [PMID: 36547467 DOI: 10.1016/j.gim.2022.11.018] [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: 06/03/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Little is known about how Medicaid coverage policies affect access to genetic tests for pediatric patients. Building upon and extending a previous analysis of prior authorization requests (PARs), we describe expected coverage of genetic tests submitted to Texas Medicaid and the PAR and diagnostic outcomes of those tests. METHODS We retrospectively reviewed genetic tests ordered at 3 pediatric outpatient genetics clinics in Texas. We compared Current Procedural Terminology (CPT) codes with the Texas Medicaid fee-for-service schedule (FFSS) to determine whether tests were expected to be covered by Medicaid. We assessed completion and diagnostic yield of commonly ordered tests. RESULTS Among the 3388 total tests submitted to Texas Medicaid, 68.9% (n = 2336) used at least 1 CPT code that was not on the FFSS and 80.7% (n = 2735) received a favorable PAR outcome. Of the tests with a CPT code not on the FFSS, 60.0% (n = 1400) received a favorable PAR outcome and were completed and 20.5% (n = 287) were diagnostic. The diagnostic yield of all tests with a favorable PAR outcome that were completed was 18.7% (n = 380/2029). CONCLUSION Most PARs submitted to Texas Medicaid used a CPT code for which reimbursement from Texas Medicaid was not guaranteed. The frequency with which clinically indicated genetic tests were not listed on the Texas Medicaid FFSS suggests misalignment between genetic testing needs and coverage policies. Our findings can inform updates to Medicaid policies to reduce coverage uncertainty and expand access to genetic tests with high diagnostic utility.
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Affiliation(s)
- Haley Streff
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX.
| | - Crescenda L Uhles
- Department of Genetics and Metabolism, Children's Medical Center, Dallas, TX
| | - Heather Fisher
- Department of Genetics and Metabolism, Children's Medical Center, Dallas, TX
| | - Rachel Franciskovich
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | | | - Amanda Gerard
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Julianna Hudnall
- Department of Genetics and Metabolism, Children's Medical Center, Dallas, TX
| | - Hadley Stevens Smith
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
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7
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Lee G, Yu L, Suarez CJ, Stevenson DA, Ling A, Killer L. Factors associated with the time to complete clinical exome sequencing in a pediatric patient population. Genet Med 2022; 24:2028-2033. [PMID: 35951015 DOI: 10.1016/j.gim.2022.06.006] [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: 01/21/2022] [Revised: 06/16/2022] [Accepted: 06/21/2022] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Exome sequencing (ES) is becoming increasingly important for diagnosing rare genetic disorders. Patients and clinicians face several barriers when attempting to obtain ES. This study is aimed to describe factors associated with a longer time interval between provider recommendation of testing and sample collection for ES. METHODS A retrospective chart review was conducted for insurance-authorized, completed pediatric ES in which initial requests were reviewed by Stanford's Genetic Testing Optimization Service between November 2018 and December 2019. Regression analysis was used to determine the association between the geocoded median household income and 3 different time point intervals defined as time to test, insurance decision, and scheduling/consent. RESULTS Of the 281 charts reviewed, 115 cases were included in the final cohort. The average time from provider preauthorization request to sample collection took 104.4 days, and income was negatively correlated with the length of the insurance decision interval. CONCLUSION Pediatric patients undergo a lengthy, uncertain process when attempting to obtain ES, some of which is associated with income. More research and clinician interventions are required to clarify specific socioeconomic factors that influence the ability to obtain timely ES and develop optimal protocols.
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Affiliation(s)
- Gabriella Lee
- Human Genetics and Genetic Counseling Master's Program, Stanford Medicine, Stanford, CA
| | - Linbo Yu
- Stanford Hospitals and Clinics Genetic Testing Optimization Service, Stanford Medicine, Stanford, CA
| | - Carlos J Suarez
- Stanford Hospitals and Clinics Genetic Testing Optimization Service, Stanford Medicine, Stanford, CA; Department of Pathology, Stanford University, Stanford, CA
| | - David A Stevenson
- Stanford Hospitals and Clinics Genetic Testing Optimization Service, Stanford Medicine, Stanford, CA; Division of Medical Genetics, Department of Pediatrics, Stanford University, Stanford, CA
| | - Albee Ling
- Quantitative Sciences Unit, Stanford University, Palo Alto, CA
| | - Lindsay Killer
- Stanford Hospitals and Clinics Genetic Testing Optimization Service, Stanford Medicine, Stanford, CA.
