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Jung W, Yu J, Park H, Chae MK, Lee SS, Choi JS, Kang M, Chang DK, Cha WC. Effect of knowledgebase transition of a clinical decision support system on medication order and alert patterns in an emergency department. Sci Rep 2023; 13:21206. [PMID: 38040729 PMCID: PMC10692153 DOI: 10.1038/s41598-023-40188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/06/2023] [Indexed: 12/03/2023] Open
Abstract
A knowledgebase (KB) transition of a clinical decision support (CDS) system occurred at the study site. The transition was made from one commercial database to another, provided by a different vendor. The change was applied to all medications in the institute. The aim of this study was to analyze the effect of KB transition on medication-related orders and alert patterns in an emergency department (ED). Data of patients, medication-related orders and alerts, and physicians in the ED from January 2018 to December 2020 were analyzed in this study. A set of definitions was set to define orders, alerts, and alert overrides. Changes in order and alert patterns before and after the conversion, which took place in May 2019, were assessed. Overall, 101,450 patients visited the ED, and 1325 physicians made 829,474 prescription orders to patients during visit and at discharge. Alert rates (alert count divided by order count) for periods A and B were 12.6% and 14.1%, and override rates (alert override count divided by alert count) were 60.8% and 67.4%, respectively. Of the 296 drugs that were used more than 100 times during each period, 64.5% of the drugs had an increase in alert rate after the transition. Changes in alert rates were tested using chi-squared test and Fisher's exact test. We found that the CDS system knowledgebase transition was associated with a significant change in alert patterns at the medication level in the ED. Careful consideration is advised when such a transition is performed.
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Affiliation(s)
- Weon Jung
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
| | - Jaeyong Yu
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
| | - Hyunjung Park
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
| | - Minjung Kathy Chae
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
| | - Sang Seob Lee
- Digital Innovation Center, Samsung Medical Center, Seoul, 06351, Korea
| | - Jong Soo Choi
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
- Digital Innovation Center, Samsung Medical Center, Seoul, 06351, Korea
| | - Mira Kang
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
- Digital Innovation Center, Samsung Medical Center, Seoul, 06351, Korea
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea
| | - Dong Kyung Chang
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
- Digital Innovation Center, Samsung Medical Center, Seoul, 06351, Korea
- Department of Gastroenterology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea.
- Digital Innovation Center, Samsung Medical Center, Seoul, 06351, Korea.
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea.
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2
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Ellis SD, Brooks JV, Birken SA, Morrow E, Hilbig ZS, Wulff-Burchfield E, Kinney AY, Ellerbeck EF. Determinants of targeted cancer therapy use in community oncology practice: a qualitative study using the Theoretical Domains Framework and Rummler-Brache process mapping. Implement Sci Commun 2023; 4:66. [PMID: 37308981 PMCID: PMC10259814 DOI: 10.1186/s43058-023-00441-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/25/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Precision medicine holds enormous potential to improve outcomes for cancer patients, offering improved rates of cancer control and quality of life. Not all patients who could benefit from targeted cancer therapy receive it, and some who may not benefit do receive targeted therapy. We sought to comprehensively identify determinants of targeted therapy use among community oncology programs, where most cancer patients receive their care. METHODS Guided by the Theoretical Domains Framework, we conducted semi-structured interviews with 24 community cancer care providers and mapped targeted therapy delivery across 11 cancer care delivery teams using a Rummler-Brache diagram. Transcripts were coded to the framework using template analysis, and inductive coding was used to identify key behaviors. Coding was revised until a consensus was reached. RESULTS Intention to deliver precision medicine was high across all participants interviewed, who also reported untenable knowledge demands. We identified distinctly different teams, processes, and determinants for (1) genomic test ordering and (2) delivery of targeted therapies. A key determinant of molecular testing was role alignment. The dominant expectation for oncologists to order and interpret genomic tests is at odds with their role as treatment decision-makers' and pathologists' typical role to stage tumors. Programs in which pathologists considered genomic test ordering as part of their staging responsibilities reported high and timely testing rates. Determinants of treatment delivery were contingent on resources and ability to offset delivery costs, which low- volume programs could not do. Rural programs faced additional treatment delivery challenges. CONCLUSIONS We identified novel determinants of targeted therapy delivery that potentially could be addressed through role re-alignment. Standardized, pathology-initiated genomic testing may prove fruitful in ensuring patients eligible for targeted therapy are identified, even if the care they need cannot be delivered at small and rural sites which may have distinct challenges in treatment delivery. Incorporating behavior specification and Rummler-Brache process mapping with determinant analysis may extend its usefulness beyond the identification of the need for contextual adaptation.
