Implementation of a Pharmacogenomic Testing Service through Community Pharmacy in the Netherlands: Results from an Early Service Evaluation

Current published evidence on barriers and proposed strategies for genetic testing implementation in health care settings: A scoping review

BACKGROUND

The slow uptake of genetic testing in routine clinical practice warrants the attention of researchers and practitioners to find effective strategies to facilitate implementation.

OBJECTIVES

This study aimed to identify the barriers to and strategies for pharmacogenetic testing implementation in a health care setting from published literature.

METHODS

A scoping review was conducted in August 2021 with an expanded literature search using Ovid MEDLINE, Web of Science, International Pharmaceutical Abstract, and Google Scholar to identify studies reporting implementation of pharmacogenetic testing in a health care setting, from a health care system's perspective. Articles were screened using DistillerSR and findings were organized using the 5 major domains of Consolidated Framework for Implementation Research (CFIR).

RESULTS

A total of 3536 unique articles were retrieved from the above sources, with only 253 articles retained after title and abstract screening. Upon screening the full texts, 57 articles (representing 46 unique practice sites) were found matching the inclusion criteria. We found that most reported barriers and their associated strategies to the implementation of pharmacogenetic testing surrounded 2 CFIR domains: intervention characteristics and inner settings. Factors relating to cost and reimbursement were described as major barriers in the intervention characteristics. In the same domain, another major barrier was the lack of utility studies to provide evidence for genetic testing uptake. Technical hurdles, such as integrating genetic information to medical records, were identified as an inner settings barrier. Collaborations and lessons from early implementers could be useful strategies to overcome majority of the barriers across different health care settings. Strategies proposed by the included implementation studies to overcome these barriers are summarized and can be used as guidance in future.

CONCLUSION

Barriers and strategies identified in this scoping review can provide implementation guidance for practice sites that are interested in implementing genetic testing.

Pharmacogenomics in practice: a review and implementation guide

Considerable efforts have been exerted to implement Pharmacogenomics (PGx), the study of interindividual variations in DNA sequence related to drug response, into routine clinical practice. In this article, we first briefly describe PGx and its role in improving treatment outcomes. We then propose an approach to initiate clinical PGx in the hospital setting. One should first evaluate the available PGx evidence, review the most relevant drugs, and narrow down to the most actionable drug-gene pairs and related variant alleles. This is done based on data curated and evaluated by experts such as the pharmacogenomics knowledge implementation (PharmGKB) and the Clinical Pharmacogenetics Implementation Consortium (CPIC), as well as drug regulatory authorities such as the US Food and Drug Administration (FDA) and European Medicinal Agency (EMA). The next step is to differentiate reactive point of care from preemptive testing and decide on the genotyping strategy being a candidate or panel testing, each of which has its pros and cons, then work out the best way to interpret and report PGx test results with the option of integration into electronic health records and clinical decision support systems. After test authorization or testing requirements by the government or drug regulators, putting the plan into action involves several stakeholders, with the hospital leadership supporting the process and communicating with payers, the pharmacy and therapeutics committee leading the process in collaboration with the hospital laboratory and information technology department, and healthcare providers (HCPs) ordering the test, understanding the results, making the appropriate therapeutic decisions, and explaining them to the patient. We conclude by recommending some strategies to further advance the implementation of PGx in practice, such as the need to educate HCPs and patients, and to push for more tests' reimbursement. We also guide the reader to available PGx resources and examples of PGx implementation programs and initiatives.

The Implementation of Pharmacogenetics in the United Kingdom

There is considerable inter-individual variability in the effectiveness and safety of pharmaceutical interventions. This phenomenon can be attributed to a multitude of factors; however, it is widely acknowledged that common genetic variation affecting drug absorption or metabolism play a substantial contributory role. This is a concept known as pharmacogenetics. Understanding how common genetic variants influence responses to medications, and using this knowledge to inform prescribing practice, could yield significant advantages for both patients and healthcare systems. Some health services around the world have introduced pharmacogenetics into routine practice, whereas others are less advanced along the implementation pathway. This chapter introduces the field of pharmacogenetics, the existing body of evidence, and discusses barriers to implementation. The chapter will specifically focus on efforts to introduce pharmacogenetics in the NHS, highlighting key challenges related to scale, informatics, and education.