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8
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Lavelle TA, Feng X, Keisler M, Cohen JT, Neumann PJ, Prichard D, Schroeder BE, Salyakina D, Espinal PS, Weidner SB, Maron JL. Cost-effectiveness of exome and genome sequencing for children with rare and undiagnosed conditions. Genet Med 2022; 24:1349-1361. [PMID: 35396982 DOI: 10.1016/j.gim.2022.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/01/2022] [Accepted: 03/03/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE This study aimed to estimate the cost-effectiveness of exome sequencing (ES) and genome sequencing (GS) for children. METHODS We modeled costs, diagnoses, and quality-adjusted life years (QALYs) for diagnostic strategies for critically ill infants (aged <1 year) and children (aged <18 years) with suspected genetic conditions: (1) standard of care (SOC) testing, (2) ES, (3) GS, (4) SOC followed by ES, (5) SOC followed by GS, (6) ES followed by GS, and (7) SOC followed by ES followed by GS. We calculated the 10-year incremental cost per additional diagnosis, and lifetime incremental cost per QALY gained, from a health care perspective. RESULTS First-line GS costs $15,048 per diagnosis vs SOC for infants and $27,349 per diagnosis for children. If GS is unavailable, ES represents the next most efficient option compared with SOC ($15,543 per diagnosis for infants and $28,822 per diagnosis for children). Other strategies provided the same or fewer diagnoses at a higher incremental cost per diagnosis. Lifetime results depend on the patient's assumed long-term prognosis after diagnosis. For infants, GS ranged from cost-saving (vs all alternatives) to $18,877 per QALY (vs SOC). For children, GS (vs SOC) ranged from $119,705 to $490,047 per QALY. CONCLUSION First-line GS may be the most cost-effective strategy for diagnosing infants with suspected genetic conditions. For all children, GS may be cost-effective under certain assumptions. ES is nearly as efficient as GS and hence is a viable option when GS is unavailable.
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Affiliation(s)
- Tara A Lavelle
- Center for the Evaluation of Value and Risk in Health (CEVR), Tufts Medical Center, Boston, MA.
| | - Xue Feng
- Center for the Evaluation of Value and Risk in Health (CEVR), Tufts Medical Center, Boston, MA
| | - Marlena Keisler
- Center for the Evaluation of Value and Risk in Health (CEVR), Tufts Medical Center, Boston, MA
| | - Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health (CEVR), Tufts Medical Center, Boston, MA
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health (CEVR), Tufts Medical Center, Boston, MA
| | | | | | - Daria Salyakina
- Personalized Medicine and Health Outcomes Research, Nicklaus Children's Hospital, Miami, FL
| | - Paula S Espinal
- Personalized Medicine and Health Outcomes Research, Nicklaus Children's Hospital, Miami, FL
| | - Samuel B Weidner
- Center for the Evaluation of Value and Risk in Health (CEVR), Tufts Medical Center, Boston, MA
| | - Jill L Maron
- Women & Infants Hospital of Rhode Island, Care New England Health System, Providence, RI
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Lippa N, Bier L, Revah-Politi A, May H, Kushary S, Vena N, Giordano JL, Rasouly HM, Cocchi E, Sands TT, Wapner RJ, Anyane-Yeboa K, Gharavi AG, Goldstein DB. Diagnostic sequencing to support genetically stratified medicine in a tertiary care setting. Genet Med 2022; 24:862-869. [PMID: 35078725 DOI: 10.1016/j.gim.2021.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The goal of stratified medicine is to identify subgroups of patients with similar disease mechanisms and specific responses to treatments. To prepare for stratified clinical trials, genome-wide genetic analysis should occur across clinical areas to identify undiagnosed genetic diseases and new genetic causes of disease. METHODS To advance genetically stratified medicine, we have developed and implemented broad exome sequencing infrastructure and research protocols at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital. RESULTS We enrolled 4889 adult and pediatric probands and identified a primary result in 572 probands. The cohort was phenotypically and demographically heterogeneous because enrollment occurred across multiple specialty clinics (eg, epilepsy, nephrology, fetal anomaly). New gene-disease associations and phenotypic expansions were discovered across clinical specialties. CONCLUSION Our study processes have enabled the enrollment and exome sequencing/analysis of a phenotypically and demographically diverse cohort of patients within 1 tertiary care medical center. Because all genomic data are stored centrally with permission for longitudinal access to the electronic medical record, subjects can be recontacted with updated genetic diagnoses or for participation in future genotype-based clinical trials. This infrastructure has allowed for the promotion of genetically stratified clinical trial readiness within the Columbia University Irving Medical Center/NewYork-Presbyterian Hospital health care system.
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Affiliation(s)
- Natalie Lippa
- Institiute for Genomic Medicine, Columbia University Irving Medical Center, New York, NY
| | - Louise Bier
- Institiute for Genomic Medicine, Columbia University Irving Medical Center, New York, NY
| | - Anya Revah-Politi
- Institiute for Genomic Medicine, Columbia University Irving Medical Center, New York, NY; Precision Genomics Laboratory, Columbia University Irving Medical Center, New York, NY
| | - Halie May
- Institiute for Genomic Medicine, Columbia University Irving Medical Center, New York, NY
| | - Sulagna Kushary
- Institiute for Genomic Medicine, Columbia University Irving Medical Center, New York, NY
| | - Natalie Vena
- Institiute for Genomic Medicine, Columbia University Irving Medical Center, New York, NY; Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Jessica L Giordano
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
| | - Hila Milo Rasouly
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Enrico Cocchi
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Tristan T Sands
- Institiute for Genomic Medicine, Columbia University Irving Medical Center, New York, NY; Division of Child Neurology, Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | - Ronald J Wapner
- Institiute for Genomic Medicine, Columbia University Irving Medical Center, New York, NY; Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
| | - Kwame Anyane-Yeboa
- Institiute for Genomic Medicine, Columbia University Irving Medical Center, New York, NY; Division of Clinical Genetics, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Ali G Gharavi
- Institiute for Genomic Medicine, Columbia University Irving Medical Center, New York, NY; Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - David B Goldstein
- Institiute for Genomic Medicine, Columbia University Irving Medical Center, New York, NY.