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Affiliation(s)
- Shellie D. Ellis
- University of Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66610 USA
| | - Joanna Veazey Brooks
- University of Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66610 USA
| | - Sarah A. Birken
- Wake Forest University School of Medicine, 525 Vine Street, Winston-Salem, NC 27101 USA
| | - Emily Morrow
- Kansas City Kansas Community College, 7250 State Ave., Kansas City, KS 66112 USA
| | - Zachary S. Hilbig
- University of Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66610 USA
| | | | - Anita Y. Kinney
- Rutgers Cancer Institute of New Jersey, Rutgers University, 195 Little Albany St., New Brunswick, NJ 08901 USA
| | - Edward F. Ellerbeck
- University of Kansas School of Medicine, 3901 Rainbow Blvd., Kansas City, KS 66610 USA
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3
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Kabbani D, Akika R, Wahid A, Daly AK, Cascorbi I, Zgheib NK. Pharmacogenomics in practice: a review and implementation guide. Front Pharmacol 2023; 14:1189976. [PMID: 37274118 PMCID: PMC10233068 DOI: 10.3389/fphar.2023.1189976] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/03/2023] [Indexed: 06/06/2023] Open
Abstract
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.
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Affiliation(s)
- Danya Kabbani
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Reem Akika
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ahmed Wahid
- Department of Pharmaceutical Biochemistry, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
| | - Ann K. Daly
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ingolf Cascorbi
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Nathalie Khoueiry Zgheib
- Department of Pharmacology and Toxicology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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Abstract
Advancements in high-throughput sequencing have yielded vast amounts of genomic data, which are studied using genome-wide association study (GWAS)/phenome-wide association study (PheWAS) methods to identify associations between the genotype and phenotype. The associated findings have contributed to pharmacogenomics and improved clinical decision support at the point of care in many healthcare systems. However, the accumulation of genomic data from sequencing and clinical data from electronic health records (EHRs) poses significant challenges for data scientists. Following the rise of artificial intelligence (AI) technology such as machine learning and deep learning, an increasing number of GWAS/PheWAS studies have successfully leveraged this technology to overcome the aforementioned challenges. In this review, we focus on the application of data science and AI technology in three areas, including risk prediction and identification of causal single-nucleotide polymorphisms, EHR-based phenotyping and CRISPR guide RNA design. Additionally, we highlight a few emerging AI technologies, such as transfer learning and multi-view learning, which will or have started to benefit genomic studies.
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Affiliation(s)
- Jing Lin
- NUHS Corporate Office, National University Health System, Singapore
| | - Kee Yuan Ngiam
- NUHS Corporate Office, National University Health System, Singapore,Department of Surgery, National University of Singapore, Singapore,Correspondence: A/Prof Kee Yuan Ngiam, Group Chief Technology Officer, NUHS Corporate Office, National University Health System, 1E Kent Ridge Road, 119228, Singapore. E-mail:
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5
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Liu M, Rossow KM, Maxwell-Horn AC, Saucier LA, Van Driest SL. Pediatric considerations for pharmacogenetic selective serotonin reuptake inhibitors clinical decision support. Pharmacotherapy 2022. [PMID: 36524442 DOI: 10.1002/phar.2751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/27/2022] [Accepted: 10/30/2022] [Indexed: 12/23/2022]
Abstract
Pharmacogenetic testing for psychiatry is growing at a rapid pace, with multiple sites utilizing results to help clinical decision-making. Genotype-guided dosing and drug selection have been implemented at several sites, including Vanderbilt University Medical Center, where clinical decision support (CDS) based on pharmacogenetic results went live for selective serotonin reuptake inhibitors in 2020 for both adult and pediatric patients. Effective and appropriate implementation of CYP2D6- and CYP2C19-guided CDS for the pediatric population requires consideration of the evidence for the pharmacogenetic associations, medication indications, and appropriate alternative therapies to be used when a pharmacogenetic contraindication is identified. In this article, we review these pediatric pharmacogenetic considerations for selective serotonin reuptake inhibitor CDS. We include a case study, the current literature supporting clinical recommendations, considerations when designing pediatric CDS, future implications, and examples of sertraline, (es)citalopram, paroxetine, and fluvoxamine alerts.
