Challenges to integrating pharmacogenetic testing into medication therapy management

Pharmacist Intention to Provide Medication Therapy Management Services in Saudi Arabia: A Study Using the Theory of Planned Behaviour

Medication therapy management (MTM) is provided by pharmacists and other healthcare providers, improves patient health status, and increases the collaboration of MTM providers with others. However, little is known about pharmacists’ intention to provide MTM services in Saudi Arabia. This study aimed to predict the pharmacists’ willingness in this nation to commit to providing MTM services there. This study used a cross-sectional questionnaire based on the theory of planned behaviour (TPB). The survey was distributed to 149 pharmacists working in hospital and community pharmacies. It included items measuring pharmacist attitudes, intentions, subjective norms, perceived behavioural control, knowledge about the provision of MTM services, and other sociodemographic and pharmacy practice-related items. The pharmacists had a positive attitude towards MTM services (mean = 6.15 ± 1.12) and strong intention (mean = 6.09 ± 1.15), highly perceived social pressure to provide those services (mean = 5.42 ± 1.03), strongly perceived control over providing those services (mean = 4.98 ± 1.05), and had good MTM knowledge (mean = 5.03 ± 1.00). Pharmacists who completed a pharmacy residency programme and had good knowledge of MTM services and a positive attitude towards them usually strongly intended to provide MTM services. Thus, encouraging pharmacists to complete pharmacy residency programmes and educating them about the importance and provision of MTM services will enhance their motivation to provide them.

Pharmacogenetic interventions to improve outcomes in patients with multimorbidity or prescribed polypharmacy: a systematic review

Conventional medicines optimisation interventions in people with multimorbidity and polypharmacy are complex and yet limited; a more holistic and integrated approach to healthcare delivery is required. Pharmacogenetics has potential as a component of medicines optimisation. Studies involving multi-medicine pharmacogenetics in adults with multimorbidity or polypharmacy, reporting on outcomes derived from relevant core outcome sets, were included in this systematic review. Narrative synthesis was undertaken to summarise the data; meta-analysis was inappropriate due to study heterogeneity. Fifteen studies of diverse design and variable quality were included. A small, randomised study involving pharmacist-led medicines optimisation, including pharmacogenetics, suggests this approach could have significant benefits for patients and health systems. However, due to study design heterogeneity and the quality of the included studies, it is difficult to draw generalisable conclusions. Further pragmatic, robust pharmacogenetics studies in diverse, real-world patient populations, are required to establish the benefit of multi-medicine pharmacogenetic screening on patient outcomes.

Delivery of Pharmacogenetic Testing with or without Medication Therapy Management in a Community Pharmacy Setting

Objective

The delivery of pharmacogenetic (PGx) testing has primarily been through clinical and hospital settings. We conducted a study to explore the feasibility of delivering PGx testing through community pharmacies, a less-studied setting.

Methods

We conducted a cluster randomized trial of community pharmacies in North Carolina through two approaches: the provision of PGx testing alone or PGx testing with medication therapy management (MTM).

Results

A total of 150 patient participants were enrolled at 17 pharmacies and reported high satisfaction with their testing experience. Participants in the PGx plus MTM arm were more likely to recall a higher number of results (p=0.04) and more likely to clearly understand their choices for prevention or early detection of side effects (p=0.01). A medication or dose change based on the PGx results was made for 8.7% of participants.

Conclusion

Limited differences were observed in the provision of PGx testing as a standalone test or combined with MTM. A limited number of treatment changes were made based on PGx test results. Patient acceptance of PGx testing offered through the community pharmacy was very high, but the addition of MTM did not impact patient-reported perceptions about PGx testing or medication adherence.

Implementation of Pharmacogenomics and Artificial Intelligence Tools for Chronic Disease Management in Primary Care Setting

Chronic disease management often requires use of multiple drug regimens that lead to polypharmacy challenges and suboptimal utilization of healthcare services. While the rising costs and healthcare utilization associated with polypharmacy and drug interactions have been well documented, effective tools to address these challenges remain elusive. Emerging evidence that proactive medication management, combined with pharmacogenomic testing, can lead to improved health outcomes and reduced cost burdens may help to address such gaps. In this report, we describe informatic and bioanalytic methodologies that integrate weak signals in symptoms and chief complaints with pharmacogenomic analysis of ~90 single nucleotide polymorphic variants, CYP2D6 copy number, and clinical pharmacokinetic profiles to monitor drug–gene pairs and drug–drug interactions for medications with significant pharmacogenomic profiles. The utility of the approach was validated in a virtual patient case showing detection of significant drug–gene and drug–drug interactions of clinical significance. This effort is being used to establish proof-of-concept for the creation of a regional database to track clinical outcomes in patients enrolled in a bioanalytically-informed medication management program. Our integrated informatic and bioanalytic platform can provide facile clinical decision support to inform and augment medication management in the primary care setting.

