National trends in prescription drug expenditures and projections for 2024

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2024 in the United States, with a focus on the nonfederal hospital and clinic sectors.

METHODS

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2024 were reviewed-including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, endocrine drugs, generics, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2024 were based on a combination of quantitative analyses and expert opinion.

RESULTS

In 2023, overall pharmaceutical expenditures in the US grew 13.6% compared to 2022, for a total of $722.5 billion. Utilization (a 6.5% increase), new drugs (a 4.2% increase) and price (a 2.9% increase) drove this increase. Semaglutide was the top drug in 2023, followed by adalimumab and apixaban. Drug expenditures were $37.1 billion (a 1.1% decrease) and $135.7 billion (a 15.0% increase) in nonfederal hospitals and clinics, respectively. In clinics, increased utilization drove growth, with a small impact from price and new products. In nonfederal hospitals, a drop in utilization led the decrease in expenditures, with price and new drugs modestly contributing to growth in spending. Several new drugs that will influence spending are expected to be approved in 2024. Specialty, endocrine, and cancer drugs will continue to drive expenditures.

CONCLUSION

For 2024, we expect overall prescription drug spending to rise by 10.0% to 12.0%, whereas in clinics and hospitals we anticipate an 11.0% to 13.0% increase and a 0% to 2.0% increase, respectively, compared to 2023. These national estimates of future pharmaceutical expenditure growth may not be representative of any health system because of the myriad of local factors that influence actual spending.

Employee investigation and contact tracing program in a pediatric cancer hospital to mitigate the spread of COVID-19 among the workforce, patients, and caregivers

Background

Case investigations and contact tracing are essential disease control measures used by health departments. Early in the pandemic, they were seen as a key strategy to stop COVID-19 spread. The CDC urged rapid action to scale up and train a large workforce and collaborate across public and private agencies to halt COVID-19 transmission.

Methods

We developed a program for case investigation and contact tracing that followed CDC and local health guidelines, compliant with the Occupational Safety and Health Administration (OSHA) regulations and tailored to the needs and resources of our institution. Program staff were trained and assessed for competency before joining the program.

Results

From March 2020 to May 2021, we performed 838 COVID-19 case investigations, which led to 136 contacts. Most employees reported a known SARS-CoV-2 exposure from the community (n = 435) or household (n = 343). Only seven (5.1%) employees were determined as more likely than not to have SARS-CoV-2 infection related to workplace exposure, and when so, lapses in following the masking recommendations were identified. Between June 2021-February 2022, our program adjusted to the demand of the different waves, particularly omicron, by significantly reducing the amount of data collected. No transmission from employees to patients or caregivers was observed during this period.

Conclusion

Prompt implementation of case investigation and contact tracing is possible, and it effectively reduces workplace exposures. This approach can be adapted to suit the specific needs and requirements of various healthcare settings, particularly those serving the most vulnerable patient populations.

ASHP and ASHP Foundation Pharmacy Forecast 2024: Strategic Planning Guidance for Pharmacy Departments in Hospitals and Health Systems

Purpose: The 2024 ASHP Pharmacy Forecast identifies and contextualizes emerging issues and trends that will influence healthcare, health systems, and the pharmacy profession and provides recommendations to inform long-term strategic planning that should prompt action by pharmacists and health-system leaders. Methods: Drawing on the “wisdom of crowds” concept, a survey was constructed with 6 general themes, each with 6 to 9 focused statements and a seventh theme on preparedness (58 survey items in total). The size of and representation within the survey panel were intended to capture opinions from a wide range of pharmacy leaders. The survey instructed panelists to consider the likelihood of the events/scenarios described in the statements occurring in the next 5 years as being likely, somewhat likely, somewhat unlikely, or very unlikely. Then, survey panelists assessed the preparedness (from very unprepared to very prepared) for 12 of the statements. Results: The 6 survey themes identified were Urgent Public Health Priorities, Responding to the Mental Health Crisis, Achieving Care Equity, New Disease Paradigms and Treatment Innovations, Workforce: Focus on Culture for the Future, and Artificial Intelligence: Can Ethics and Regulators Catch Up? The survey was completed by 250 respondents, yielding an 88% response rate. Analysis of survey results was provided by chapter authors along with strategic recommendations to guide actions for each theme. Conclusion: The focus of the Pharmacy Forecast is on large-scale, long-term trends that will influence healthcare and the pharmacy profession over months and years and not on day-to-day situational dynamics. The report provides insight to stimulate thinking and discussion and provides a starting point to proactively position leaders, their teams, and departments for potential future events and trends.

National trends in prescription drug expenditures and projections for 2023

PURPOSE

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2023 in the United States, with a focus on the nonfederal hospital and clinic sectors.

METHODS

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2023 were reviewed, including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, diabetes medications, generics, COVID-19 pandemic influence, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2023 were based on a combination of quantitative analyses and expert opinion.

RESULTS

In 2022, overall pharmaceutical expenditures in the US grew 9.4% compared to 2021, for a total of $633.5 billion. Utilization (a 5.9% increase), price (a 1.7% increase) and new drugs (a 1.8% increase) drove this increase. Adalimumab was the top-selling drug in 2022, followed by semaglutide and apixaban. Drug expenditures were $37.2 billion (a 5.9% decrease) and $116.9 billion (a 10.4% increase) in nonfederal hospitals and clinics, respectively. In clinics, new products and increased utilization growth drove growth, with a small impact from price changes. In nonfederal hospitals, a drop in utilization led to a decrease in expenditures, with price changes and new drugs contributing to growth in spending. Several new drugs that will influence spending have been or are expected to be approved in 2023. Specialty and cancer drugs will continue to drive expenditures along with the evolution of the COVID-19 pandemic.

CONCLUSION

For 2023, we expect overall prescription drug spending to rise by 6.0% to 8.0%, whereas in clinics and hospitals we anticipate increases of 8.0% to 10.0% and 1.0% to 3.0%, respectively, compared to 2022. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

Association between Electronic Health Record Implementations and Hospital-Acquired Conditions in Pediatric Hospitals

BACKGROUND

Implementing an electronic health record (EHR) is one of the most disruptive operational tasks a health system can undergo. Despite anecdotal reports of adverse events around the time of EHR implementations, there is limited corroborating research, particularly in pediatrics. We utilized data from Solutions for Patient Safety (SPS), a network of 145+ children's hospitals that share data and protocols to reduce harm in pediatric care delivery, to study the impact of EHR implementations on patient safety.