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Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katelyn M Rossow
- Developmental-Behavioral Pediatrics, Norton Children's Development Center, Louisville, Kentucky, USA
| | - Angela C Maxwell-Horn
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leigh Ann Saucier
- Vanderbilt Institute for Clinical & Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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6
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Haidar CE, Crews KR, Hoffman JM, Relling MV, Caudle KE. Advancing Pharmacogenomics from Single-Gene to Preemptive Testing. Annu Rev Genomics Hum Genet 2022; 23:449-473. [PMID: 35537468 PMCID: PMC9483991 DOI: 10.1146/annurev-genom-111621-102737] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Cyrine E Haidar
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA; , , , ,
| | - Kristine R Crews
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA; , , , ,
| | - James M Hoffman
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA; , , , ,
- Office of Quality and Safety, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Mary V Relling
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA; , , , ,
| | - Kelly E Caudle
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA; , , , ,
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7
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Snowdon JL, Weeraratne D, Huang H, Brotman D, Xue S, Willis VC, Lee YK, Jeon K, Zang DY, Kim HJ, Kim HY, Han B, Kim M. Clinical insights into hematologic malignancies and comparative analysis of molecular signatures of acute myeloid leukemia in different ethnicities using an artificial intelligence offering. Medicine (Baltimore) 2021; 100:e27969. [PMID: 34941036 PMCID: PMC8702055 DOI: 10.1097/md.0000000000027969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/09/2021] [Indexed: 11/27/2022] Open
Abstract
Next generation sequencing generates copious amounts of genomics data, causing manual interpretation to be laborious and non-scalable while remaining subjective (even for highly trained specialists). We evaluated the performance of the artificial intelligence-based offering Watson for Genomics (WfG), a variant interpretation platform, in hematologic malignancies for the first time.Next generation sequencing was performed for patients treated for various hematological malignancies at Hallym University Sacred Heart Hospital, South Korea, between December 2017 and August 2020 using a 54-gene panel. Both WfG and expert manual curation were used to evaluate the performance of WfG. Acute myeloid leukemia (AML) molecular profiles were compared between Koreans and other ethnic groups using a publicly available dataset.Seventy-seven patients were analyzed (AML: 45, myeloproliferative neoplasms: 12, multiple myeloma: 7, myelodysplastic syndromes: 6, and others: 7). The concordance between the manual and WfG interpretations of 35 variants in 11 random patients was 94%. Among all patients, WfG identified 39 (51%) with at least 1 clinically actionable therapeutic alteration (i.e., a variant targeted by a United States Food and Drug Administration [US FDA]-approved drug, off-label drug, or clinical trial). Moreover, 46% of these patients (18/39) had genes that were targeted by a US FDA-approved therapy. WfG identified diagnostic or prognostic insights in 65% of the patients with no targetable alterations. In those with AML, FLT3-internal tandem duplications or tyrosine kinase domain mutations were less frequent among Koreans than among Caucasians (6.7% vs 30.2%, P < .001) or Hispanics (6.7% vs 28.3%, P = .005), suggesting ethnic differences.Variant interpretation using WfG correlated well with manually curated expert opinions. WfG provided therapeutic insights (including variant-specific drugs and clinical trials that cannot easily be provided by expert manual curation), as well as diagnostic and/or prognostic information.