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10
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Current Trends in Genetics and Neonatal Care. Adv Neonatal Care 2021; 21:473-481. [PMID: 33538495 DOI: 10.1097/anc.0000000000000834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Genetic and genomic health applications are rapidly changing. A clear and updated description of these applications for the neonatal population is needed to guide current nursing practice. PURPOSE To provide scientific evidence and guidance on the current genetic and genomic applications pertinent to neonatal care. METHODS A search of CINAHL and PubMed was conducted using the search terms "newborn/neonatal" and "genetics," "genomics," "newborn screening," "pharmacogenomics," "ethical," and "legal." Google searches were also conducted to synthesize professional guidelines, position statements, and current genetic practices. FINDINGS/RESULTS Components of the newborn genetic assessment, including details on the newborn physical examination, family history, and laboratory tests pertinent to the newborn, are reported. The history and process of newborn screening are described, in addition to the impact of advancements, such as whole exome and genome sequencing, on newborn screening. Pharmacogenomics, a genomic application that is currently utilized primarily in the research context for neonates, is described and future implications stated. Finally, the specific ethical and legal implications for these genetic and genomic applications are detailed, along with genetic/genomic resources for nurses. IMPLICATIONS FOR PRACTICE Providing nurses with the most up-to-date evidence on genetic and genomic applications ensures their involvement and contributions to quality neonatal care. IMPLICATIONS FOR RESEARCH Ongoing genetic/genomic research is needed to understand the implications of genetic/genomic applications on the neonatal population and how these new applications will change neonatal care.
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11
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Schroeder BE, Gonzaludo N, Everson K, Than KS, Sullivan J, Taft RJ, Belmont JW. The diagnostic trajectory of infants and children with clinical features of genetic disease. NPJ Genom Med 2021; 6:98. [PMID: 34811359 PMCID: PMC8609026 DOI: 10.1038/s41525-021-00260-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/21/2021] [Indexed: 11/09/2022] Open
Abstract
We characterized US pediatric patients with clinical indicators of genetic diseases, focusing on the burden of disease, utilization of genetic testing, and cost of care. Curated lists of diagnosis, procedure, and billing codes were used to identify patients with clinical indicators of genetic disease in healthcare claims from Optum's de-identified Clinformatics® Database (13,076,038 unique patients). Distinct cohorts were defined to represent permissive and conservative estimates of the number of patients. Clinical phenotypes suggestive of genetic diseases were observed in up to 9.4% of pediatric patients and up to 44.7% of critically-ill infants. Compared with controls, patients with indicators of genetic diseases had higher utilization of services (e.g., mean NICU length of stay of 31.6d in a cohort defined by multiple congenital anomalies or neurological presentations compared with 10.1d for patients in the control population (P < 0.001)) and higher overall costs. Very few patients received any genetic testing (4.2-8.4% depending on cohort criteria). These results highlight the substantial proportion of the population with clinical features associated with genetic disorders and underutilization of genetic testing in these populations.
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Affiliation(s)
| | - Nina Gonzaludo
- grid.185669.50000 0004 0507 3954Illumina, Inc., San Diego, CA USA
| | | | | | | | - Ryan J. Taft
- grid.185669.50000 0004 0507 3954Illumina, Inc., San Diego, CA USA
| | - John W. Belmont
- grid.185669.50000 0004 0507 3954Illumina, Inc., San Diego, CA USA
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12
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US private payers' perspectives on insurance coverage for genome sequencing versus exome sequencing: A study by the Clinical Sequencing Evidence-Generating Research Consortium (CSER). Genet Med 2021; 24:238-244. [PMID: 34906461 DOI: 10.1016/j.gim.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/12/2021] [Accepted: 08/13/2021] [Indexed: 11/22/2022] Open
Abstract
PURPOSE There is limited payer coverage for genome sequencing (GS) relative to exome sequencing (ES) in the U.S. Our objective was to assess payers' considerations for coverage of GS versus coverage of ES and requirements payers have for coverage of GS. The study was conducted by the NIH-funded Clinical Sequencing Evidence-Generating Research Consortium (CSER). METHODS We conducted semi-structured interviews with representatives of private payer organizations (payers, N = 12) on considerations and evidentiary and other needs for coverage of GS and ES. Data were analyzed using thematic analysis. RESULTS We described four categories of findings and solutions: demonstrated merits of GS versus ES, enhanced methods for evidence generation, consistent laboratory processes/sequencing methods, and enhanced implementation/care delivery. Payers see advantages to GS vs. ES and are open to broader GS coverage but need more proof of these advantages to consider them in coverage decision-making. Next steps include establishing evidence of benefits in specific clinical scenarios, developing quality standards, ensuring transparency of laboratory methods, developing clinical centers of excellence, and incorporating the role of genetic professionals. CONCLUSION By comparing coverage considerations for GS and ES, we identified a path forward for coverage of GS. Future research should explicitly address payers' conditions for coverage.