OBJECTIVE

Determine if there is an association between the time immediately surrounding an EHR implementation and hospital-acquired conditions (HACs) rates in pediatrics.

METHODS

A survey of information technology leaders at pediatric institutions identified EHR implementations occurring between 2012 and 2022. This list was cross-referenced with the SPS database to create an anonymized dataset of 27 sites comprising monthly HAC and care bundle compliance rates in the 7 months preceding and succeeding the transition. Six HACs were analyzed: central-line associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), adverse drug events, surgical site infections (SSIs), pressure injuries (PIs), and falls, in addition to four associated care bundle compliance rates: CLABSI and CAUTI maintenance bundles, SSI bundle, and PI bundle. To determine if there was a statistically significant association with EHR implementation, the observation period was divided into three eras: "before" (months -7 to -3), "during" (months -2 to +2), and "after" go-live (months +3 to +7). Average monthly HAC and bundle compliance rates were calculated across eras. Paired t-tests were performed to compare rates between the eras.

RESULTS

No statistically significant increase in HAC rates or decrease in bundle compliance rates was observed across the EHR implementation eras.

CONCLUSION

This multisite study detected no significant increase in HACs and no decrease in preventive care bundle compliance in the months surrounding an EHR implementation.

Building new standards to prevent harm from medication errors in children with cancer

Children with cancer receive many medications outside the hospital administered by their caregivers. The study by Walsh et al. shows the number and types of medication errors in these patients. The study includes data from three different centers. Importantly, the study shows the types of errors that cause harm. The authors describe how the harmful errors can be prevented. We suggest ways these results can be used to identify which patients and families will benefit from additional attention. Providing more help at clinic and in the home may help prevent harmful medication errors in children with cancer.

Clinician adherence to pharmacogenomics prescribing recommendations in clinical decision support alerts

Thoughtful integration of interruptive clinical decision support (CDS) alerts within the electronic health record is essential to guide clinicians on the application of pharmacogenomic results at point of care. St. Jude Children's Research Hospital implemented a preemptive pharmacogenomic testing program in 2011 in a multidisciplinary effort involving extensive education to clinicians about pharmacogenomic implications. We conducted a retrospective analysis of clinicians' adherence to 4783 pharmacogenomically guided CDS alerts that triggered for 12 genes and 60 drugs. Clinicians adhered to the therapeutic recommendations provided in 4392 alerts (92%). In our population of pediatric patients with catastrophic illnesses, the most frequently presented gene/drug CDS alerts were TPMT/NUDT15 and thiopurines (n = 3850), CYP2D6 and ondansetron (n = 667), CYP2D6 and oxycodone (n = 99), G6PD and G6PD high-risk medications (n  = 51), and CYP2C19 and proton pump inhibitors (omeprazole and pantoprazole; n = 50). The high adherence rate was facilitated by our team approach to prescribing and our collaborative CDS design and delivery.

Association Between Hospital-Acquired Harm Outcomes and Membership in a National Patient Safety Collaborative

IMPORTANCE

Hospital engagement networks supported by the US Centers for Medicare & Medicaid Services Partnership for Patients program have reported significant reductions in hospital-acquired harm, but methodological limitations and lack of peer review have led to persistent questions about the effectiveness of this approach.

OBJECTIVE

To evaluate associations between membership in Children's Hospitals' Solutions for Patient Safety (SPS), a federally funded hospital engagement network, and hospital-acquired harm using standardized definitions and secular trend adjustment.

DESIGN, SETTING, AND PARTICIPANTS

This prospective hospital cohort study included 99 children's hospitals. Using interrupted time series analyses with staggered intervention introduction, immediate and postimplementation changes in hospital-acquired harm rates were analyzed, with adjustment for preexisting secular trends. Outcomes were further evaluated by early-adopting (n = 73) and late-adopting (n = 26) cohorts.

EXPOSURES

Hospitals implemented harm prevention bundles, reported outcomes and bundle compliance using standard definitions to the network monthly, participated in learning events, and implemented a broad safety culture program. Hospitals received regular reports on their comparative performance.

MAIN OUTCOMES AND MEASURES

Outcomes for 8 hospital-acquired conditions were evaluated over 1 year before and 3 years after intervention.

RESULTS

In total, 99 hospitals met the inclusion criteria and were included in the analysis. A total of 73 were considered part of the early-adopting cohort (joined between 2012-2013) and 26 were considered part of the late-adopting cohort (joined between 2014-2016). A total of 42 hospitals were freestanding children's hospitals, and 57 were children's hospitals within hospital or health systems. The implementation of SPS was associated with an improvement in hospital-acquired condition rates in 3 of the 8 conditions after accounting for secular trends. Membership in the SPS was associated with an immediate reduction in central catheter-associated bloodstream infections (coefficient = -0.152; 95% CI, -0.213 to -0.019) and falls of moderate or greater severity (coefficient = -0.331; 95% CI, -0.594 to -0.069). The implementation of the SPS was associated with a reduction in the monthly rate of adverse drug events (coefficient = -0.021; 95% CI, -0.034 to -0.008) in the post-SPS period. The study team observed larger decreases for the early-adopting cohort compared with the late-adopting cohort.

CONCLUSIONS AND RELEVANCE

Through the application of rigorous methods (standard definitions and longitudinal time series analysis with adjustment for secular trends), this study provides a more thorough analysis of the association between the Partnership for Patients hospital engagement network model and reductions in hospital-acquired conditions. These findings strengthen previous claims of an association between this model and improvement. However, inconsistent observations across hospital-acquired conditions when adjusted for secular trends suggests that some caution regarding attributing all effects observed to this model is warranted.

Why do subcutaneous ports get stuck? A case-control study

PURPOSE

We sought to identify clinical features associated with difficult subcutaneous port removals in children.

METHODS

Ports placed between April 2014 and September 2017 at our institution were prospectively tracked for difficult removals. A case-control analysis was performed. Patients with ports that were difficult to remove (stuck; cases) were compared to biological sex and age-matched controls in a ratio of 1:3. Logistic regression determined the association between case/control status and clinical features adjusting for biological sex and age as covariates. A multivariable analysis was performed to identify independent associations.