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Affiliation(s)
| | | | - Hu Huang
- IBM Watson Health, Cambridge, MA, USA
| | | | - Shang Xue
- IBM Watson Health, Cambridge, MA, USA
| | | | - Young Kyung Lee
- Department of Laboratory Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Kibum Jeon
- Department of Laboratory Medicine, Hallym University Hangang Sacred Heart Hospital, Seoul, Republic of Korea
| | - Dae Young Zang
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Hyo Jung Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Ho Young Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Boram Han
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Miyoung Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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8
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Brunette CA, Vassy JL. The role of SLCO1B1 genotyping in lowering cardiovascular risk. Pharmacogenomics 2021; 22:649-656. [PMID: 34196599 DOI: 10.2217/pgs-2021-0075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Charles A Brunette
- Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA.,Department of Psychological and Brain Sciences, University of Iowa, Iowa City, IA 52242, USA
| | - Jason L Vassy
- Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, MA 02130, USA.,Department of Medicine, Harvard Medical School, Boston, MA 02115, USA.,Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Boston, MA 02115, USA.,Population Precision Health, Ariadne Labs, Boston, MA 02215, USA
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9
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Bagaev A, Kotlov N, Nomie K, Svekolkin V, Gafurov A, Isaeva O, Osokin N, Kozlov I, Frenkel F, Gancharova O, Almog N, Tsiper M, Ataullakhanov R, Fowler N. Conserved pan-cancer microenvironment subtypes predict response to immunotherapy. Cancer Cell 2021; 39:845-865.e7. [PMID: 34019806 DOI: 10.1016/j.ccell.2021.04.014] [Citation(s) in RCA: 454] [Impact Index Per Article: 151.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/14/2020] [Accepted: 04/23/2021] [Indexed: 12/18/2022]
Abstract
The clinical use of molecular targeted therapy is rapidly evolving but has primarily focused on genomic alterations. Transcriptomic analysis offers an opportunity to dissect the complexity of tumors, including the tumor microenvironment (TME), a crucial mediator of cancer progression and therapeutic outcome. TME classification by transcriptomic analysis of >10,000 cancer patients identifies four distinct TME subtypes conserved across 20 different cancers. The TME subtypes correlate with patient response to immunotherapy in multiple cancers, with patients possessing immune-favorable TME subtypes benefiting the most from immunotherapy. Thus, the TME subtypes act as a generalized immunotherapy biomarker across many cancer types due to the inclusion of malignant and microenvironment components. A visual tool integrating transcriptomic and genomic data provides a global tumor portrait, describing the tumor framework, mutational load, immune composition, anti-tumor immunity, and immunosuppressive escape mechanisms. Integrative analyses plus visualization may aid in biomarker discovery and the personalization of therapeutic regimens.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Nathan Fowler
- BostonGene, Waltham, MA 02453, USA; Department of Lymphoma and Myeloma, Unit 0429, the University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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10
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Schneider TM, Eadon MT, Cooper-DeHoff RM, Cavanaugh KL, Nguyen KA, Arwood MJ, Tillman EM, Pratt VM, Dexter PR, McCoy AB, Orlando LA, Scott SA, Nadkarni GN, Horowitz CR, Kannry JL. Multi-Institutional Implementation of Clinical Decision Support for APOL1, NAT2, and YEATS4 Genotyping in Antihypertensive Management. J Pers Med 2021; 11:jpm11060480. [PMID: 34071920 PMCID: PMC8226809 DOI: 10.3390/jpm11060480] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/21/2021] [Accepted: 05/25/2021] [Indexed: 01/13/2023] Open
Abstract
(1) Background: Clinical decision support (CDS) is a vitally important adjunct to the implementation of pharmacogenomic-guided prescribing in clinical practice. A novel CDS was sought for the APOL1, NAT2, and YEATS4 genes to guide optimal selection of antihypertensive medications among the African American population cared for at multiple participating institutions in a clinical trial. (2) Methods: The CDS committee, made up of clinical content and CDS experts, developed a framework and contributed to the creation of the CDS using the following guiding principles: 1. medical algorithm consensus; 2. actionability; 3. context-sensitive triggers; 4. workflow integration; 5. feasibility; 6. interpretability; 7. portability; and 8. discrete reporting of lab results. (3) Results: Utilizing the principle of discrete patient laboratory and vital information, a novel CDS for APOL1, NAT2, and YEATS4 was created for use in a multi-institutional trial based on a medical algorithm consensus. The alerts are actionable and easily interpretable, clearly displaying the purpose and recommendations with pertinent laboratory results, vitals and links to ordersets with suggested antihypertensive dosages. Alerts were either triggered immediately once a provider starts to order relevant antihypertensive agents or strategically placed in workflow-appropriate general CDS sections in the electronic health record (EHR). Detailed implementation instructions were shared across institutions to achieve maximum portability. (4) Conclusions: Using sound principles, the created genetic algorithms were applied across multiple institutions. The framework outlined in this study should apply to other disease-gene and pharmacogenomic projects employing CDS.