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Pollard S, Weymann D, Dunne J, Mayanloo F, Buckell J, Buchanan J, Wordsworth S, Friedman JM, Stockler-Ipsiroglu S, Dragojlovic N, Elliott AM, Harrison M, Lynd LD, Regier DA. Toward the diagnosis of rare childhood genetic diseases: what do parents value most? Eur J Hum Genet 2021; 29:1491-1501. [PMID: 33903739 PMCID: PMC8484431 DOI: 10.1038/s41431-021-00882-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/18/2021] [Accepted: 03/23/2021] [Indexed: 02/07/2023] Open
Abstract
Genomic testing is becoming routine for diagnosing rare childhood genetic disease. Evidence underlying sustainable implementation is limited, focusing on short-term endpoints such as diagnostic yield, unable to fully characterize patient and family valued outcomes. Although genomic testing is becoming widely available, evidentiary and outcomes uncertainty persist as key challenges for implementation. We examine whether the current evidence base reflects public tolerance for uncertainty for genomics to diagnose rare childhood genetic disease. We conducted focus groups with general population parents in Vancouver, Canada, and Oxford, United Kingdom, to discuss expectations and concerns related to genomic testing to diagnose rare childhood genetic disease. Applying a purposive sampling technique, recruitment continued until thematic saturation was reached. Transcripts were analysed using thematic analysis. Thirty-three parents participated across four focus groups. Participants valued causal diagnoses alongside management strategies to improve patient health and wellbeing. Further, participants valued expanding the evidence base to reduce evidentiary uncertainty while ensuring security of information. Willingness to pay out of pocket for testing reflected perceived familial health benefit. Diagnostic yield fails to fully capture valued outcomes, and efforts to resolve uncertainty better reflect public priorities. Evaluations of genomic testing that fully integrate valued endpoints are necessary to ensure consistency with best practices and public willingness to accept the uncertain familial benefit.
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Affiliation(s)
- Samantha Pollard
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, Canada
| | - Deirdre Weymann
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, Canada
| | - Jessica Dunne
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, Canada
| | - Fatemeh Mayanloo
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, Canada
| | - John Buckell
- grid.4991.50000 0004 1936 8948Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - James Buchanan
- grid.4991.50000 0004 1936 8948Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Sarah Wordsworth
- grid.4991.50000 0004 1936 8948Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Jan M. Friedman
- grid.17091.3e0000 0001 2288 9830Department of Medical Genetics, University of British Columbia, Vancouver, Canada ,grid.414137.40000 0001 0684 7788BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Sylvia Stockler-Ipsiroglu
- grid.414137.40000 0001 0684 7788BC Children’s Hospital Research Institute, Vancouver, Canada ,grid.17091.3e0000 0001 2288 9830Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada ,grid.414137.40000 0001 0684 7788Division of Biochemical Genetics, BC Children’s Hospital, Vancouver, Canada
| | - Nick Dragojlovic
- grid.17091.3e0000 0001 2288 9830Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Alison M. Elliott
- grid.17091.3e0000 0001 2288 9830Department of Medical Genetics, University of British Columbia, Vancouver, Canada ,grid.414137.40000 0001 0684 7788BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Mark Harrison
- grid.17091.3e0000 0001 2288 9830Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada ,Centre for Health Evaluation and Outcomes Sciences, Providence Health Research Institute, Vancouver, Canada
| | - Larry D. Lynd
- grid.17091.3e0000 0001 2288 9830Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada ,Centre for Health Evaluation and Outcomes Sciences, Providence Health Research Institute, Vancouver, Canada
| | - Dean A. Regier
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, Canada ,grid.17091.3e0000 0001 2288 9830School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Gutierrez AM, Robinson JO, Outram SM, Smith HS, Kraft SA, Donohue KE, Biesecker BB, Brothers KB, Chen F, Hailu B, Hindorff LA, Hoban H, Hsu RL, Knight SJ, Koenig BA, Lewis KL, Lich KH, O’Daniel JM, Okuyama S, Tomlinson GE, Waltz M, Wilfond BS, Ackerman SL, Majumder MA. Examining access to care in clinical genomic research and medicine: Experiences from the CSER Consortium. J Clin Transl Sci 2021; 5:e193. [PMID: 34888063 PMCID: PMC8634302 DOI: 10.1017/cts.2021.855] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/30/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Ensuring equitable access to health care is a widely agreed-upon goal in medicine, yet access to care is a multidimensional concept that is difficult to measure. Although frameworks exist to evaluate access to care generally, the concept of "access to genomic medicine" is largely unexplored and a clear framework for studying and addressing major dimensions is lacking. METHODS Comprised of seven clinical genomic research projects, the Clinical Sequencing Evidence-Generating Research consortium (CSER) presented opportunities to examine access to genomic medicine across diverse contexts. CSER emphasized engaging historically underrepresented and/or underserved populations. We used descriptive analysis of CSER participant survey data and qualitative case studies to explore anticipated and encountered access barriers and interventions to address them. RESULTS CSER's enrolled population was largely lower income and racially and ethnically diverse, with many Spanish-preferring individuals. In surveys, less than a fifth (18.7%) of participants reported experiencing barriers to care. However, CSER project case studies revealed a more nuanced picture that highlighted the blurred boundary between access to genomic research and clinical care. Drawing on insights from CSER, we build on an existing framework to characterize the concept and dimensions of access to genomic medicine along with associated measures and improvement strategies. CONCLUSIONS Our findings support adopting a broad conceptualization of access to care encompassing multiple dimensions, using mixed methods to study access issues, and investing in innovative improvement strategies. This conceptualization may inform clinical translation of other cutting-edge technologies and contribute to the promotion of equitable, effective, and efficient access to genomic medicine.