RESULTS

57 stuck ports (28 extreme [10 endovascular intervention] and 29 moderate) and 171 controls were analyzed. Stuck ports were associated with a diagnosis of acute lymphoblastic leukemia (86% cases versus 22.2% controls; p < 0.001) and a longer placement duration (median 2.6 years [interquartile range (IQR) 2.5-2.6] versus 0.8 years [IQR 0.5-1.4]; p < 0.001). On univariate analysis, procedural and device features associated with stuck ports included subclavian access (71.9% cases versus 48.5% controls; p = 0.0126), a polyurethane versus silicone catheter (96.5% cases versus 79.9% controls; p = 0.001), and a rough catheter appearance at removal (92.6% cases versus 9.4% controls; p < 0.0001). A diagnosis of ALL and duration of line placement were associated with having a stuck port on multivariate analysis.

CONCLUSION

Polyurethane central venous catheters placed for the two-year treatment of acute lymphoblastic leukemia may become difficult to remove. This constellation of factors warrants more extensive preoperative discussion of risk, endovascular backup availability, and scheduling for longer operating room time.

Advancing Pharmacogenomics from Single-Gene to Preemptive Testing

Pharmacogenomic testing can be an effective tool to enhance medication safety and efficacy. Pharmacogenomically actionable medications are widely used, and approximately 90-95% of individuals have an actionable genotype for at least one pharmacogene. For pharmacogenomic testing to have the greatest impact on medication safety and clinical care, genetic information should be made available at the time of prescribing (preemptive testing). However, the use of preemptive pharmacogenomic testing is associated with some logistical concerns, such as consistent reimbursement, processes for reporting preemptive results over an individual's lifetime, and result portability. Lessons can be learned from institutions that have implemented preemptive pharmacogenomic testing. In this review, we discuss the rationale and best practices for implementing pharmacogenomics preemptively.

Quality improvement knowledge in pediatric hematology/oncology physicians: A need for improved education

Pediatric hematology/oncology fellows face unique quality improvement challenges given the danger of chemotherapy and caring for immunocompromised patients. Curricula to teach pediatric hematology/oncology fellows about quality improvement are lacking. We conducted a needs assessment of pediatric hematology/oncology physicians as a first step for creating a quality improvement curriculum for pediatric hematology/oncology fellows. Curricular topics were identified: root cause analysis, run charts, process mapping, chemotherapy/medication safety, implementation/adherence to guidelines. Identified barriers to curriculum implementation included a possible lack of quality improvement expertise, lack of awareness of quality improvement resources, and limited time.

covidscreen: a web app and R Package for assessing asymptomatic COVID-19 testing strategies

Background

COVID-19 has caused over 305 million infections and nearly 5.5 million deaths globally. With complete eradication unlikely, organizations will need to evaluate their risk and the benefits of mitigation strategies, including the effects of regular asymptomatic testing. We developed a web application and R package that provides estimates and visualizations to aid the assessment of organizational infection risk and testing benefits to facilitate decision-making, which combines internal and community information with malleable assumptions.

Results

Our web application, covidscreen, presents estimated values of risk metrics in an intuitive graphical format. It shows the current expected number of active, primarily community-acquired infections among employees in an organization. It calculates and explains the absolute and relative risk reduction of an intervention, relative to the baseline scenario, and shows the value of testing vaccinated and unvaccinated employees. In addition, the web interface allows users to profile risk over a chosen range of input values. The performance and output are illustrated using simulations and a real-world example from the employee testing program of a pediatric oncology specialty hospital.

Conclusions

As the COVID-19 pandemic continues to evolve, covidscreen can assist organizations in making informed decisions about whether to incorporate covid test based screening as part of their on-campus risk-mitigation strategy. The web application, R package, and source code are freely available online (see “Availability of data and materials”).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13718-4.

A nucleic acid amplification test-based strategy does not help inform return to work for healthcare workers with COVID-19

Objective

The objective of this study is to assess the utility of a nucleic acid amplification test‐based approach to shorten isolation of healthcare workers (HCWs) with COVID‐19 in the setting of the highly transmissible omicron variant.

Methods

Between December 24, 2021, and January 5, 2022, HCWs who tested positive for SARS‐CoV‐2 were retested with PCR at least 5 days since onset of symptoms.

Results

Forty‐six sequential fully COVID‐19 vaccinated HCWs who had tested positive for SARS‐CoV‐2 underwent follow‐up testing. All the samples were confirmed as omicron variants and only four (8.7%) were negative in the follow‐up test performed at a median of 6 (range 5–12) since onset of symptoms.

Conclusions

Implementation of a test‐based strategy is logistically challenging, increases costs, and did not lead to shorter isolation in our institution.

An adaptive, asymptomatic SARS-CoV-2 workforce screening program providing real-time, actionable monitoring of the COVID-19 pandemic

COVID-19 remains a challenge worldwide, and testing of asymptomatic individuals remains critical to pandemic control measures. Starting March 2020, a total of 7497 hospital employees were tested at least weekly for SARS CoV-2; the cumulative incidence of asymptomatic infections was 5.64%. Consistently over a 14-month period half of COVID-19 infections (414 of 820, total) were detected through the asymptomatic screening program, a third of whom never developed any symptoms during follow-up. Prompt detection and isolation of these cases substantially reduced the risk of potential workplace and outside of workplace transmission. COVID-19 vaccinations of the workforce were initiated in December 2020. Twenty-one individuals tested positive after being fully vaccinated (3.9 per 1000 vaccinated). Most (61.9%) remained asymptomatic and in majority (75%) the virus could not be sequenced due to low template RNA levels in swab samples. Further routine testing of vaccinated asymptomatic employees was stopped and will be redeployed if needed; routine testing for those not vaccinated continues. Asymptomatic SARS-CoV-2 testing, as a part of enhanced screening, monitors local dynamics of the COVID-19 pandemic and can provide valuable data to assess the ongoing impact of COVID-19 vaccination and SARS-CoV-2 variants, inform risk mitigation, and guide adaptive, operational planning including titration of screening strategies over time, based on infection risk modifiers such as vaccination.