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Affiliation(s)
- Thomas M. Schneider
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (C.R.H.); (J.L.K.)
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Correspondence:
| | - Michael T. Eadon
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (M.T.E.); (E.M.T.); (P.R.D.)
| | - Rhonda M. Cooper-DeHoff
- Center for Pharmacogenetics and Precision Medicine and Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida Gainesville, Gainesville, FL 32610, USA; (R.M.C.-D.); (K.A.N.); (M.J.A.)
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Kerri L. Cavanaugh
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Khoa A. Nguyen
- Center for Pharmacogenetics and Precision Medicine and Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida Gainesville, Gainesville, FL 32610, USA; (R.M.C.-D.); (K.A.N.); (M.J.A.)
| | - Meghan J. Arwood
- Center for Pharmacogenetics and Precision Medicine and Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida Gainesville, Gainesville, FL 32610, USA; (R.M.C.-D.); (K.A.N.); (M.J.A.)
| | - Emma M. Tillman
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (M.T.E.); (E.M.T.); (P.R.D.)
| | - Victoria M. Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Paul R. Dexter
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (M.T.E.); (E.M.T.); (P.R.D.)
| | - Allison B. McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
| | - Lori A. Orlando
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, 101 Science Drive, Box 3382, Durham, NC 27708, USA;
| | - Stuart A. Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Girish N. Nadkarni
- Department of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Carol R. Horowitz
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (C.R.H.); (J.L.K.)
- Department of Population Health Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Joseph L. Kannry
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (C.R.H.); (J.L.K.)
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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11
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Richesson RL, Staes CJ, Douthit BJ, Thoureen T, Hatch DJ, Kawamoto K, Del Fiol G. Measuring implementation feasibility of clinical decision support alerts for clinical practice recommendations. J Am Med Inform Assoc 2021; 27:514-521. [PMID: 32027357 DOI: 10.1093/jamia/ocz225] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/11/2019] [Accepted: 12/18/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The study sought to describe key features of clinical concepts and data required to implement clinical practice recommendations as clinical decision support (CDS) tools in electronic health record systems and to identify recommendation features that predict feasibility of implementation. MATERIALS AND METHODS Using semistructured interviews, CDS implementers and clinician subject matter experts from 7 academic medical centers rated the feasibility of implementing 10 American College of Emergency Physicians Choosing Wisely Recommendations as electronic health record-embedded CDS and estimated the need for additional data collection. Ratings were combined with objective features of the guidelines to develop a predictive model for technical implementation feasibility. RESULTS A linear mixed model showed that the need for new data collection was predictive of lower implementation feasibility. The number of clinical concepts in each recommendation, need for historical data, and ambiguity of clinical concepts were not predictive of implementation feasibility. CONCLUSIONS The availability of data and need for additional data collection are essential to assess the feasibility of CDS implementation. Authors of practice recommendations and guidelines can enable organizations to more rapidly assess data availability and feasibility of implementation by including operational definitions for required data.