The potential role of community pharmacy staff in reducing patient delay in consulting with symptoms of rheumatoid arthritis: a qualitative study

Background

Rheumatoid arthritis (RA) is a chronic inflammatory arthritis which can cause joint damage and reduced quality of life. Early treatment of RA within 3 months of symptom onset is associated with improved clinical outcomes. However, this window of opportunity is often missed. One important contributing factor is patients with symptoms of RA delaying consulting their general practitioner (GP). Previous research indicates that patients with inflammatory arthritis are likely to visit pharmacies for advice before consulting their GP. Therefore, pharmacists are well positioned to identify patients with symptoms of early inflammatory arthritis and signpost them appropriately. This research examines community pharmacy staff’s knowledge, perceptions, and approaches to management of patients presenting with symptoms of RA in order to identify training needs and other opportunities for intervention to enhance the role of pharmacy staff in the pathway to care.

Methods

Semi-structured interviews were conducted with 19 community pharmacy staff in the West Midlands (UK), during a 12-month period (2017–2018). The interviews were audio-recorded, transcribed, and analyzed using thematic analysis facilitated by NVivo 12.

Results

There was considerable variation in knowledge and perceptions of RA and the need for early treatment amongst pharmacists and other pharmacy staff. The potential role of pharmacists and other pharmacy staff in reducing delay in help-seeking was also discussed. Four themes emerged from thematic analysis: (1) Variations in perceptions and knowledge about RA. (2) The role of the pharmacy in increasing public awareness about RA. (3) The role of the pharmacy staff in facilitating access to the GP. (4) Practical considerations for pharmacy-based interventions.

Conclusion

Variability in knowledge and perceptions of RA amongst pharmacists, and amongst other pharmacy staff will affect effective signposting of suspected RA cases. This study identifies opportunities for enhanced training of community pharmacists and other pharmacy staff in relation to inflammatory arthritis as well as other pharmacy-based interventions, such as public awareness campaigns about RA and other musculoskeletal conditions. Together with existing referral services and other pharmacy-based initiatives this could result in enhanced signposting to GP consultation or other appropriate NHS services for inflammatory symptoms and reduced treatment delay.

Characterizing pharmacogenetic programs using the consolidated framework for implementation research: A structured scoping review

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.

Knowledge, attitude and perception of community pharmacists towards pharmacogenomics services in northern Nigeria: a cross-sectional study

Objectives

To evaluate knowledge, attitude and perception of community pharmacists towards pharmacogenomics services.

Methods

A cross-sectional study was conducted among community pharmacists in two cities in Northern Nigeria using a self-administered, validated and pre-tested questionnaire. The data were collected from December 2021 to February 2022 and were analysed using both descriptive and inferential analyses.

Results

A total of 161 completed questionnaires were included in this study (response rate was 61.9%). Most of the respondents were males (59.0%). Only 25.5% had previous pharmacogenomics training but 90.1% indicated an interest in attending pharmacogenomics training in the future. Overall, respondents had moderate knowledge of pharmacogenomics with higher knowledge score found among those who had previous pharmacogenomics training (11.9 ± 1.7 vs 10.5 ± 2.4; p = 0.001), and those with postgraduate qualification (11.7 ± 1.9 vs 10.7 ± 2.3; p = 0.028). The mean attitude score was 6.8 ± 2.0 out of 10.0 indicating a good attitude towards pharmacogenomics services. Those with previous training (8.1 ± 1.7 vs 6.2 ± 1.9; p < 0.001) and those with postgraduate qualification (7.2 ± 2.3 vs 6.6 ± 1.9; p = 0.042) had better attitude towards pharmacogenomics services. The median perception score was 34.0 out of 45.0, indicating a positive perception towards pharmacogenomics. There was a better perception among those with previous pharmacogenomics training (40.0 [21–45] vs 34.0 [0–45]; p = 0.002) and those with postgraduate qualifications (39.0 [0–45] vs 34.0 [21–45]; p = 0.010). Barriers to the implementation of pharmacogenomics included lack of knowledge (89.4%), lack of guidelines (87.5%) and lack of reimbursement (81.4%).