National trends in prescription drug expenditures and projections for 2022

Purpose

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2022 in the United States, with a focus on the nonfederal hospital and clinic sectors.

Methods

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2022 were reviewed—including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, generics, COVID-19 pandemic influence, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2022 were based on a combination of quantitative analyses and expert opinion.

Results

In 2021, overall pharmaceutical expenditures in the US grew 7.7% compared to 2020, for a total of $576.9 billion. Utilization (a 4.8% increase), price (a 1.9% increase) and new drugs (a 1.1% increase) drove this increase. Adalimumab was the top drug in terms of overall expenditures in 2021, followed by apixaban and dulaglutide. Drug expenditures were $39.6 billion (a 8.4% increase) and $105.0 billion (a 7.7% increase) in nonfederal hospitals and in clinics, respectively. In clinics and hospitals, new products and increased utilization growth drove growth, with decreasing prices for both sectors acting as an expense restraint. Several new drugs that are likely to influence spending are expected to be approved in 2022. Specialty and cancer drugs will continue to drive expenditures along with the evolution of the COVID-19 pandemic.

Conclusion

For 2022, we expect overall prescription drug spending to rise by 4.0% to 6.0%, whereas in clinics and hospitals we anticipate increases of 7.0% to 9.0% and 3.0% to 5.0%, respectively, compared to 2021. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

Pharmacists Leading the Way to Precision Medicine: Updates to the Core Pharmacist Competencies in Genomics

Genomics is becoming an increasingly important part of health care, and pharmacists are well-positioned to be practice-based leaders in pharmacogenomics and precision medicine. Competencies available through the Genetics/Genomics Competency Center provide a framework for pharmacogenomics instruction in both pharmacy school curricula and continuing education programs. Given the significant advancements in pharmacogenomics over the past decade, the 2019-2020 American Association of Colleges of Pharmacy Pharmacogenomics Special Interest Group updated the pharmacist competencies. The process used a systematic approach which included mapping pharmacogenomics-specific competencies to the entrustable professional activities for pharmacists and seeking consensus from key stakeholders. The result is an expansion to 30 competencies that reflect the contemporary roles pharmacists play in the application of pharmacogenomics in clinical practice. When implemented into curricula, these competencies will ensure that learners are "practice ready" to integrate pharmacogenomics into patient care. Additional postgraduate training is needed for advanced roles in pharmacogenomics implementation, education, and research.

Advancing pharmacogenomics into practice

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Validation of the Second Victim Experience and Support Tool-Revised in the Neonatal Intensive Care Unit

OBJECTIVE

The aim of the study was to validate a revised version of the Second Victim Experience and Support Tool (SVEST-R). The SVEST survey instrument was developed to measure the emotional and professional impact of medical errors and adverse patient events on healthcare providers and can help healthcare organizations evaluate the effectiveness of support resources.

METHODS

An SVEST-R was completed by 316 healthcare providers from seven neonatal intensive care units affiliated with a large, pediatric hospital. The original 29-item measure was expanded to 43 items to assess eight psychosocial domains (psychological distress, physical distress, colleague support, supervisor support, institutional support, nonwork-related support, professional self-efficacy, resilience) and two employment-related domains (turnover intentions, absenteeism) associated with the second victim experience. Seven additional items assessed desired forms of support (e.g., time away from the unit). A confirmatory factor analysis evaluated the factor structure of the modified measure.

RESULTS

The initial confirmatory factor analysis did not reveal an acceptable factor structure; thus, eight items were removed because of inadequate factor loadings or for conceptual reasons. This resulted in an acceptable model for the final 35-item measure. The final version included nine factors (i.e., psychological distress, physical distress, colleague support, supervisor support, institutional support, professional self-efficacy, resilience, turnover intentions, and absenteeism), with Cronbach α ranging from 0.66 to 0.86.

CONCLUSIONS

The SVEST-R is a valid measure for assessing the impact of errors or adverse events on healthcare providers. Importantly, the SVEST-R now includes positive outcomes (i.e., resilience) that may result from the second victim experience.

Developing Evidence for New Patient Safety Bundles Through Multihospital Collaboration

OBJECTIVE

Multihospital collaboration for safety improvements is increasingly common, but strategies for developing bundles when effective evidence-based practices are not well described are limited. The Children's Hospitals' Solutions for Patient Safety (SPS) Network sought to further reduce patient harm by developing improvement bundles when preliminary evidence was limited.

METHODS

As part of the novel Pioneer process, cohorts of volunteer SPS hospitals collaborated to identify a harm reduction bundle for carefully selected hospital-acquired harm categories where evidence-based practices were limited. For each harm type, a leadership team selected interventions (factors) for testing and guided the work throughout the Pioneer process. Using fundamental quality improvement techniques and a planned experimentation design, each participating hospital submitted outcome and process compliance data for the factor implemented. Data from all hospitals implementing that factor were analyzed together using Shewhart charts, response plots, and analysis of covariance to identify whether reliable implementation of the factor influenced outcomes. Factors were categorized based on strength of evidence and other clinical or evidentiary support. Factors with strong support were included in a final bundle and disseminated to all SPS hospitals.

RESULTS

The SPS began the bundle identification process for nine harm types and three have completed the process. The analytic approach resulted in four scenarios that along with clinical input guided the inclusion or rejection of the factor in the final bundle.

CONCLUSIONS

In this multihospital collaborative, quality improvement methods and planned experimentation were effective at developing evidence-based harm reduction bundles in situations where limited data for interventions exist.

Associations of job demands and patient safety event involvement on burnout among a multidisciplinary group of pediatric hematology/oncology clinicians

BACKGROUND

Workplace burnout can result in negative consequences for clinicians and patients. We assessed burnout prevalence and sources among pediatric hematology/oncology inpatient nurses, ambulatory nurses, physicians (MDs), and advanced practice providers (APPs) by evaluating effects of job demands and involvement in patient safety events (PSEs).

METHODS

A cross-sectional survey (Maslach Burnout Inventory) measured emotional exhaustion, depersonalization, and reduced personal accomplishment. The National Aeronautics and Space Administration Task Load Index measured mental demand, physical demand, temporal demand, effort, and frustration. Relative weights analyses estimated the unique contributions of tasks and PSEs on burnout. Post hoc analyses evaluated open-response comments for burnout factors.

