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Farmaki A, Manolopoulos E, Natsiavas P. Will Precision Medicine Meet Digital Health? A Systematic Review of Pharmacogenomics Clinical Decision Support Systems Used in Clinical Practice. OMICS : A JOURNAL OF INTEGRATIVE BIOLOGY 2024; 28:442-460. [PMID: 39136110 DOI: 10.1089/omi.2024.0131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
Digital health, an emerging scientific domain, attracts increasing attention as artificial intelligence and relevant software proliferate. Pharmacogenomics (PGx) is a core component of precision/personalized medicine driven by the overarching motto "the right drug, for the right patient, at the right dose, and the right time." PGx takes into consideration patients' genomic variations influencing drug efficacy and side effects. Despite its potentials for individually tailored therapeutics and improved clinical outcomes, adoption of PGx in clinical practice remains slow. We suggest that e-health tools such as clinical decision support systems (CDSSs) can help accelerate the PGx, precision/personalized medicine, and digital health emergence in everyday clinical practice worldwide. Herein, we present a systematic review that examines and maps the PGx-CDSSs used in clinical practice, including their salient features in both technical and clinical dimensions. Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and research of the literature, 29 relevant journal articles were included in total, and 19 PGx-CDSSs were identified. In addition, we observed 10 technical components developed mostly as part of research initiatives, 7 of which could potentially facilitate future PGx-CDSSs implementation worldwide. Most of these initiatives are deployed in the United States, indicating a noticeable lack of, and the veritable need for, similar efforts globally, including Europe.
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Affiliation(s)
- Anastasia Farmaki
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
| | - Evangelos Manolopoulos
- Laboratory of Pharmacology, Medical School, Democritus University of Thrace, Alexandroupoli, Greece
| | - Pantelis Natsiavas
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
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Kaur G, Nwabufo CK. Healthcare provider and patient perspectives on the implementation of pharmacogenetic-guided treatment in routine clinical practice. Pharmacogenet Genomics 2024; 34:236-245. [PMID: 38917295 DOI: 10.1097/fpc.0000000000000541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
OBJECTIVE This study aims to understand patient and healthcare provider perspectives on the integration and application of pharmacogenetics (PGx) testing in routine clinical practice. METHODS Two anonymous online surveys were distributed globally for healthcare providers and patients respectively on the Qualtrics platform (version 3.24). The surveys were distributed through social platforms, email, and posters with QR codes from 27 October 2023 to 7 March 2024. The surveys evaluated participant familiarity with PGx, previous experience with PGx testing, perceived implementation challenges, and opinions on point-of-care (PoC) PGx testing devices. RESULTS This study collected 78 responses from healthcare providers and 98 responses from patients. The results revealed that 64% of healthcare providers had some level of familiarity with PGx, however, PGx testing in clinical practice was low. The primary challenges identified by healthcare providers included limited access to testing and lack of knowledge on PGx test interpretation. In contrast, 52% of patient respondents were aware of PGx testing, with a significant association between awareness and positive opinions toward PGx. Both healthcare providers and patients recognized the value of PoC PGx testing devices, with 98% of healthcare providers and 71% of patients believing PoC devices would improve the accessibility and implementation of PGx testing. Comparative analysis revealed a statistically significant difference in PGx awareness between healthcare providers and patients, with providers being more informed. CONCLUSION Improved PGx awareness, training, clinical guidelines, and PoC PGx testing devices may help promote the implementation of PGx-guided treatments in routine clinical practice.