Integrating pharmacogenetic testing via medication therapy management in an outpatient family medicine clinic

Introduction: Pharmacogenetic (PGx) implementation has lagged behind the development of drug/gene pair guidelines. Materials & methods: This was a prospective study assessing the integration of PGx through medication therapy management in an outpatient clinic. Variables collected included patient diagnosis, current medications, failed or discontinued medications, PGx results/recommendations, turnaround time and pre/post clinical ratings. Results: A total of 91 participants completed study procedures with an average enrollment of approximately one consult per week. Participants were referred for testing primarily for guidance for current and future medications. The average number of recommendations per participant was 0.93. Conclusion: Integrating PGx testing into medication therapy management is feasible with PGx results available in under a week resulting in clinical recommendations in over half of patients tested.

Development of Customizable Implementation Guides to Support Clinical Adoption of Pharmacogenomics: Experiences of the Implementing GeNomics In pracTicE (IGNITE) Network

Introduction

Clinical adoption of genomic medicine has lagged behind the pace of scientific discovery. Practice-based resources can help overcome implementation challenges.

Methods

In 2015, the IGNITE (Implementing GeNomics In pracTicE) Network created an online genomic medicine implementation resource toolbox that was expanded in 2017 to incorporate the ability for users to create targeted implementation guides. This expansion was led by a multidisciplinary team that developed an evidence-based, structured framework for the guides, oversaw the technical process/build, and pilot tested the first guide, CYP2C19-Clopidogrel Testing Implementation.

Results

Sixty-five resources were collected from 12 institutions and categorized according to a seven-step implementation framework for the pilot CYP2C19-Clopidogrel Testing Implementation Guide. Five months after its launch, 96 CYP2C19-Clopidogrel Testing Implementation Guides had been created. Eighty percent of the resources most frequently selected by users were created by IGNITE to fill an identified resource gap. Resources most often included in guides were from the test reimbursement (22%), Implementation support gathering (22%), EHR integration (17%), and genetic testing workflow steps (17%).

Conclusion

Lessons learned from this implementation guide development process provide insight for prioritizing development of future resources and support the value of collaborative efforts to create resources for genomic medicine implementation.

Recommendations to protect patients and health care practices from Medicare and Medicaid fraud

Fraud is defined as knowingly submitting, or causing to be submitted, false claims or making misrepresentations of a fact to obtain a federal health care payment for which no entitlement would otherwise exist. In today's health care environment, Medicare and Medicaid fraud is not uncommon. The negative impact of fraud is vast because it diverts resources meant to care for patients in need to the benefit of fraudsters. Fraud increases the overall costs for vital health care services and can potentially be harmful to Medicare and Medicaid beneficiaries. The objectives of this commentary are to describe the types and trends of Medicare and Medicaid fraud that are committed, and provide recommendations to protect patients and health care practices. Specifically, this article identifies types of Medicare and Medicaid fraud at beneficiary (patient) and provider level, and it can be intentional or unintentional. This article also describes the 3 primary laws that prohibit fraud and gives fraud case examples relevant to each law, including the False Claims Act, Anti-Kickback Statute, and the Stark Law. We also discuss currently trending and emerging areas, including opioid and pharmacogenetic testing; both have experienced heavier and higher-profile instances of fraud in today's health care landscape. Last, the article summarizes detection methods and recommendations for health care providers and patients to protect themselves against fraud. Recommended strategies to combat fraud are discussed at policy, practice, and grassroots levels. Health care practitioners, including pharmacists, can use these strategies to protect themselves and their patients from becoming victims of fraud or unknowingly committing fraud.

Medication Therapy Management: Current Challenges

Medication therapy management (MTM) services have evolved as a means for pharmacists and other providers to assist patients and caregivers in improving therapeutic outcomes and reducing health care expenditures. More than a decade has passed since the Medicare Modernization Act of 2003 provided pharmacists with the opportunity to deliver MTM services to Medicare beneficiaries. MTM continues to offer pharmacists the opportunity to use their knowledge; yet, pharmacists have reported challenges with service delivery. Identifying the challenges that affect MTM services in pharmacy practice is necessary in order to seek improvement to MTM delivery. This narrative review explores the current challenges pharmacists face with MTM delivery, summarizes potential solutions for addressing challenges, and seeks to incite further debate, service reconfiguration, and ultimately service improvement of pharmacist-provided MTM services.

Polypharmacy: a healthcare conundrum with a pharmacogenetic solution

The use of multiple medications is growing at an alarming rate with some reports documenting an average of 12-22 prescriptions being used by individuals ≥50 years of age. The indirect consequences of polypharmacy include exacerbation of drug-drug interactions, adverse drug reactions, increased likelihood of prescribing cascades, chronic dependence, and hospitalizations - all of which have significant health and economic burden. While many practical solutions for reducing polypharmacy have been proposed, they have been met with limited efficacy. This highlights the need for a new systematic approach for fine-tuning dispensing of medications. Pharmacogenetic testing provides an empirical and scientifically rigorous approach for guiding appropriate selection of medicines, with the potential to reduce unnecessary polypharmacy while improving clinical outcomes. The goal of this review article is to provide healthcare providers with an understanding of polypharmacy, its adverse effects on the healthcare system and highlight how pharmacogenetic information can be used to avoid polypharmacy in patients.