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Affiliation(s)
- Amanda M. Gutierrez
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Jill O. Robinson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Simon M. Outram
- Program in Bioethics, University of California, San Francisco, San Francisco, CA, USA
| | - Hadley S. Smith
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Stephanie A. Kraft
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Katherine E. Donohue
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Barbara B. Biesecker
- RTI International, GenOmics, BiOinformatics and Translational Science, Washington DC, USA
| | - Kyle B. Brothers
- Department of Pediatrics, University of Louisville, Louisville, KY, USA
| | - Flavia Chen
- Program in Bioethics, University of California, San Francisco, San Francisco, CA, USA
- Institute for Human Genetics, University of California, San Francisco, San Francisco, CA, USA
| | - Benyam Hailu
- National Institute of Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Lucia A. Hindorff
- Division of Genomic Medicine, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Hannah Hoban
- Institute for Human Genetics, University of California, San Francisco, San Francisco, CA, USA
| | - Rebecca L. Hsu
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Sara J. Knight
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Katie L. Lewis
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| | - Julianne M. O’Daniel
- Department of Genetics, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| | - Sonia Okuyama
- Division of Hematology-Oncology, Denver Health and Hospital Authority, Denver, CO, USA
| | - Gail E. Tomlinson
- Division of Hematology-Oncology, Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
- Greehey Children’s Cancer Research Institute, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Margaret Waltz
- Department of Social Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| | - Benjamin S. Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Sara L. Ackerman
- Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Mary A. Majumder
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
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15
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Margaretos NM, Panzer AD, Lai RC, Sanon M, Michalopoulos E, Redmond AM, Moghadam R, Chambers JD. Variation in health plan coverage of ESAs for anemia due to chronic kidney disease. J Manag Care Spec Pharm 2021; 27:1221-1229. [PMID: 34464213 PMCID: PMC10391084 DOI: 10.18553/jmcp.2021.27.9.1221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Because health plans each issue their own policies, drug coverage can vary. This variation can result in patients having unequal access to treatment. In this study, we evaluate commercial health plans' coverage policies for erythropoiesis-stimulating agents (ESAs) for patients with anemia resulting from chronic kidney disease (CKD). OBJECTIVES: To assess how a set of US commercial health plans cover ESAs for patients with anemia due to CKD. Our second objective was to examine the evidence that the plans reviewed when formulating their coverage policies. METHODS: We used the Tufts Medical Center Specialty Drug and Evidence and Coverage Database to identify coverage policies issued by 17 of the largest US commercial health plans for ESAs. The following drugs were indicated for anemia due to CKD: darbepoetin alfa, methoxy polyethylene glycol-epoetin beta, epoetin alfa (available as two brands), and epoetin alfa-epbx. Coverage policies were current as of May 2019. We determined whether the health plans applied any restrictions, such as step therapy protocols or patient subgroup restrictions, in their coverage policies. We categorized the evidence that plans cited to support their policies into seven categories: randomized controlled trials (RCTs), real-world evidence (RWE) studies (studies based on data collected in a real-world setting), other clinical studies (eg, single arm trials), systematic reviews and/or meta-analyses, clinical or treatment guidelines, health technology assessments, and economic evaluations. RESULTS: We categorized 72.5% of coverage policies (58/80 policies) as equivalent to the FDA label and 27.5% (22/80 policies) as more restrictive. In restricted policies, plans most often applied step therapy protocols (18/22 policies), followed by prescriber requirements (4/22 policies), and patient subgroup restrictions (3/22 policies). Five health plans applied restrictions in at least half of their coverage policies; seven plans did not apply restrictions in any policy. Plans that cited evidence reviewed an average of 10 citations across their ESA coverage policies, ranging from one to 29 studies. Plans varied with respect to the types of cited studies: at least 50% of evidence cited by five health plans was RCTs, while half or more of the evidence cited by four health plans was clinical or treatment guidelines. CONCLUSIONS: Health plans varied in how they covered ESAs for patients with anemia due to CKD and in the evidence cited in their coverage policies. Inconsistencies in plans' coverage policies may have implications for patients' access to ESAs. DISCLOSURES: This study was funded by Otsuka Pharmaceutical Development and Commercialization. Sanon, Redmond, and Mogahadam are employed by Otsuka Pharmaceutical. Michalopoulos was employed by Otsuka Pharmaceutical at the time of this study. Margaretos, Panzer, and Chambers are employed by Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Center for the Evaluation of Value and Risk in Health. Lai was with Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Center for the Evaluation of Value and Risk in Health at the time of this study.
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Affiliation(s)
- NikoLetta M Margaretos
- Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Center for the Evaluation of Value and Risk in Health, Boston, MA
| | - Ari D Panzer
- Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Center for the Evaluation of Value and Risk in Health, Boston, MA
| | - Rachel C Lai
- Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Center for the Evaluation of Value and Risk in Health, Boston, MA
| | - Myrlene Sanon
- Otsuka Pharmaceutical Development & Commercialization, Princeton, NJ
| | | | - Ann-Marie Redmond
- Otsuka Pharmaceutical Development & Commercialization, Princeton, NJ
| | - Reza Moghadam
- Otsuka Pharmaceutical Development & Commercialization, Princeton, NJ
| | - James D Chambers
- Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Center for the Evaluation of Value and Risk in Health, Boston, MA
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16
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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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17
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Shalhub S, Wallace S, Okunbor O, Newhall K. Genetic aortic disease epidemiology, management principles, and disparities in care. Semin Vasc Surg 2021; 34:79-88. [PMID: 33757640 DOI: 10.1053/j.semvascsurg.2021.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Patients with syndromic and nonsyndromic heritable aortopathies (also known as genetic aortic disease) are a heterogeneous group of patients who present at younger ages with more rapid growth of aortic aneurysms and/or increased frequency of dissections compared with patients with atherosclerotic aortopathies. In this review, we describe the etiology, epidemiology, and appropriate care delivery for these conditions at each stage of management. Within each section, we discuss sex, gender, and race differences and highlight disparities in care and knowledge. We then discuss the role of the vascular team throughout the cycle of care and the evolving inclusion of patient input in research. This understanding is essential to the creation of effective health care policies that support equitable, appropriate, and patient-centered clinical practices.