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Affiliation(s)
| | - Chukwunonso K Nwabufo
- OneDrug Inc
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto
- Program in Translational Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
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Sharma V, McDermott J, Keen J, Foster S, Whelan P, Newman W. Pharmacogenetics Clinical Decision Support Systems for Primary Care in England: Co-Design Study. J Med Internet Res 2024; 26:e49230. [PMID: 39042886 PMCID: PMC11303890 DOI: 10.2196/49230] [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: 05/23/2023] [Revised: 12/22/2023] [Accepted: 05/13/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Pharmacogenetics can impact patient care and outcomes through personalizing the selection of medicines, resulting in improved efficacy and a reduction in harmful side effects. Despite the existence of compelling clinical evidence and international guidelines highlighting the benefits of pharmacogenetics in clinical practice, implementation within the National Health Service in the United Kingdom is limited. An important barrier to overcome is the development of IT solutions that support the integration of pharmacogenetic data into health care systems. This necessitates a better understanding of the role of electronic health records (EHRs) and the design of clinical decision support systems that are acceptable to clinicians, particularly those in primary care. OBJECTIVE Explore the needs and requirements of a pharmacogenetic service from the perspective of primary care clinicians with a view to co-design a prototype solution. METHODS We used ethnographic and think-aloud observations, user research workshops, and prototyping. The participants for this study included general practitioners and pharmacists. In total, we undertook 5 sessions of ethnographic observation to understand current practices and workflows. This was followed by 3 user research workshops, each with its own topic guide starting with personas and early ideation, through to exploring the potential of clinical decision support systems and prototype design. We subsequently analyzed workshop data using affinity diagramming and refined the key requirements for the solution collaboratively as a multidisciplinary project team. RESULTS User research results identified that pharmacogenetic data must be incorporated within existing EHRs rather than through a stand-alone portal. The information presented through clinical decision support systems must be clear, accessible, and user-friendly as the service will be used by a range of end users. Critically, the information should be displayed within the prescribing workflow, rather than discrete results stored statically in the EHR. Finally, the prescribing recommendations should be authoritative to provide confidence in the validity of the results. Based on these findings we co-designed an interactive prototype, demonstrating pharmacogenetic clinical decision support integrated within the prescribing workflow of an EHR. CONCLUSIONS This study marks a significant step forward in the design of systems that support pharmacogenetic-guided prescribing in primary care settings. Clinical decision support systems have the potential to enhance the personalization of medicines, provided they are effectively implemented within EHRs and present pharmacogenetic data in a user-friendly, actionable, and standardized format. Achieving this requires the development of a decoupled, standards-based architecture that allows for the separation of data from application, facilitating integration across various EHRs through the use of application programming interfaces (APIs). More globally, this study demonstrates the role of health informatics and user-centered design in realizing the potential of personalized medicine at scale and ensuring that the benefits of genomic innovation reach patients and populations effectively.
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Affiliation(s)
- Videha Sharma
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, University of Manchester, Manchester, United Kingdom
- Pankhurst Institute for Health Technology Research and Innovation, University of Manchester, Manchester, United Kingdom
| | - John McDermott
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Evolution, Infection and Genomics, School of Biological Sciences, University of Manchester, Manchester, United Kingdom
| | - Jessica Keen
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Simon Foster
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, University of Manchester, Manchester, United Kingdom
| | - Pauline Whelan
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, University of Manchester, Manchester, United Kingdom
| | - William Newman
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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Cernat A, Samaan Z, Abelson J, Ramdyal A, Shaikh H, Vanstone M. Patient perspectives on pharmacogenomic (PGx) testing for antidepressant prescribing in primary care: a qualitative description study. J Community Genet 2024; 15:293-309. [PMID: 38587601 PMCID: PMC11217204 DOI: 10.1007/s12687-024-00705-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 03/28/2024] [Indexed: 04/09/2024] Open
Abstract
Many patients with major depressive disorder (MDD) try multiple antidepressants before finding one that works well and is tolerable. Pharmacogenomic (PGx) testing was developed to facilitate more efficacious prescribing. This technology has not been robustly implemented clinically. Patient perspectives are critical to policy decisions, but the views of patients with MDD about the use of PGx testing to guide antidepressant prescribing have not been extensively examined, particularly in publicly funded healthcare systems. The purpose of this qualitative description study was to produce actionable patient perspectives evidence to inform future technology assessment of PGx testing. We conducted semi-structured interviews with 21 adults with MDD for which antidepressants were indicated in Ontario, Canada, and used the Ontario Decision Determinants Framework to conduct an unconstrained deductive content analysis. Patients expressed views about the overall clinical benefit of PGx testing in depression care, preferences for deployment of testing, perspectives on ethical considerations, opinions about equity and patient care, and beliefs regarding the feasibility of adopting PGx testing into the healthcare system. They also worried about the possibility of conflicts of interest between PGx test manufacturers and pharmaceutical companies. This study provides policymakers with patient priorities to facilitate the development of patient-centred policies. It highlights that formal adoption of PGx testing into the healthcare system requires a focus on equity of access and health outcomes.