Conclusion

Community pharmacists have a moderate knowledge, a good attitude and a positive perception towards pharmacogenomics services. Those with previous pharmacogenomics training and those with postgraduate qualifications had better knowledge, attitude and perception towards pharmacogenomics services. Lack of knowledge, lack of guidelines and lack of reimbursement were the major barriers to the implementation of pharmacogenomics services in community pharmacies in Nigeria. Pharmacogenomics should be included in pharmacy training curricula to prepare pharmacists for the provision of pharmacogenomics services. Development of local guidelines and a robust reimbursement plan for pharmacogenomics services is recommended.

Co-designing a community pharmacy pharmacogenomics testing service in the UK

Introduction

Pharmacogenomics (PGx) testing services have been delivered through community pharmacies across the globe, though not yet in the UK. This paper is reporting a focus group study, the first stage of a participatory co-design process to increase the chance of a successful implementation of a PGx service through community pharmacy in the UK.

Aim

To identify the barriers and enablers to implementing a community pharmacy based PGx service in the UK.

Method

Three focus groups were conducted with community pharmacists (n = 10), prescribers (n = 8) and patients (n = 8) in England. The focus groups were recorded, transcribed and thematically analysed using the Braun and Clarke six phase reflexive thematic analysis approach.

Results

The analysis identified five themes about PGx testing in community pharmacies: (1) In- principle receptiveness, (2) Appreciation of the benefits, (3) Lack of implementation resources (4) Ambiguity about implications for implementation and (5) Interprofessional relationship challenges.

Conclusion

The identified enablers for implementation of a PGx service were at a macro health system strategic level; the concerns were more at a granular operational procedural level. Overall receptiveness was noted by all three participant groups, and both prescriber and pharmacist groups appreciated the potential benefits for patients and the healthcare system. Prior to implementation in the UK, there is a need to disambiguate health professional’s concerns of the guidance, resources, and knowledge required to set up and deliver the service and to resolve patient concerns about the nature of genomics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07730-y.

Pharmacogenomics: A road ahead for precision medicine in psychiatry

Psychiatric genomics is providing insights into the nature of psychiatric conditions that in time should identify new drug targets and improve patient care. Less attention has been paid to psychiatric pharmacogenomics research, despite its potential to deliver more rapid change in clinical practice and patient outcomes. The pharmacogenomics of treatment response encapsulates both pharmacokinetic ("what the body does to a drug") and pharmacodynamic ("what the drug does to the body") effects. Despite early optimism and substantial research in both these areas, they have to date made little impact on clinical management in psychiatry. A number of bottlenecks have hampered progress, including a lack of large-scale replication studies, inconsistencies in defining valid treatment outcomes across experiments, a failure to routinely incorporate adverse drug reactions and serum metabolite monitoring in study designs, and inadequate investment in the longitudinal data collections required to demonstrate clinical utility. Nonetheless, advances in genomics and health informatics present distinct opportunities for psychiatric pharmacogenomics to enter a new and productive phase of research discovery and translation.

Moving Pharmacogenetics Into Practice: It's All About the Evidence!

The evidence for pharmacogenetics has grown rapidly in recent decades. However, the strength of evidence required for the clinical implementation of pharmacogenetics is highly debated. Therefore, the purpose of this review is to summarize different perspectives on the evidence required for the clinical implementation of pharmacogenetics. First, we present two patient cases that demonstrate how knowledge of pharmacogenetic evidence affected their care. Then we summarize resources that curate pharmacogenetic evidence, types of evidence (with an emphasis on randomized controlled trials [RCT]) and their limitations, and different perspectives from implementers, clinicians, and patients. We compare pharmacogenetics to a historical example (i.e., the evidence required for the clinical implementation of pharmacokinetics/therapeutic drug monitoring), and we provide future perspectives on the evidence for pharmacogenetic panels and the need for more education in addition to evidence. Although there are differences in the interpretation of pharmacogenetic evidence across resources, efforts for standardization are underway. Survey data illustrate the value of pharmacogenetic testing from the patient perspective, with their providers seen as key to ensuring maximum benefit from test results. However, clinicians and practice guidelines from medical societies often rely on RCT data to guide treatment decisions, which are not always feasible or ethical in pharmacogenetics. Thus, recognition of other types of evidence to support pharmacogenetic implementation is needed. Among pharmacogenetic implementers, consistent evidence of pharmacogenetic associations is deemed most critical. Ultimately, moving pharmacogenetics into practice will require consideration of multiple stakeholder perspectives, keeping particularly attuned to the voice of the ultimate stakeholder-the patient.