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Affiliation(s)
- Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195.
| | - Stephanie Wallace
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195
| | - Osa Okunbor
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195
| | - Karina Newhall
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195
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18
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Douglas MP, Gray SW, Phillips KA. Private Payer and Medicare Coverage for Circulating Tumor DNA Testing: A Historical Analysis of Coverage Policies From 2015 to 2019. J Natl Compr Canc Netw 2020; 18:866-872. [PMID: 32634780 DOI: 10.6004/jnccn.2020.7542] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/29/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinical adoption of the sequencing of circulating tumor DNA (ctDNA) for cancer has rapidly increased in recent years. This sequencing is used to select targeted therapy and monitor nonresponding or progressive tumors to identify mechanisms of therapeutic resistance. Our study objective was to review available coverage policies for cancer ctDNA-based testing panels to examine trends from 2015 to 2019. METHODS We analyzed publicly available private payer policies and Medicare national coverage determinations and local coverage determinations (LCDs) for ctDNA-based panel tests for cancer. We coded variables for each year representing policy existence, covered clinical scenario, and specific ctDNA test covered. Descriptive analyses were performed. RESULTS We found that 38% of private payer coverage policies provided coverage of ctDNA-based panel testing as of July 2019. Most private payer policy coverage was highly specific: 87% for non-small cell lung cancer, 47% for EGFR gene testing, and 79% for specific brand-name tests. There were 8 final, 2 draft, and 2 future effective final LCDs (February 3 and March 15, 2020) that covered non-FDA-approved ctDNA-based tests. The draft and future effective LCDs were the first policies to cover pan-cancer use. CONCLUSIONS Coverage of ctDNA-based panel testing for cancer indications increased from 2015 to 2019. The trend in private payer and Medicare coverage is an increasing number of coverage policies, number of positive policies, and scope of coverage. We found that Medicare coverage policies are evolving to pan-cancer uses, signifying a significant shift in coverage frameworks. Given that genomic medicine is rapidly changing, payers and policymakers (eg, guideline developers) will need to continue to evolve policies to keep pace with emerging science and standards in clinical care.
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Affiliation(s)
- Michael P Douglas
- 1Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), San Francisco
| | - Stacy W Gray
- 2Department of Population Science, and.,3Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte; and
| | - Kathryn A Phillips
- 1Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), San Francisco.,4UCSF Philip R. Lee Institute for Health Policy, and.,5UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
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19
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Trosman JR, Douglas MP, Liang SY, Weldon CB, Kurian AW, Kelley RK, Phillips KA. Insights From a Temporal Assessment of Increases in US Private Payer Coverage of Tumor Sequencing From 2015 to 2019. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:551-558. [PMID: 32389219 PMCID: PMC7217867 DOI: 10.1016/j.jval.2020.01.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/09/2019] [Accepted: 01/08/2020] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To examine the temporal trajectory of insurance coverage for next-generation tumor sequencing (sequencing) by private US payers, describe the characteristics of coverage adopters and nonadopters, and explore adoption trends relative to the Centers for Medicare and Medicaid Services' National Coverage Determination (CMS NCD) for sequencing. METHODS We identified payers with positive coverage (adopters) or negative coverage (nonadopters) of sequencing on or before April 1, 2019, and abstracted their characteristics including size, membership in the BlueCross BlueShield Association, and whether they used a third-party policy. Using descriptive statistics, payer characteristics were compared between adopters and nonadopters and between pre-NCD and post-NCD adopters. An adoption timeline was constructed. RESULTS Sixty-nine payers had a sequencing policy. Positive coverage started November 30, 2015, with 1 payer and increased to 33 (48%) as of April 1, 2019. Adopters were less likely to be BlueCross BlueShield members (P < .05) and more likely to use a third-party policy (P < .001). Fifty-eight percent of adopters were small payers. Among adopters, 52% initiated coverage pre-NCD over a 25-month period and 48% post-NCD over 17 months. CONCLUSIONS We found an increase, but continued variability, in coverage over 3.5 years. Temporal analyses revealed important trends: the possible contribution of the CMS NCD to a faster pace of coverage adoption, the interdependence in coverage timing among BlueCross BlueShield members, the impact of using a third-party policy on coverage timing, and the importance of small payers in early adoption. Our study is a step toward systematic temporal research of coverage for precision medicine, which will inform policy and affordability assessments.