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Affiliation(s)
- Alexandra Cernat
- Department of Family Medicine, McMaster University, 100 Main St W, Hamilton, ON, L8P 1H6, Canada
- Health Policy PhD Program, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, L8S 4L8, Canada
| | - Zainab Samaan
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, L8S 4L8, Canada
| | - Julia Abelson
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, L8S 4L8, Canada
| | - Amanada Ramdyal
- Department of Family Medicine, McMaster University, 100 Main St W, Hamilton, ON, L8P 1H6, Canada
| | - Hadia Shaikh
- Department of Family Medicine, McMaster University, 100 Main St W, Hamilton, ON, L8P 1H6, Canada
- Biomedical Discovery and Commercialization Program, Faculty of Health Sciences, McMaster University, Hamilton, L8S 4L8, Canada
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, 100 Main St W, Hamilton, ON, L8P 1H6, Canada.
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Taylor K, Umbreit A, Lea C, Holm E, Kosloski Tarpenning K. Implementing a Pharmacist-Led Primary Care Pharmacogenomics Medication Management Service. Innov Pharm 2024; 15:10.24926/iip.v15i2.6178. [PMID: 39166145 PMCID: PMC11333096 DOI: 10.24926/iip.v15i2.6178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2024] Open
Abstract
Background: Pharmacogenomics (PGx) is a tool to guide optimal medication selection. Increased demand for personalized medicine and the growing occurrence of chronic diseases are drivers for pharmacogenomic medication management services. A review of implementation models identified a paucity of models delivering these services utilizing pharmacists in primary care. Lack of standardization of this process remains a barrier to widespread implementation within health systems. Purpose: Describe the process of developing an institutional guidance document and applying it to implement a pharmacogenomics medication management service at clinic sites within an integrated health system in the United States. Measure the growth in the number of PGx visits completed. Method: A task force of pharmacists reviewed literature, guidelines, and institutional policies to create a comprehensive guidance document. The document included six minimum practice requirements for implementation in the primary care setting, and six additional recommendations. A retrospective chart review of all face to face, phone and eConsult PGx visit types occurring from January 1, 2022 through September 30, 2022 was conducted. Results: A pharmacist-led pharmacogenomics medication management service is now offered at all primary care sites within the health system. During the study timeframe, 1378 patients had a PGx visit, resulting in 1939 PGx visits. Of those visits, 1777 (92%) were referred by a primary care provider and 1675 (86.7%) were conducted by a primary care pharmacist. Twenty-nine primary care pharmacists offered the PGX service and 25 (89%) completed at least one visit. Patients were referred by providers from 56 of the 64 (87.5%) primary care departments. Conclusions: Developing an institutional process and guidance document for the implementation of a new pharmacist-led pharmacogenomics medication management service at clinic sites within an integrated health system was beneficial in developing and standardizing the workflow. Dissemination of workflow expectations to the primary care providers and pharmacists resulted in adoption of the service.
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Affiliation(s)
- Kathryn Taylor
- Instructor in Pharmacy, Mayo Clinic School of Health Sciences; Mayo Clinic Health System, Eau Claire WI
| | - Audrey Umbreit
- Assistant Professor of Pharmacy, Mayo Clinic School of Health Sciences; Mayo Clinic Health System, Mankato MN
| | - Catherine Lea
- Assistant Professor of Pharmacy, Mayo Clinic Health System, Eau Claire WI
| | - Emily Holm
- Instructor in Pharmacy, Mayo Clinic School of Health Sciences; Mayo Clinic Health System, Mankato MN
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Zhou Y, Lauschke VM. Next-generation sequencing in pharmacogenomics - fit for clinical decision support? Expert Rev Clin Pharmacol 2024; 17:213-223. [PMID: 38247431 DOI: 10.1080/17512433.2024.2307418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/16/2024] [Indexed: 01/23/2024]
Abstract
INTRODUCTION The technological advances of sequencing methods during the past 20 years have fuelled the generation of large amounts of sequencing data that comprise common variations, as well as millions of rare and personal variants that would not be identified by conventional genotyping. While comprehensive sequencing is technically feasible, its clinical utility for guiding personalized treatment decisions remains controversial. AREAS COVERED We discuss the opportunities and challenges of comprehensive sequencing compared to targeted genotyping for pharmacogenomic applications. Current pharmacogenomic sequencing panels are heterogeneous and clinical actionability of the included genes is not a major focus. We provide a current overview and critical discussion of how current studies utilize sequencing data either retrospectively from biobanks, databases or repurposed diagnostic sequencing, or prospectively using pharmacogenomic sequencing. EXPERT OPINION While sequencing-based pharmacogenomics has provided important insights into genetic variations underlying the safety and efficacy of a multitude pharmacological treatments, important hurdles for the clinical implementation of pharmacogenomic sequencing remain. We identify gaps in the interpretation of pharmacogenetic variants, technical challenges pertaining to complex loci and variant phasing, as well as unclear cost-effectiveness and incomplete reimbursement. It is critical to address these challenges in order to realize the promising prospects of pharmacogenomic sequencing.