RESULTS

Burnout prevalence was 33%, 20%, 34%, and 33% in inpatient nurses, ambulatory nurses, and MD, and APPs, respectively (N = 481, response rate 69%). Reduced personal accomplishment was significantly higher in inpatient nurses than MDs and APPs. Job frustration was the most significant predictor of burnout across all four cohorts. Other significant predictors of burnout included temporal demand (nursing groups and MDs), effort (inpatient nurses and MDs), and PSE involvement (ambulatory nurses). Open-response comments identified time constraints, lack of administrator support, insufficient institutional support for self-care, and inadequate staffing and/or turnover as sources of frustration.

CONCLUSIONS

All four clinician groups reported substantial levels of burnout, and job demands predicted burnout. The body of knowledge on job stress and workplace burnout supports targeting organizational-level sources versus individual-level factors as the most effective prevention and reduction strategy. This study elaborates on this evidence by identifying structural drivers of burnout within a multidisciplinary context of pediatric hematology/oncology clinicians.

National trends in prescription drug expenditures and projections for 2021

Purpose

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2021 in the United States, with a focus on the nonfederal hospital and clinic sectors.

Methods

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2021 were reviewed—including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for biosimilars, cancer drugs, generics, coronavirus disease 2019 (COVID-19) pandemic influence, and specialty drugs. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2021 were based on a combination of quantitative analyses and expert opinion.

Results

In 2020, overall pharmaceutical expenditures in the United States grew 4.9% compared to 2019, for a total of $535.3 billion. Utilization (a 2.9% increase) and new drugs (a 1.8% increase) drove this increase, with price changes having minimal influence (a 0.3% increase). Adalimumab was the top drug in 2020, followed by apixaban and insulin glargine. Drug expenditures were $35.3 billion (a 4.6% decrease) and $98.4 billion (an 8.1% increase) in nonfederal hospitals and clinics, respectively. In clinics, growth was driven by new products and increased utilization, whereas in hospitals the decrease in expenditures was driven by reduced utilization. Several new drugs that will influence spending are expected to be approved in 2021. Specialty and cancer drugs will continue to drive expenditures along with the evolution of the COVID-19 pandemic.

Conclusion

For 2021, we expect overall prescription drug spending to rise by 4% to 6%, whereas in clinics and hospitals we anticipate increases of 7% to 9% and 3% to 5%, respectively, compared to 2020. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

Never Enough Time: Mixed Methods Study Identifies Drivers of Temporal Demand That Contribute to Burnout Among Physicians Who Care for Pediatric Hematology-Oncology Patients

PURPOSE

Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment because of chronic occupational stress. Approximately one third of pediatric hematology-oncology physicians experience burnout. The goal of this mixed methods study was to determine the prevalence and drivers of burnout among physicians caring for pediatric hematology-oncology patients at our institution.

MATERIALS AND METHODS

This mixed methods, cross-sectional study was conducted at a large academic cancer center. Validated survey instruments were used to measure burnout, job demands, experience with patient safety events, and workplace culture. Quantitative data informed development of a semistructured interview guide, and physicians were randomly selected to participate in individual interviews. Interviews were transcribed and analyzed via content analysis based on a priori codes.

RESULTS

The survey was distributed to 132 physicians, and 53 complete responses were received (response rate 40%). Of the 53 respondents, 15 (28%) met criteria for burnout. Experiencing burnout was associated with increased temporal demand. Twenty-six interviews were conducted. Qualitative themes revealed that frequent meetings, insufficient support staff, and workflow interruptions were key drivers of temporal demand and that temporal demand contributed to burnout through emotional exhaustion and reduced personal accomplishment.

CONCLUSION

Nearly one-third of participating physicians met criteria for burnout, and burnout was associated with increased temporal demand. Qualitative interviews identified specific drivers of temporal demand and burnout, which can be targeted for intervention. This methodology can be easily adapted for broad use and may represent an effective strategy for identifying and mitigating institution-specific drivers of burnout.

Asymptomatic and Symptomatic SARS-CoV-2 Infections After BNT162b2 Vaccination in a Routinely Screened Workforce

This study aims to describe an association between the Pfizer-BioNTech (BNT162b2) vaccine and decreased risk of symptomatic and asymptomatic infections with SARS-CoV-2 in hospital employees.

Approaches to assessing the provider experience with clinical pharmacogenomic information: a scoping review

PURPOSE

Barriers to the implementation of pharmacogenomics in clinical practice have been thoroughly discussed over the past decade.

METHODS

The objective of this scoping review was to characterize the peer-reviewed literature surrounding the experiences and actions of prescribers, pharmacists, or genetic counselors when using pharmacogenomic information in real-world or hypothetical research settings.

RESULTS

A total of 33 studies were included in the scoping review. The majority of studies were conducted in the United States (70%), used quantitative or mixed methods (79%) with physician or pharmacist respondents (100%). The qualitative content analysis revealed five major methodological approaches: hypothetical clinical case scenarios, real-world studies evaluating prescriber response to recommendations or alerts, cross-sectional quantitative surveys, cross-sectional qualitative surveys/interviews, and a quasi-experimental real-world study.

CONCLUSION

The findings of this scoping review can guide further research on the factors needed to successfully integrate pharmacogenomics into clinical care.

The Effects of the Second Victim Phenomenon on Work-Related Outcomes: Connecting Self-Reported Caregiver Distress to Turnover Intentions and Absenteeism

OBJECTIVES

Second victim experiences can affect the well-being of healthcare providers and compromise patient safety. The purpose of this study was to assess the relationships between self-reported second victim-related distress to turnover intention and absenteeism. Organizational support was examined concurrently because it was hypothesized to explain the potential relationships between distress and work-related outcomes.

METHODS

A cross-sectional, self-report survey (the Second Victim Experience and Support Tool) of nurses directly involved in patient care (N = 155) was analyzed by using hierarchical linear regression. The tool assesses organizational support, distress due to patient safety event involvement, and work-related outcomes.

RESULTS

Second victim distress was significantly associated with turnover intentions (P < 0.001) and absenteeism (P < 0.001), while controlling for the effects of demographic variables. Organizational support fully mediated the distress-turnover intentions (P < 0.05) and distress-absenteeism (P < 0.05) relationships, which indicates that perceptions of organizational support may explain turnover intentions and absenteeism related to the second victim experience.