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Affiliation(s)
- Julia R Trosman
- Center for Translational and Policy Research on Personalized Medicine, University of California at San Francisco, San Francisco, CA, USA; Center for Business Models in Healthcare, Chicago, IL, USA.
| | - Michael P Douglas
- Center for Translational and Policy Research on Personalized Medicine, University of California at San Francisco, San Francisco, CA, USA
| | - Su-Ying Liang
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Christine B Weldon
- Center for Translational and Policy Research on Personalized Medicine, University of California at San Francisco, San Francisco, CA, USA; Center for Business Models in Healthcare, Chicago, IL, USA
| | - Allison W Kurian
- Departments of Medicine & of Health Research & Policy, Stanford University, Palo Alto, CA, USA
| | - Robin K Kelley
- Philip R. Lee Institute for Health Policy, University of California, San Francisco, San Francisco, CA, USA
| | - Kathryn A Phillips
- Center for Translational and Policy Research on Personalized Medicine, University of California at San Francisco, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy, University of California, San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, CA, USA
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20
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Deverka PA, Douglas MP, Phillips KA. Use of Real-World Evidence in US Payer Coverage Decision-Making for Next-Generation Sequencing-Based Tests: Challenges, Opportunities, and Potential Solutions. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:540-550. [PMID: 32389218 PMCID: PMC7219085 DOI: 10.1016/j.jval.2020.02.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 01/26/2020] [Accepted: 02/02/2020] [Indexed: 05/05/2023]
Abstract
OBJECTIVES Given the potential of real-world evidence (RWE) to inform understanding of the risk-benefit profile of next-generation sequencing (NGS)-based testing, we undertook a study to describe the current landscape of whether and how payers use RWE as part of their coverage decision making and potential solutions for overcoming barriers. METHODS We performed a scoping literature review of existing RWE evidentiary frameworks for evaluating new technologies and identified barriers to clinical integration and evidence gaps for NGS. We synthesized findings as potential solutions for improving the relevance and utility of RWE for payer decision-making. RESULTS Payers require evidence of clinical utility to inform coverage decisions, yet we found a relatively small number of published RWE studies, and these are predominately focused on oncology, pharmacogenomics, and perinatal/pediatric testing. We identified 3 categories of innovation that may help address the current undersupply of RWE studies for NGS: (1) increasing use of RWE to inform outcomes-based contracting for new technologies, (2) precision medicine initiatives that integrate clinical and genomic data and enable data sharing, and (3) Food and Drug Administration reforms to encourage the use of RWE. Potential solutions include development of data and evidence review standards, payer engagement in RWE study design, use of incentives and partnerships to lower the barriers to RWE generation, education of payers and providers concerning the use of RWE and NGS, and frameworks for conducting outcomes-based contracting for NGS. CONCLUSIONS We provide numerous suggestions to overcome the data, methodologic, infrastructure, and policy challenges constraining greater integration of RWE in assessments of NGS.
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Affiliation(s)
| | - Michael P Douglas
- Center for Translational and Policy Research on Personalized Medicine, Department of Clinical Pharmacy, University of California at San Francisco, San Francisco, CA, USA
| | - Kathryn A Phillips
- Center for Translational and Policy Research on Personalized Medicine, Department of Clinical Pharmacy, University of California at San Francisco, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy, University of California, San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer, University of California at San Francisco, San Francisco, CA, USA
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21
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Conway ME, Kalejta CD, Sternen DL, Singh IR. The Importance of Genetics Experts in Optimizing Genetic Test Orders Through Prospective and Retrospective Reviews. Am J Clin Pathol 2020; 153:537-547. [PMID: 31802100 DOI: 10.1093/ajcp/aqz188] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To demonstrate the impact of genetics specialists on identifying test order errors and improving reimbursement for genetic testing. METHODS Forty-four cases in which whole exome sequencing (WES) was performed but not reimbursed were reviewed by a genetic counselor through simulated prospective and retrospective reviews. RESULTS Fifty-two percent of WES requests were ordered by nongenetics providers. Retrospective review revealed that 50% of cases were denied because of contractual constraints on billing. If review by a genetic counselor had occurred in real time, modifications or cancellations would have been recommended in 82% of the cases. CONCLUSIONS A laboratory stewardship program involving genetics experts identified test order errors and opportunities for improved reimbursement and cost savings. Significant variables affected reimbursement, including inpatient status, payer criteria, and ordering provider specialty.
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Affiliation(s)
| | | | - Darci L Sternen
- Department of Laboratories, Seattle Children’s Hospital, Seattle, WA
| | - Ila R Singh
- Department of Pathology, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
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22
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Reuter CM, Kohler JN, Bonner D, Zastrow D, Fernandez L, Dries A, Marwaha S, Davidson J, Brokamp E, Herzog M, Hong J, Macnamara E, Rosenfeld JA, Schoch K, Spillmann R, Loscalzo J, Krier J, Stoler J, Sweetser D, Palmer CG, Phillips JA, Shashi V, Adams DA, Yang Y, Ashley EA, Fisher PG, Mulvihill JJ, Bernstein JA, Wheeler MT. Yield of whole exome sequencing in undiagnosed patients facing insurance coverage barriers to genetic testing. J Genet Couns 2019; 28:1107-1118. [PMID: 31478310 PMCID: PMC6901723 DOI: 10.1002/jgc4.1161] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/12/2019] [Accepted: 07/27/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Despite growing evidence of diagnostic yield and clinical utility of whole exome sequencing (WES) in patients with undiagnosed diseases, there remain significant cost and reimbursement barriers limiting access to such testing. The diagnostic yield and resulting clinical actions of WES for patients who previously faced insurance coverage barriers have not yet been explored. METHODS We performed a retrospective descriptive analysis of clinical WES outcomes for patients facing insurance coverage barriers prior to clinical WES and who subsequently enrolled in the Undiagnosed Diseases Network (UDN). Clinical WES was completed as a result of participation in the UDN. Payer type, molecular diagnostic yield, and resulting clinical actions were evaluated. RESULTS Sixty-six patients in the UDN faced insurance coverage barriers to WES at the time of enrollment (67% public payer, 26% private payer). Forty-two of 66 (64%) received insurance denial for clinician-ordered WES, 19/66 (29%) had health insurance through a payer known not to cover WES, and 5/66 (8%) had previous payer denial of other genetic tests. Clinical WES results yielded a molecular diagnosis in 23 of 66 patients (35% [78% pediatric, 65% neurologic indication]). Molecular diagnosis resulted in clinical actions in 14 of 23 patients (61%). CONCLUSIONS These data demonstrate that a substantial proportion of patients who encountered insurance coverage barriers to WES had a clinically actionable molecular diagnosis, supporting the notion that WES has value as a covered benefit for patients who remain undiagnosed despite objective clinical findings.