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Affiliation(s)
- Yitian Zhou
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Volker M Lauschke
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
- University of Tübingen, Tübingen, Germany
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Hayward J, Evans W, Miller E, Rafi I. Embedding genomics across the NHS: a primary care perspective. Future Healthc J 2023; 10:263-269. [PMID: 38162198 PMCID: PMC10753202 DOI: 10.7861/fhj.2023-0116] [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] [Indexed: 01/03/2024]
Abstract
Primary care remains the point of access to the NHS as well as having key roles in care coordination and prescribing. Therefore, embedding of genomic medicine in the NHS relies on successful implementation into the primary care landscape. Primary care is currently facing considerable challenges, including increasing numbers of patients and consultations per GP, multiple health conditions and polypharmacy, all contributing to increasing workload within a resource-constrained system. Although genomic medicine has enormous potential to benefit patients, its successful implementation demands alignment with existing skills and working practices, development of underpinning informatics infrastructure, integration into care pathways with consideration of commissioning and leadership. Here, we set out current initiatives and future strategies to support primary care colleagues in the delivery of genomic medicine, covering issues of workforce development and education, primary care leadership, and data and digital considerations.
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Affiliation(s)
- Judith Hayward
- National Genomics Education, RCGP joint clinical champion in genomics medicine, Royal College of General Practitioners, and honorary research fellow, St George's University London, London UK
| | - Will Evans
- Yorkshire Regional Genetics Service, and clinical assistant professor, Centre for Academic Primary Care, School of Medicine, University of Nottingham, UK
| | | | - Imran Rafi
- St George's University of London, London, UK, and joint clinical champion in genomics medicine, Royal College of General Practitioners
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Haga SB. The Critical Role of Pharmacists in the Clinical Delivery of Pharmacogenetics in the U.S. PHARMACY 2023; 11:144. [PMID: 37736916 PMCID: PMC10514841 DOI: 10.3390/pharmacy11050144] [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: 07/31/2023] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023] Open
Abstract
Since the rebirth of pharmacogenomics (PGx) in the 1990s and 2000s, with new discoveries of genetic variation underlying adverse drug response and new analytical technologies such as sequencing and microarrays, there has been much interest in the clinical application of PGx testing. The early involvement of pharmacists in clinical studies and the establishment of organizations to support the dissemination of information about PGx variants have naturally resulted in leaders in clinical implementation. This paper presents an overview of the evolving role of pharmacists, and discusses potential challenges and future paths, primarily focused in the U.S. Pharmacists have positioned themselves as leaders in clinical PGx testing, and will prepare the next generation to utilize PGx testing in their scope of practice.
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Affiliation(s)
- Susanne B Haga
- Division of General Internal Medicine, Department of Medicine, School of Medicine, Duke University, 101 Science Drive, Durham, NC 27708, USA
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9
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Kerman BJ, Brunette CA, Harris EJ, Antwi AA, Lemke AA, Vassy JL. Primary care physician use of patient race and polygenic risk scores in medical decision-making. Genet Med 2023; 25:100800. [PMID: 36748708 PMCID: PMC10085844 DOI: 10.1016/j.gim.2023.100800] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The use of patient race in medicine is controversial for its potential either to exacerbate or address health disparities. Polygenic risk scores (PRSs) have emerged as a tool for risk stratification models used in preventive medicine. We examined whether PRS results affect primary care physician (PCP) medical decision-making and whether that effect varies by patient race. METHODS Using an online survey with a randomized experimental design among PCPs in a national database, we ascertained decision-making around atherosclerotic cardiovascular disease prevention and prostate cancer screening for case scenario patients who were clinically identical except for randomized reported race. RESULTS Across 369 PCPs (email open rate = 10.8%, partial completion rate = 93.7%), recommendations varied with PRS results in expected directions (low-risk results, no available PRS results, and high-risk results). Still, physicians randomized to scenarios with Black patients were more likely to recommend statin therapy than those randomized to scenarios with White patients (odds ratio = 1.74, 95% CI = 1.16-2.59, P = .007) despite otherwise identical clinical profiles and independent of PRS results. Similarly, physicians were more likely to recommend prostate cancer screening for Black patients than for White patients (odds ratio = 1.58, 95% CI = 1.06-2.35, P = .025) despite otherwise identical clinical and genetic profiles. CONCLUSION Despite advances in precision risk stratification, physicians will likely continue to use patient race implicitly or explicitly in medical decision-making.