CONCLUSIONS

Involvement in patient safety events and the important role of organizational support in limiting caregiver event-related trauma have been acknowledged. This study is one of the first to connect second victim distress to work-related outcomes. This study reinforces the efforts health care organizations are making to develop resources to support their staff after patient safety events occur. This study broadens the understanding of the negative effects of a second victim experience and the need to support caregivers as they recover from adverse event involvement.

Biomedical Data Science and Informatics Challenges to Implementing Pharmacogenomics with Electronic Health Records

Pharmacogenomic information must be incorporated into electronic health records (EHRs) with clinical decision support in order to fully realize its potential to improve drug therapy. Supported by various clinical knowledge resources, pharmacogenomic workflows have been implemented in several healthcare systems. Little standardization exists across these efforts, however, which limits scalability both within and across clinical sites. Limitations in information standards, knowledge management, and the capabilities of modern EHRs remain challenges for the widespread use of pharmacogenomics in the clinic, but ongoing efforts are addressing these challenges. Although much work remains to use pharmacogenomic information more effectively within clinical systems, the experiences of pioneering sites and lessons learned from those programs may be instructive for other clinical areas beyond genomics. We present a vision of what can be achieved as informatics and data science converge to enable further adoption of pharmacogenomics in the clinic.

Improving Patient Handoffs and Transitions through Adaptation and Implementation of I-PASS Across Multiple Handoff Settings

INTRODUCTION

Communication failures are common root causes of serious medical errors. Standardized, structured handoffs improve communication and patient safety. I-PASS is a handoff program that decreases medical errors and preventable patient harm. The I-PASS mnemonic is defined as illness severity, patient information, action list, situational awareness and contingency plans, and synthesis by receiver. I-PASS was validated for physician handoffs, yet has the potential for broader application. The objectives of this quality improvement initiative were to adapt and implement I-PASS to handoff contexts throughout a pediatric hospital, including those with little or no known evidence of using I-PASS.

METHODS

We adapted and implemented I-PASS for inpatient nursing bedside report, physician handoff, and imaging/procedures handoff. Throughout the initiative, end-user stakeholders participated as team members and informed the adaptation of the I-PASS mnemonic, handoff processes, written handoff documents, and performance evaluation methods. Peers observed handoffs, scored performance, and provided formative feedback. Adherence to I-PASS was the primary outcome. We also evaluated changes in handoff-related error frequency and clinician attitudes about the effects of I-PASS on personal and overall handoff performance.

RESULTS

All 5 elements of the I-PASS mnemonic were used in 87% of inpatient nursing, 76% of physician, and 89% of imaging/procedures handoffs. Inpatient nurses reported reductions in handoff-related errors following I-PASS implementation. Clinicians across most handoff settings reported that using I-PASS improved both general and personal handoff performance.

CONCLUSIONS

I-PASS is adaptable to many handoff settings, which expands its potential to improve patient safety. Clinicians reported reductions in errors and improvements in handoff performance. We identified broad institutional support, customized written handoff documents, and peer observations with feedback as crucial factors in sustaining I-PASS usage.

National trends in prescription drug expenditures and projections for 2020

Purpose

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2020 in the United States, with a focus on the nonfederal hospital and clinic sectors.

Methods

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2020 were reviewed, including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for specialty drugs, biosimilars, and diabetes medications. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2020 were based on a combination of quantitative analyses and expert opinion.

Results

In 2019, overall US pharmaceutical expenditures grew 5.4% compared to 2018, for a total of $507.9 billion. This increase was driven to similar degrees by prices, utilization, and new drugs. Adalimumab was the top drug in US expenditures in 2019, followed by apixaban and insulin glargine. Drug expenditures were $36.9 billion (a 1.5% increase from 2018) and $90.3 billion (an 11.8% increase from 2018) in nonfederal hospitals and clinics, respectively. In clinics, growth was driven by new products and increased utilization, whereas in hospitals growth was driven by new products and price increases. Several new drugs that will likely influence spending are expected to be approved in 2020. Specialty and cancer drugs will continue to drive expenditures.

Conclusion

For 2020 we expect overall prescription drug spending to rise by 4.0% to 6.0%, whereas in clinics and hospitals we anticipate increases of 9.0% to 11.0% and 2.0% to 4.0%, respectively, compared to 2019. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

National trends in prescription drug expenditures and projections for 2019

PURPOSE

Historical trends and factors likely to influence future pharmaceutical expenditures are discussed, and projections are made for drug spending in 2019 in nonfederal hospitals, clinics, and overall (all sectors).

METHODS

Drug expenditure data through calendar year 2018 were obtained from the IQVIA National Sales Perspectives database and analyzed. New drug approvals, patent expirations, and other factors that may influence drug spending in hospitals and clinics in 2019 were also reviewed. Expenditure projections for 2019 for nonfederal hospitals, clinics, and overall (all sectors) were made through a combination of quantitative analyses and expert opinion.

RESULTS

U.S. prescription sales in calendar year 2018 totaled $476.2 billion, a 5.5% increase from 2017 spending. The top 3 drugs by expenditures were adalimumab ($19.1 billion), insulin glargine ($9.3 billion), and etanercept ($8.0 billion). Prescription expenditures in nonfederal hospitals totaled $35.8 billion, a 4.8% increase from 2017. Expenditures in clinics in 2018 increased by 13.0% to $80.5 billion. The increase in spending in nonfederal hospitals was largely driven by new products and increased utilization of existing products. The list of the top 25 drugs by expenditures in nonfederal hospitals and clinics was dominated by specialty drugs.

CONCLUSION

We predict continued moderate growth of 4-6% in overall drug expenditures (across the entire U.S. market). We expect the clinic sector to continue to experience high (11-13%) growth in drug spending in 2019. Finally, for nonfederal hospitals we anticipate growth in the range of 3-5%. These estimates are at the national level. Health-system pharmacy leaders should carefully examine local drug utilization patterns to determine their own organization's anticipated spending in 2019.

