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.

PARC report: a health-systems focus on reimbursement and patient access to pharmacogenomics testing

Pharmacogenomics test coverage and reimbursement are major obstacles to clinical uptake. Several early adopter programs have been successfully initiated through dedicated investments by federal and institutional research funding. As a result of research endeavors, evidence has grown sufficiently to support development of pharmacogenomics guidelines. However, clinical uptake is still limited. Third-party payer support plays an important role in increasing adoption, which to date has been limited to reactive single-gene testing. Access to and interest in direct-to-consumer genetic testing are driving demand for increasing healthcare providers and third-party awareness of this burgeoning field. Pharmacogenomics implementation models developed by early adopters promise to expand patient access and options, as testing continues to increase due to growing consumer interest and falling test prices.

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.

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.

Neutrophil-lymphocyte ratio as a prognostic factor in colorectal cancer

BACKGROUND AND OBJECTIVES

Simple methods to identify colorectal cancer patients at risk of recurrence are needed. This study aimed to determine if neutrophil-to-lymphocyte ratio (NLR) predicts survival in colorectal cancer patients.

METHODS

Two-hundred thirty patients diagnosed with colorectal cancer over a two-year period were identified from a prospectively maintained colorectal cancer database. NLR was calculated from pre-operative full blood counts. In the case of patients who did not undergo surgery, the full blood count from their out-patient visit was used. Known prognostic factors were recorded. Overall and cancer-specific survival were calculated.

RESULTS

Pre-operative NLR greater than 5 correlated with overall and cancer-specific survival in univariate analyses. NLR was not independent of Dukes stage.

CONCLUSIONS

Pre-operative NLR may represent a simple method of identifying colorectal cancer patients with a poor prognosis pre-operatively.

Neutrophil-lymphocyte ratio as a prognostic factor in colorectal cancer

BACKGROUND AND OBJECTIVES

Simple methods to identify colorectal cancer patients at risk of recurrence are needed. This study aimed to determine if neutrophil-to-lymphocyte ratio (NLR) predicts survival in colorectal cancer patients.

METHODS

Two-hundred thirty patients diagnosed with colorectal cancer over a two-year period were identified from a prospectively maintained colorectal cancer database. NLR was calculated from pre-operative full blood counts. In the case of patients who did not undergo surgery, the full blood count from their out-patient visit was used. Known prognostic factors were recorded. Overall and cancer-specific survival were calculated.

RESULTS

Pre-operative NLR greater than 5 correlated with overall and cancer-specific survival in univariate analyses. NLR was not independent of Dukes stage.

CONCLUSIONS

Pre-operative NLR may represent a simple method of identifying colorectal cancer patients with a poor prognosis pre-operatively.

Laparoscopic exploration of the common bile duct: beyond the learning curve

BACKGROUND

Bile duct clearance at open cholecystectomy had become normal surgical practice before the introduction of laparoscopic cholecystectomy. However, perceived technical difficulties have deterred many surgeons from treating common bile duct stones at the time of laparoscopic cholecystectomy. This has led to a reliance on preoperative clearance of ducts known to have stones and postoperative clearance of ducts found to have stones at operation or those that subsequently develop complications of retained stones.

METHODS

The authors describe a series of 120 consecutive bile duct explorations carried out between April 1991 and February 1997 in a series of 1,237 laparoscopic cholecystectomies.

RESULTS

Laparoscopic exploration and clearance of the bile ducts was achieved in 89% of cases in the whole series, and 97% success was attained in the last 60 cases, which also were associated with a decrease in operating time.

CONCLUSIONS

We believe that for surgeons familiar with open common bile duct exploration and laparoscopic cholecystectomy, the next logical step is laparoscopic exploration of the common bile duct at the time of cholecystectomy, which is safe and readily mastered.

A survey of glove preferences of general and orthopaedic surgeons in North West Thames Regional Health Authority

The glove preferences of all the consultant surgeons and consultant orthopaedic surgeons in North West Thames were surveyed by questionnaire. Responses were received from 59 of 78 general surgeons and 47 of 55 orthopaedic surgeons. Twenty-two percent of general surgeons never double gloved compared with 4% of orthopaedic surgeons (P < 0.01). Seventy-three percent of general surgeons double gloved for 'high risk' patients compared with 17% of orthopaedic surgeons (P < 0.001). When double gloving the majority of surgeons (67%) used their normal sized glove inside and half a size larger on the outside.

Inpatient and post-discharge wound infections in general surgery

The wound infection incidence during inpatient stay was compared with the post-discharge infection incidence for 1 month using audit data and a patient questionnaire. The true infection rate was found to be 20% compared with an apparent rate of 2.4% (P < 0.001). The study highlights the problems of postoperative monitoring in the context of shorter inpatient stays and fewer routine outpatient appointments.