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Affiliation(s)
- Benjamin J Kerman
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA
| | | | - Elizabeth J Harris
- Department of Medicine, Harvard Medical School, Boston, MA; Veterans Affairs Boston Healthcare System, Boston, MA
| | | | - Amy A Lemke
- Norton Children's Research Institute, Affiliated with the University of Louisville School of Medicine, Louisville, KY
| | - Jason L Vassy
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA; Veterans Affairs Boston Healthcare System, Boston, MA; Precision Population Health, Ariadne Labs, Boston, MA.
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Pharmacokinetic Markers of Clinical Outcomes in Severe Mental Illness: A Systematic Review. Int J Mol Sci 2023; 24:ijms24054776. [PMID: 36902205 PMCID: PMC10003720 DOI: 10.3390/ijms24054776] [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: 01/13/2023] [Revised: 02/20/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
The term severe mental illness (SMI) encompasses those psychiatric disorders exerting the highest clinical burden and socio-economic impact on the affected individuals and their communities. Pharmacogenomic (PGx) approaches hold great promise in personalizing treatment selection and clinical outcomes, possibly reducing the burden of SMI. Here, we sought to review the literature in the field, focusing on PGx testing and particularly on pharmacokinetic markers. We performed a systematic review on PUBMED/Medline, Web of Science, and Scopus. The last search was performed on the 17 September 2022, and further augmented with a comprehensive pearl-growing strategy. In total, 1979 records were screened, and after duplicate removal, 587 unique records were screened by at least 2 independent reviewers. Ultimately, forty-two articles were included in the qualitative analysis, eleven randomized controlled trials and thirty-one nonrandomized studies. The observed lack of standardization in PGx tests, population selection, and tested outcomes limit the overall interpretation of the available evidence. A growing body of evidence suggests that PGx testing might be cost-effective in specific settings and may modestly improve clinical outcomes. More efforts need to be directed toward improving PGx standardization, knowledge for all stakeholders, and clinical practice guidelines for screening recommendations.
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Fragala MS, Shaman JA, Lorenz RA, Goldberg SE. Role of Pharmacogenomics in Comprehensive Medication Management: Considerations for Employers. Popul Health Manag 2022; 25:753-762. [PMID: 36301527 DOI: 10.1089/pop.2022.0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Rising prescription costs, poor medication adherence, and safety issues pose persistent challenges to employer-sponsored health care plans and their beneficiaries. Comprehensive medication management (CMM), a patient-centered approach to medication optimization, enriched by pharmacogenomics (PGx), has been shown to improve the efficacy and safety of pharmaceutical regimens. This has contributed to improved health care outcomes, reduced costs of treatments, better adherence, shorter durations of treatment, and fewer adverse effects from drug therapy. Despite compelling clinical and economic evidence to justify the application of CMM guided by PGx, implementation in clinical settings remains sparse; notable barriers include limited physician adoption and health insurance coverage. Ultimately, these challenges may be overcome through comprehensive programs that include clinical decision support systems and education through employer-sponsored population health management channels to the benefit of the employees, employers, health care providers, and health care systems. This article discusses benefits, considerations, and barriers of scalable PGx-enriched CMM programs in the context of self-insured employers.
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A Theory-Informed Systematic Review of Barriers and Enablers to Implementing Multi-Drug Pharmacogenomic Testing. J Pers Med 2022; 12:jpm12111821. [PMID: 36579514 PMCID: PMC9696651 DOI: 10.3390/jpm12111821] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
PGx testing requires a complex set of activities undertaken by practitioners and patients, resulting in varying implementation success. This systematic review aimed (PROSPERO: CRD42019150940) to identify barriers and enablers to practitioners and patients implementing pharmacogenomic testing. We followed PRISMA guidelines to conduct and report this review. Medline, EMBASE, CINAHL, PsycINFO, and PubMed Central were systematically searched from inception to June 2022. The theoretical domain framework (TDF) guided the organisation and reporting of barriers or enablers relating to pharmacogenomic testing activities. From the twenty-five eligible reports, eleven activities were described relating to four implementation stages: ordering, facilitating, interpreting, and applying pharmacogenomic testing. Four themes were identified across the implementation stages: IT infrastructure, effort, rewards, and unknown territory. Barriers were most consistently mapped to TDF domains: memory, attention and decision-making processes, environmental context and resources, and belief about consequences.