Neuropsychological, Psychiatric, and Functional Correlates of Clinical Trial Enrollment

Screen failure rates in Alzheimer's disease (AD) clinical trial research are unsustainable, with participant recruitment being a top barrier to AD research progress. The purpose of this project was to understand the neuropsychological, psychiatric, and functional features of individuals who failed screening measures for AD trials. Previously collected clinical data from 38 patients (aged 50-83) screened for a specific industry-sponsored clinical trial of MCI/early AD (Biogen 221AD302, [EMERGE]) were analyzed to identify predictors of AD trial screen pass/fail status. Worse performance on non-memory cognitive domains like crystalized knowledge, executive functioning, and attention, and higher self-reported anxiety, was associated with failing the screening visit for the EMERGE AD clinical trial, whereas we were not able to detect a relationship between screening status and memory performance, self-reported depression, or self-reported daily functioning. By identifying predictors of AD trial screen passing/failure, this research may influence decision-making about which patients are most likely to successfully enroll in a trial, thereby potentially lowering participant burden, maximizing study resources, and reducing costs.

The Clinical Pharmacogenetics Implementation Consortium: 10 Years Later

In 2009, the Clinical Pharmacogenetics Implementation Consortium (CPIC, www.cpicpgx.org), a shared project between Pharmacogenomics Knowledge Base (PharmGKB, http://www.pharmgkb.org) and the National Institutes of Health (NIH), was created to provide freely available, evidence-based, peer-reviewed, and updated pharmacogenetic clinical practice guidelines. To date, CPIC has published 23 guidelines (of which 11 have been updated), covering 19 genes and 46 drugs across several therapeutic areas. CPIC also now provides additional resources to facilitate the implementation of pharmacogenetics into routine clinical practice and the electronic health record. Furthermore, since its inception, CPIC's interactions with other resources, databases, websites, and genomic communities have grown. The purpose of this paper is to highlight the progress of CPIC over the past 10 years.

Accelerating Improvement in Children's Healthcare Through Quality Improvement Collaboratives: A Synthesis of Recent Efforts

Purpose of review

Quality improvement collaboratives can accelerate quality improvement and patient safety efforts. We reviewed major pediatric quality improvement collaboratives that have published results in the past five years and discussed common success factors and barriers encountered by these collaboratives.

Recent Findings

Many pediatric quality improvement collaboratives are active in neonatal, cystic fibrosis, congenital heart disease, hematology/oncoogy, chronic kidney disease, rheumatology, critical care, and general pediatric care.

Summary

Factors important to the success of these pediatric quality improvement collaboratives include data sharing and communication, trust among institutions, financial support, support from national organizations, use of a theoretical framework to guide collaboration, patient and family involvement, and incentives for participation at both the individual and institutional levels. Common barriers encountered by these collaboratives include insufficient funding or resources, legal concerns, difficulty coming to consensus on best practices and outcome measures, and overcoming cultural barriers to change. Learning from the successes and challenges encountered by these collaboratives will enable the pediatric healthcare quality improvement community to continue to evolve this approach to maximize benefits to children.

Optimizing Drug-Drug Interaction Alerts Using a Multidimensional Approach

OBJECTIVES

Excessive alerts are a common concern associated with clinical decision support systems that monitor drug-drug interactions (DDIs). To reduce the number of low-value interruptive DDI alerts at our hospital, we implemented an iterative, multidimensional quality improvement effort, which included an interdisciplinary advisory group, alert metrics, and measurement of perceived clinical value.

METHODS

Alert data analysis indicated that DDIs were the most common interruptive medication alert. An interdisciplinary alert advisory group was formed to provide expert advice and oversight for alert refinement and ongoing review of alert data. Alert data were categorized into drug classes and analyzed to identify DDI alerts for refinement. Refinement strategies included alert suppression and modification of alerts to be contextually aware.

RESULTS

On the basis of historical analysis of classified DDI alerts, 26 alert refinements were implemented, representing 47% of all alerts. Alert refinement efforts resulted in the following substantial decreases in the number of interruptive DDI alerts: 40% for all clinicians (22.9-14 per 100 orders) and as high as 82% for attending physicians (6.5-1.2 per 100 orders). Two patient safety events related to alert refinements were reported during the project period.

CONCLUSIONS

Our quality improvement effort refined 47% of all DDI alerts that were firing during historical analysis, significantly reduced the number of DDI alerts in a 54-week period, and established a model for sustained alert refinements.

Development of a postgraduate year 2 pharmacy residency in clinical pharmacogenetics

PURPOSE

The structure and development of an innovative, ASHP-accredited postgraduate year 2 (PGY2) clinical pharmacogenetics residency program are described.

SUMMARY

A 12-month PGY2 clinical pharmacogenetics residency was created at St. Jude Children's Research Hospital in accordance with the ASHP standards for advanced practice residencies. The purpose of this 12-month residency program is to prepare pharmacy residents to implement pharmacogenetics in clinical practice. The program helps residents develop expertise in the science of pharmacogenetics as well as an understanding of translational research, innovative pharmacy practice model development, and clinical informatics. The resident learns to optimize patient outcomes through the expert provision of evidence-based, patient-centered precision medicine as an integral part of an interprofessional team. After completing the program, residents are expected to have the clinical skills necessary to practice in the field of clinical pharmacogenetics and independently implement pharmacogenetic testing in other health-system settings. Because implementation of pharmacogenetics requires collaboration across many disciplines, residents works within an interprofessional team of physicians, nurses, informatics specialists, pharmacists, and clinical laboratory personnel to achieve program goals. Since the first resident graduated in 2012, the program has graduated 1 resident each year. Graduated residents have accepted pharmacogenetics positions at major academic medical centers and community hospitals, as well as academic and research positions with a pharmacogenetics emphasis.

CONCLUSION

A PGY2 clinical pharmacogenetics residency was successfully developed at St. Jude in 2013. After completion of the program, residents are equipped with the clinical skills and necessary experience to drive precision medicine forward and lead the implementation of pharmacogenetic testing in other healthcare settings.

Priorities for Pediatric Patient Safety Research

: media-1vid110.1542/5972296743001PEDS-VA_2018-0496Video Abstract BACKGROUND: Developing a research agenda that is focused on the priorities of key stakeholders may expedite implementation and dissemination. Our objective was to identify the highest-priority patient-safety research topics among pediatric clinicians, health care leaders, and families.