Consideration for Employer-Based and Geographic Attributes Included in Value Assessment Methods of Next-Generation Sequencing Tests

There is a need for formal cost-effectiveness evidence to better model the real-world payer decision context in which general economic models are currently being used, specifically regarding clinical genomics health services (for next-generation sequencing (NGS) tests). We reviewed literature focused on cost-effectiveness studies after completion of the Human Genome Project within the Tufts Cost-Effectiveness Analysis (CEA) Registry and found that only 33% of eligible studies were conducted from the U.S. payer perspective. Additional interpretation challenges include economic models that do not account for true payer-negotiated costs, limits in internal expertise for quality-adjusted life-year inferences, and limited internal policies to use CEA research in decision making. This Viewpoints article highlights numerous opportunities to increase the translational effect of economic modeling work. Specifically, geographically relevant cost and outcomes data should be considered for integration within best practices for economic evaluations of NGS tests. Such data integration may provide more informed decision making regarding the allocation of constrained resources for health care services and technology. DISCLOSURES: No outside funding supported the writing of this article. Hart is supported by an unrestricted gift from Pfizer, which played no role in the study referred to in this article. The authors have no conflicts of interest to report.

Ready or not, here it comes: Direct-to-consumer pharmacogenomic testing and its implications for community pharmacists

OBJECTIVE

To explore the implications of direct-to-consumer pharmacogenomic testing for community pharmacy practice.

SUMMARY

In October 2018, the U.S. Food and Drug Administration provided approval for direct-to-consumer genetic testing company, 23andMe (Mountain View, CA), to return select pharmacogenomic test results to their customers. Given the community pharmacist's high accessibility to the public and in-depth knowledge of pharmacology, and the availability of direct-to-consumer genetic testing kits at pharmacies, it is likely that patients will present their pharmacogenomic test results to their pharmacists and expect them to incorporate those results into their care. It is important, therefore, that community pharmacists are aware of the clinical implications of these results, know where to turn for evidence-based clinical pharmacogenomics information, and be mindful of the need for confirmatory testing before changing therapy.

CONCLUSION

Community pharmacists are at the frontlines of health care, and as such will be at the frontlines of direct-to-consumer pharmacogenomic testing. In the near future, it is likely that community pharmacists will need to counsel patients on the interpretation and appropriate use of direct-to-consumer pharmacogenomic test results.

Community pharmacists and their role in pharmacogenomics testing: an Australian perspective drawing on international evidence

Patients obtaining a prescription from a pharmacy expect that the drug will be effective and have minimal side-effects. Unfortunately, drugs exhibit the desired effect in ~25-60% of people prescribed any medication. Adverse effects occur at a rate of 10% in patients taking a medication, and this rate increases during and after hospitalisation, with the transition of care back to the ambulatory setting posing a particular risk. Pharmacogenomics testing has been shown to optimise pharmacotherapy by increasing medication effectiveness and reducing drug-related toxicity, thus curtailing overall healthcare costs. Evidence from international studies have shown that community pharmacists would be able to offer this highly relevant professional service to their clients, given suitable training. This specific training complements pharmacists' existing skills and expertise by educating them in an emerging scientific area of pharmacogenomics. However, in an increasingly tight financial climate, the provision of pharmacogenomics testing by Australian community pharmacists will only be viable with an appropriate reimbursement through the Medicare Benefits Schedule, currently accessible by other allied health practitioners but not by pharmacists.

Frequency distribution of polymorphisms of CYP2C19, CYP2C9, VKORC1 and SLCO1B1 genes in the Yakut population

Allele frequencies of single nucleotide polymorphisms (SNPs) are variable among different populations; therefore the study of SNPs in ethnic groups is important for establishing the clinical significance of the screening of these polymorphisms. The main goal of the research is to study the polymorphisms of CYP2C9, CYP2C19, VKORC1, and SLCO1B1 in Yakuts. Genomic DNA from 229 Yakut subjects were analyzed by real-time polymerase chain reaction (PCR) (SLCO1B1 +521T > C, VKORC1 -1639G>A, CYP2C19 +681G>A, +636G>A, CYP2C9 +430С>T, +1075A>C). Genotype frequencies of polymorphisms in the population of the Yakuts were more characteristic of the Asian population. The results have been included in the software application "Lekgen" that we developed for the interpretation of pharmacogenetic testing. The data of our study obtained on frequency carriers of polymorphisms of genes SLCO1B1, CYP2C19, CYP2C9, VKORC1 among the Yakuts may be useful in developing recommendations for a personalized therapy.