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Dusic EJ, Theoryn T, Wang C, Swisher EM, Bowen DJ. Barriers, interventions, and recommendations: Improving the genetic testing landscape. Front Digit Health 2022; 4:961128. [PMID: 36386046 PMCID: PMC9665160 DOI: 10.3389/fdgth.2022.961128] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022] Open
Abstract
Individual, provider, clinic, and societal level barriers have been shown to undermine the potential impact of genetic testing. The current approach in the primary care setting places an exorbitant burden on both providers and patients. Current literature provides insight into how to address barriers across multiple levels (patient, provider, clinic, system) and at multiple stages in the testing process (identification, referral, counseling, and testing) but interventions have had limited success. After outlining the current approach to genetic testing in the primary care setting, including the barriers that prevent genetic testing uptake and the methods proposed to address these issues, we recommend integrating genetic testing into routine medical care through population-based testing. Success in efforts to increase the uptake of genetic testing will not occur without significant changes to the way genetic services are delivered. These changes will not be instantaneous but are critical in moving this field forward to realize the potential for cancer risk genetic assessment to reduce cancer burden.
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Affiliation(s)
- E. J. Dusic
- Institute of Public Health Genetics, Department of Biostatistics, University of Washington, Seattle, WA, United States
- Correspondence: E. J. Dusic
| | - Tesla Theoryn
- Institute of Public Health Genetics, Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Catharine Wang
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, United States
| | - Elizabeth M. Swisher
- Department of Obstetrics and Gynecology, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA, United States
| | - Deborah J. Bowen
- Institute of Public Health Genetics, Department of Biostatistics, University of Washington, Seattle, WA, United States
- Department of Bioethics, University of Washington, Seattle, WA, United States
| | - EDGE Study Team
- Beth Devine, Department of Pharmacy, University of Washington, Seattle, WA, United States
- Barbara Norquist, Department of Obstetrics & Gynecology, University of Washington Medical Center, University of Washington, Seattle, WA, United States
- Brian Shirts, Department of Laboratory Medicine & Pathology, University of Washington Medical Center, University of Washington, Seattle, WA, United States
- Mariebeth Velasquez, Department of Family Medicine, University of Washington Medical Center, University of Washington, Seattle, WA, United States
- Michael Raff, Genomics Institute, MultiCare Health System, Tacoma, WA, United States
- Jeannine M. Brant, Clinical Science & Innovation, Billings Clinic, Billings, MT, United States
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McDermott JH, Wright S, Sharma V, Newman WG, Payne K, Wilson P. Characterizing pharmacogenetic programs using the consolidated framework for implementation research: A structured scoping review. Front Med (Lausanne) 2022; 9:945352. [PMID: 36059837 PMCID: PMC9433561 DOI: 10.3389/fmed.2022.945352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/29/2022] [Indexed: 12/11/2022] Open
Abstract
Several healthcare organizations have developed pre-emptive pharmacogenetic testing programs, where testing is undertaken prior to the prescription of a medicine. This review characterizes the barriers and facilitators which influenced the development of these programs. A bidirectional citation searching strategy identified relevant publications before a standardized data extraction approach was applied. Publications were grouped by program and data synthesis was undertaken using the Consolidated Framework for Implementation Research (CFIR). 104 publications were identified from 40 programs and 4 multi-center initiatives. 26 (66%) of the programs were based in the United States and 95% in high-income countries. The programs were heterogeneous in their design and scale. The Characteristics of the Intervention, Inner Setting, and Process domains were referenced by 92.5, 80, and 77.5% of programs, respectively. A positive institutional culture, leadership engagement, engaging stakeholders, and the use of clinical champions were frequently described as facilitators to implementation. Clinician self-efficacy, lack of stakeholder knowledge, and the cost of the intervention were commonly cited barriers. Despite variation between the programs, there were several similarities in approach which could be categorized via the CFIR. These form a resource for organizations planning the development of pharmacogenetic programs, highlighting key facilitators which can be leveraged to promote successful implementation.