METHODS

The Children's Hospitals Solutions for Patient Safety Network is a network of >100 children's hospitals working together to eliminate harm due to health care. Parents and site leaders responded to an open-ended, anonymous e-mail survey used to elicit research topics. A key stakeholder panel winnowed related topics and prioritized topics using Likert scale ratings. Site leaders and parents responded to a second anonymous e-mail survey and rated the importance of each topic. Health system executive interviews were used to elicit their opinions regarding top priorities for patient-safety research.

RESULTS

The elicitation survey had 107 respondents who produced 49 unique research topics. The key stakeholder panel developed a final list of 24 topics. The prioritization survey had 74 respondents. Top-priority research topics concerned high reliability, safety culture, open communication, and early detection of patient deterioration and sepsis. During 7 qualitative interviews, health system executives highlighted diagnostic error, medication safety, deterioration, and ambulatory patient safety as priority areas.

CONCLUSIONS

With this study, we take a first step toward a stakeholder-driven research agenda on the basis of the assumption that stakeholders are best positioned to determine what research will be used to address the problems of most concern to them.

Standardization can accelerate the adoption of pharmacogenomics: current status and the path forward

Successfully implementing pharmacogenomics into routine clinical practice requires an efficient process to order genetic tests and report the results to clinicians and patients. Lack of standardized approaches and terminology in clinical laboratory processes, ordering of the test and reporting of test results all impede this workflow. Expert groups such as the Association for Molecular Pathology and the Clinical Pharmacogenetics Implementation Consortium have published recommendations for standardizing laboratory genetic testing, reporting and terminology. Other resources such as PharmGKB, ClinVar, ClinGen and PharmVar have established databases of nomenclature for pharmacogenetic alleles and variants. Opportunities remain to develop new standards and further disseminate existing standards which will accelerate the implementation of pharmacogenomics.

Using EHR Data to Detect Prescribing Errors in Rapidly Discontinued Medication Orders

BACKGROUND

Previous research developed a new method for locating prescribing errors in rapidly discontinued electronic medication orders. Although effective, the prospective design of that research hinders its feasibility for regular use.

OBJECTIVES

Our objectives were to assess a method to retrospectively detect prescribing errors, to characterize the identified errors, and to identify potential improvement opportunities.

METHODS

Electronically submitted medication orders from 28 randomly selected days that were discontinued within 120 minutes of submission were reviewed and categorized as most likely errors, nonerrors, or not enough information to determine status. Identified errors were evaluated by amount of time elapsed from original submission to discontinuation, error type, staff position, and potential clinical significance. Pearson's chi-square test was used to compare rates of errors across prescriber types.

RESULTS

In all, 147 errors were identified in 305 medication orders. The method was most effective for orders that were discontinued within 90 minutes. Duplicate orders were most common; physicians in training had the highest error rate (p < 0.001), and 24 errors were potentially clinically significant. None of the errors were voluntarily reported.

CONCLUSION

It is possible to identify prescribing errors in rapidly discontinued medication orders by using retrospective methods that do not require interrupting prescribers to discuss order details. Future research could validate our methods in different clinical settings. Regular use of this measure could help determine the causes of prescribing errors, track performance, and identify and evaluate interventions to improve prescribing systems and processes.

Integrating pharmacogenomics into electronic health records with clinical decision support

PURPOSE

Existing pharmacogenomic informatics models, key implementation steps, and emerging resources to facilitate the development of pharmacogenomic clinical decision support (CDS) are described.

SUMMARY

Pharmacogenomics is an important component of precision medicine. Informatics, especially CDS in the electronic health record (EHR), is a critical tool for the integration of pharmacogenomics into routine patient care. Effective integration of pharmacogenomic CDS into the EHR can address implementation challenges, including the increasing volume of pharmacogenomic clinical knowledge, the enduring nature of pharmacogenomic test results, and the complexity of interpreting results. Both passive and active CDS provide point-of-care information to clinicians that can guide the systematic use of pharmacogenomics to proactively optimize pharmacotherapy. Key considerations for a successful implementation have been identified; these include clinical workflows, identification of alert triggers, and tools to guide interpretation of results. These considerations, along with emerging resources from the Clinical Pharmacogenetics Implementation Consortium and the National Academy of Medicine, are described.

CONCLUSION

The EHR with CDS is essential to curate pharmacogenomic data and disseminate patient-specific information at the point of care. As part of the successful implementation of pharmacogenomics into clinical settings, all relevant clinical recommendations pertaining to gene-drug pairs must be summarized and presented to clinicians in a manner that is seamlessly integrated into the clinical workflow of the EHR. In some situations, ancillary systems and applications outside the EHR may be integrated to augment the capabilities of the EHR.

Preemptive pharmacogenetic testing: exploring the knowledge and perspectives of US payers

PURPOSE

Preemptive pharmacogenetic testing aims to optimize medication use by having genetic information at the point of prescribing. Payers’ decisions influence implementation of this technology. We investigated U.S. payers’ knowledge, awareness, and perspectives on preemptive pharmacogenetic testing.

METHODS

A qualitative study was conducted using semi-structured interviews. Participants were screened for eligibility through an online survey. A blended inductive and deductive approach was used to analyze the transcripts. Two authors conducted an iterative reading process to code and categorize the data.

RESULTS

Medical or pharmacy directors from 14 payer organizations covering 122 million U.S. lives were interviewed. Three concept domains and ten dimensions were developed. Key findings include: clinical utility concerns and limited exposure to preemptive germline testing, continued preference for outcomes from randomized controlled trials, interest in guideline development, importance of demonstrating an impact on clinical decision making, concerns of downstream costs and benefit predictability, and the impact of public stakeholders such as the FDA and CMS.

CONCLUSION

Both barriers and potential facilitators exist to developing cohesive reimbursement policy for pharmacogenetics, and there are unique challenges for the preemptive testing model. Prospective outcome studies, more precisely defining target populations, and predictive economic models are important considerations for future research.

Implementing Genomic Clinical Decision Support for Drug-Based Precision Medicine

The explosive growth of patient-specific genomic information relevant to drug therapy will continue to be a defining characteristic of biomedical research. To implement drug-based personalized medicine (PM) for patients, clinicians need actionable information incorporated into electronic health records (EHRs). New clinical decision support (CDS) methods and informatics infrastructure are required in order to comprehensively integrate, interpret, deliver, and apply the full range of genomic data for each patient.