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Affiliation(s)
| | - Catherine J Staes
- University of Utah College of Nursing, Salt Lake City, Utah.,Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, Utah
| | | | - Traci Thoureen
- Division of Emergency Medicine, Duke University Medical Center, Durham, North Carolina
| | - Daniel J Hatch
- Duke University School of Nursing, Durham, North Carolina
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, Utah
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12
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Kannan V, Basit MA, Bajaj P, Carrington AR, Donahue IB, Flahaven EL, Medford R, Melaku T, Moran BA, Saldana LE, Willett DL, Youngblood JE, Toomay SM. User stories as lightweight requirements for agile clinical decision support development. J Am Med Inform Assoc 2021; 26:1344-1354. [PMID: 31512730 PMCID: PMC6798563 DOI: 10.1093/jamia/ocz123] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/17/2019] [Accepted: 07/01/2019] [Indexed: 02/02/2023] Open
Abstract
Objective We sought to demonstrate applicability of user stories, progressively elaborated by testable acceptance criteria, as lightweight requirements for agile development of clinical decision support (CDS). Materials and Methods User stories employed the template: As a [type of user], I want [some goal] so that [some reason]. From the “so that” section, CDS benefit measures were derived. Detailed acceptance criteria were elaborated through ensuing conversations. We estimated user story size with “story points,” and depicted multiple user stories with a use case diagram or feature breakdown structure. Large user stories were split to fit into 2-week iterations. Results One example user story was: As a rheumatologist, I want to be advised if my patient with rheumatoid arthritis is not on a disease-modifying anti-rheumatic drug (DMARD), so that they receive optimal therapy and can experience symptom improvement. This yielded a process measure (DMARD use), and an outcome measure (Clinical Disease Activity Index). Following implementation, the DMARD nonuse rate decreased from 3.7% to 1.4%. Patients with a high Clinical Disease Activity Index improved from 13.7% to 7%. For a thromboembolism prevention CDS project, diagrams organized multiple user stories. Discussion User stories written in the clinician’s voice aid CDS governance and lead naturally to measures of CDS effectiveness. Estimation of relative story size helps plan CDS delivery dates. User stories prove to be practical even on larger projects. Conclusions User stories concisely communicate the who, what, and why of a CDS request, and serve as lightweight requirements for agile development to meet the demand for increasingly diverse CDS.
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Affiliation(s)
- Vaishnavi Kannan
- Clinical Informatics, University of Texas Southwestern Health System, Dallas, Texas, USA.,Health System Information Resources Department, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mujeeb A Basit
- Clinical Informatics, University of Texas Southwestern Health System, Dallas, Texas, USA.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Puneet Bajaj
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Angela R Carrington
- Health System Information Resources Department, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Irma B Donahue
- Health System Information Resources Department, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emily L Flahaven
- Clinical Informatics, University of Texas Southwestern Health System, Dallas, Texas, USA
| | - Richard Medford
- Clinical Informatics, University of Texas Southwestern Health System, Dallas, Texas, USA.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tsedey Melaku
- Clinical Informatics, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Brett A Moran
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Clinical Informatics, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Luis E Saldana
- Clinical Informatics, Texas Health Resources, Arlington, Texas, USA
| | - Duwayne L Willett
- Clinical Informatics, University of Texas Southwestern Health System, Dallas, Texas, USA.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Josh E Youngblood
- Health System Information Resources Department, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Seth M Toomay
- Clinical Informatics, University of Texas Southwestern Health System, Dallas, Texas, USA.,Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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13
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Liu M, Vnencak-Jones CL, Roland BP, Gatto CL, Mathe JL, Just SL, Peterson JF, Van Driest SL, Weitkamp AO. A Tutorial for Pharmacogenomics Implementation Through End-to-End Clinical Decision Support Based on Ten Years of Experience from PREDICT. Clin Pharmacol Ther 2020; 109:101-115. [PMID: 33048353 DOI: 10.1002/cpt.2079] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/25/2020] [Indexed: 12/24/2022]
Abstract
Vanderbilt University Medical Center implemented pharmacogenomics (PGx) testing with the Pharmacogenomic Resource for Enhanced Decisions in Care and Treatment (PREDICT) initiative in 2010. This tutorial reviews the laboratory considerations, technical infrastructure, and programmatic support required to deliver panel-based PGx testing across a large health system with examples and experiences from the first decade of the PREDICT initiative. From the time of inception, automated clinical decision support (CDS) has been a critical capability for delivering PGx results to the point-of-care. Key features of the CDS include human-readable interpretations and clinical guidance that is anticipatory, actionable, and adaptable to changes in the scientific literature. Implementing CDS requires that structured results from the laboratory be encoded in standards-based messages that are securely ingested by electronic health records. Translating results to guidance also requires an informatics infrastructure with multiple components: (1) to manage the interpretation of raw genomic data to "star allele" results to expected phenotype, (2) to define the rules that associate a phenotype with recommended changes to clinical care, and (3) to manage and update the knowledge base. Knowledge base management is key to processing new results with the latest guidelines, and to ensure that historical genomic results can be reinterpreted with revised CDS. We recommend that these components be deployed with institutional authorization, programmatic support, and clinician education to govern the CDS content and policies around delivery.