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Affiliation(s)
- John H. McDermott
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- Division of Evolution, Infection and Genomics, School of Biological Sciences, The University of Manchester, Manchester, United Kingdom
- *Correspondence: John H. McDermott,
| | - Stuart Wright
- Division of Population Health, Manchester Centre for Health Economics, Health Services Research and Primary Care, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Videha Sharma
- Division of Informatics, Centre for Health Informatics, Imaging and Data Science, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - William G. Newman
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- Division of Evolution, Infection and Genomics, School of Biological Sciences, The University of Manchester, Manchester, United Kingdom
| | - Katherine Payne
- Division of Population Health, Manchester Centre for Health Economics, Health Services Research and Primary Care, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Paul Wilson
- Division of Population Health, Centre for Primary Care and Health Services Research, Health Services Research and Primary Care, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
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15
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Allen JD, Pittenger AL, Bishop JR. A Scoping Review of Attitudes and Experiences with Pharmacogenomic Testing among Patients and the General Public: Implications for Patient Counseling. J Pers Med 2022; 12:jpm12030425. [PMID: 35330430 PMCID: PMC8953117 DOI: 10.3390/jpm12030425] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 12/16/2022] Open
Abstract
The use of pharmacogenomic (PGx) tests is increasing, but there are not standard approaches to counseling patients on their implications or results. To inform approaches for patient counseling, we conducted a scoping review of published literature on patient experiences with PGx testing and performed a thematic analysis of qualitative and quantitative reports. A structured scoping review was conducted using Joanna Briggs Institute guidance. The search identified 37 articles (involving n = 6252 participants) published between 2010 and 2021 from a diverse range of populations and using a variety of study methodologies. Thematic analysis identified five themes (reasons for testing/perceived benefit, understanding of results, psychological response, impact of testing on patient/provider relationship, concerns about testing/perceived harm) and 22 subthemes. These results provide valuable context and potential areas of focus during patient counseling on PGx. Many of the knowledge gaps, misunderstandings, and concerns that participants identified could be mitigated by pre- and post-test counseling. More research is needed on patients’ PGx literacy needs, along with the development of a standardized, open-source patient education curriculum and the development of validated PGx literacy assessment tools.
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Affiliation(s)
- Josiah D. Allen
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA;
- Medigenics Consulting, LLC, Minneapolis, MN 55407, USA
| | - Amy L. Pittenger
- Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Jeffrey R. Bishop
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA;
- Department of Psychiatry and Behavioral Sciences, Medical School, University of Minnesota, Minneapolis, MN 55455, USA
- Correspondence:
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16
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Pearce A, Terrill B, Alffenaar JW, Patanwala S, Kummerfeld S, Day R, Young MA, Stocker S. Pharmacogenomic testing: perception of clinical utility, enablers and barriers to adoption in Australian hospitals. Intern Med J 2022; 52:1135-1143. [PMID: 35191159 PMCID: PMC9541847 DOI: 10.1111/imj.15719] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 11/29/2022]
Abstract
Background Despite healthcare professionals (HCP) endorsing the clinical utility of pharmacogenomics testing, use in clinical practice is limited. Aims To assess HCP' perceptions of pharmacogenomic testing and identify barriers to implementation. Methods HCP involved in prescribing decisions at three hospitals in Sydney, Australia, were invited to participate. The online survey assessed perceptions of pharmacogenomic testing, including: (i) demographic and practice variables; (ii) use, knowledge and confidence; (iii) perceived benefits; (iv) barriers to implementation; and (v) operational and/or system changes and personnel required to implement on site. Results HCP were predominantly medical practitioners (75/107) and pharmacists (25/107). HCP perceived pharmacogenomic testing was beneficial to identify reasons for drug intolerance (85/95) and risk of side‐effects (86/95). Although testing was considered relevant to their practice (79/100), few HCP (23/100) reported past or intended future use (26/100). Few HCP reported confidence in their ability to identify indications for pharmacogenomic testing (14/107), order tests (19/106) and communicate results with patients (16/107). Lack of clinical practice guidelines (62/79) and knowledge (54/77) were identified as major barriers to implementation of pharmacogenomics. Comprehensive reimbursement for testing and clinical practice guidelines, alongside models‐of‐care involving multidisciplinary teams and local clinical champions were suggested as strategies to facilitate implementation of pharmacogenomic testing into practice. Conclusions Pharmacogenomic testing was considered important to guide drug selection and dosing decisions. However, limited knowledge, low confidence and an absence of guidelines impede the use of pharmacogenomic testing. Establishment of local resources including multidisciplinary models‐of‐care was suggested to facilitate implementation of pharmacogenomics.