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Affiliation(s)
- Chloe M. Reuter
- Center for Undiagnosed Diseases, Stanford University School of Medicine, Stanford, CA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jennefer N. Kohler
- Center for Undiagnosed Diseases, Stanford University School of Medicine, Stanford, CA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Devon Bonner
- Center for Undiagnosed Diseases, Stanford University School of Medicine, Stanford, CA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Diane Zastrow
- Center for Undiagnosed Diseases, Stanford University School of Medicine, Stanford, CA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Liliana Fernandez
- Center for Undiagnosed Diseases, Stanford University School of Medicine, Stanford, CA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Annika Dries
- Center for Undiagnosed Diseases, Stanford University School of Medicine, Stanford, CA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Shruti Marwaha
- Center for Undiagnosed Diseases, Stanford University School of Medicine, Stanford, CA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jean Davidson
- Center for Undiagnosed Diseases, Stanford University School of Medicine, Stanford, CA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Elly Brokamp
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew Herzog
- Department of Human Genetics, University of California Los Angeles, Los Angeles, CA
| | - Joyce Hong
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Ellen Macnamara
- Undiagnosed Diseases Program, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | - Jill A. Rosenfeld
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Kelly Schoch
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Rebecca Spillmann
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | | | - Joseph Loscalzo
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Joel Krier
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Joan Stoler
- Division of Genetics, Boston Children’s Hospital, Boston, MA
| | - David Sweetser
- Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, MA
| | - Christina G.S. Palmer
- Department of Human Genetics, University of California Los Angeles, Los Angeles, CA
- Psychiatry & Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA
- Institute for Society & Genetics, University of California Los Angeles, Los Angeles, CA
| | - John A Phillips
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Vandana Shashi
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - David A. Adams
- Undiagnosed Diseases Program, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | - Yaping Yang
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Euan A. Ashley
- Center for Undiagnosed Diseases, Stanford University School of Medicine, Stanford, CA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
- Department of Genetics, Stanford University School of Medicine, Stanford, CA
| | - Paul G. Fisher
- Center for Undiagnosed Diseases, Stanford University School of Medicine, Stanford, CA
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - John J. Mulvihill
- Division of Genomic Medicine, National Human Genome Research Institute, Bethesda, MD
| | - Jonathan A. Bernstein
- Center for Undiagnosed Diseases, Stanford University School of Medicine, Stanford, CA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Matthew T. Wheeler
- Center for Undiagnosed Diseases, Stanford University School of Medicine, Stanford, CA
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
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23
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Using the Delphi method to identify clinicians’ perceived importance of pediatric exome sequencing results. Genet Med 2019; 22:69-76. [DOI: 10.1038/s41436-019-0601-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/19/2019] [Indexed: 01/14/2023] Open
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24
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Phillips KA, Douglas MP. The Global Market for Next-Generation Sequencing Tests Continues Its Torrid Pace. THE JOURNAL OF PRECISION MEDICINE 2018; 4:https://www.thejournalofprecisionmedicine.com/wp-content/uploads/2018/11/Phillips-Online.pdf. [PMID: 32149190 PMCID: PMC7059995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The market for next-generation sequencing technologies (NGS) has grown dramatically. Health care decision-makers need empirical evidence on market growth and future trends in order to develop appropriate strategies and policies, but little has been published about the nature and size of these trends. We provide a snapshot of market trends through 2020. We found rapid growth of clinical NGS - the global clinical NGS services market was $2.2 billion in 2015 and is forecast to reach $7.7 billion by 2020. The reproductive health NGS test market is the largest market followed by the oncology NGS test market. The largest market is for tests that sequence >50 genes but not the entire exome or genome. Markets are growing rapidly in countries outside of the US. Despite rapid NGS test growth, there are a number of key issues that will need to be addressed to facilitate appropriate future growth.
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Affiliation(s)
- Kathryn A. Phillips
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco
- Philip R. Lee Institute for Health Policy, University of California San Francisco, San Francisco
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco
| | - Michael P. Douglas
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco
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25
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Towards Cultural Competence in the Genomic Age: a Review of Current Health Care Provider Educational Trainings and Interventions. CURRENT GENETIC MEDICINE REPORTS 2018. [DOI: 10.1007/s40142-018-0150-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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