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Affiliation(s)
- Angela Pearce
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, Sydney, Australia
| | - Bronwyn Terrill
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, Sydney, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, Faculty of Medicine & Health, The University of Sydney, Sydney, Australia.,Westmead Hospital, Sydney, Australia
| | - Sid Patanwala
- Sydney Pharmacy School, Faculty of Medicine & Health, The University of Sydney, Sydney, Australia.,Royal Prince Alfred Hospital, Sydney, Australia
| | - Sarah Kummerfeld
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, Sydney, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Richard Day
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Mary-Anne Young
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, Sydney, Australia.,St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Sophie Stocker
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Sydney Pharmacy School, Faculty of Medicine & Health, The University of Sydney, Sydney, Australia.,Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
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17
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Qureshi S, Latif A, Condon L, Akyea RK, Kai J, Qureshi N. Understanding the barriers and enablers of pharmacogenomic testing in primary care: a qualitative systematic review with meta-aggregation synthesis. Pharmacogenomics 2022; 23:135-154. [PMID: 34911350 PMCID: PMC8759425 DOI: 10.2217/pgs-2021-0131] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Introduction: Pharmacogenomic testing can indicate which drugs may have limited therapeutic action or lead to adverse effects, hence guiding rational and safe prescribing. However, in the UK and other countries, there are still significant barriers to implementation of testing in primary care. Objective: This systematic review presents the barriers and enablers to the implementation of pharmacogenomics in primary care setting. Materials & methods: MEDLINE, EMBASE, PsycINFO and CINAHL databases were searched through to July 2020 for studies that reported primary qualitative data of primary care professionals and patient views. Following screening, data extraction and quality assessment, data synthesis was undertaken using meta-aggregation based on the theoretical domain's framework (TDF). Confidence in the synthesized findings relating to credibility and dependability was established using CONQual. Eligible papers were categorized into six TDF domains - knowledge; social and professional roles; behavioral regulation; beliefs and consequences; environmental context and resources; and social influences. Results: From 1669 citations, eighteen eligible studies were identified across seven countries, with a sample size of 504 participants including both primary care professionals and patients. From the data, 15 synthesized statements, all with moderate CONQual rating emerged. These categories range from knowledge, awareness among Primary Care Physicians and patients, professional relationships, negative impact of PGx, belief that PGx can reduce adverse drug reactions, clinical evidence, cost-effectiveness, informatics, reporting issues and social issues. Conclusion: Through use of TDF, fifteen synthesized statements provide policymakers with valuable recommendations for the implementation of pharmacogenomics in primary care. In preparation, policymakers need to consider the introduction of effective educational strategies for both PCPs and patients to raise knowledge, awareness, and engagement. The actual introduction of PGx will require reorganization with decision support tools to aid use of PGx in primary care, with a clear delegation of roles and responsibilities between general professionals and pharmacists supplemented by a local pool of experts. Furthermore, policy makers need to address the cost effectiveness of pharmacogenomics and having appropriate infrastructure supporting testing and interpretation including informatic solutions for utilizing pharmacogenomic results.
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Affiliation(s)
- Sadaf Qureshi
- NHS Derby & Derbyshire Clinical Commissioning Group, Medicines Management,10 Nottingham Road, Derby, DE1 3QT, UK,Author for correspondence:
| | - Asam Latif
- School of Health Sciences, University Park, University of Nottingham, NG2 7RD, UK
| | - Laura Condon
- Primary Care Stratified Medicine Research Group (PRISM), School of Medicine, University Park, University of Nottingham, NG2 7RD, UK
| | - Ralph K Akyea
- Primary Care Stratified Medicine Research Group (PRISM), School of Medicine, University Park, University of Nottingham, NG2 7RD, UK
| | - Joe Kai
- Primary Care Stratified Medicine Research Group (PRISM), School of Medicine, University Park, University of Nottingham, NG2 7RD, UK
| | - Nadeem Qureshi
- Primary Care Stratified Medicine Research Group (PRISM), School of Medicine, University Park, University of Nottingham, NG2 7RD, UK
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