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Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cindy L Vnencak-Jones
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bartholomew P Roland
- Vanderbilt Institute for Clinical & Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cheryl L Gatto
- Vanderbilt Institute for Clinical & Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Janos L Mathe
- Health IT Decision Support and Knowledge Engineering, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shari L Just
- Health IT Decision Support and Knowledge Engineering, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Josh F Peterson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Asli O Weitkamp
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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14
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Qoronfleh MW, Chouchane L, Mifsud B, Al Emadi M, Ismail S. THE FUTURE OF MEDICINE, healthcare innovation through precision medicine: policy case study of Qatar. LIFE SCIENCES, SOCIETY AND POLICY 2020; 16:12. [PMID: 33129349 PMCID: PMC7603723 DOI: 10.1186/s40504-020-00107-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/24/2020] [Indexed: 06/11/2023]
Abstract
In 2016, the World Innovation Summit for Health (WISH) published its Forum Report on precision medicine "PRECISION MEDICINE - A GLOBAL ACTION PLAN FOR IMPACT". Healthcare is undergoing a transformation, and it is imperative to leverage new technologies to generate new data and support the advent of precision medicine (PM). Recent scientific breakthroughs and technological advancements have improved our disease knowledge and altered diagnosis and treatment approaches resulting in a more precise, predictive, preventative and personalized health care that is customized for the individual patient. Consequently, the big data revolution has provided an opportunity to apply artificial intelligence and machine learning algorithms to mine such a vast data set. Additionally, personalized medicine promises to revolutionize healthcare, with its key goal of providing the right treatment to the right patient at the right time and dose, and thus the potential of improving quality of life and helping to bring down healthcare costs.This policy briefing will look in detail at the issues surrounding continued development, sustained investment, risk factors, testing and approval of innovations for better strategy and faster process. The paper will serve as a policy bridge that is required to enhance a conscious decision among the powers-that-be in Qatar in order to find a way to harmonize multiple strands of activity and responsibility in the health arena. The end goal will be for Qatar to enhance public awareness and engagement and to integrate effectively the incredible advances in research into healthcare systems, for the benefit of all patients.The PM policy briefing provides concrete recommendations on moving forward with PM initiatives in Qatar and internationally. Equally important, integration of PM within a primary care setting, building a coalition of community champions through awareness and advocacy, finally, communicating PM value, patient engagement/empowerment and education/continued professional development programs of the healthcare workforce.Key recommendations for implementation of precision medicine inside and outside Qatar: 1. Create Community Awareness and PM Education Programs 2. Engage and Empower Patients 3. Communicate PM Value 4. Develop appropriate Infrastructure and Information Management Systems 5. Integrate PM into standard Healthcare System and Ensure Access to Care PM is no longer futuristic. It is here. Implementing PM in routine clinical care does require some investment and infrastructure development. Invariably, cost and lack of expertise are cited as barriers to PM implementation. Equally consequential, are the curriculum and professional development of medical care experts.Policymakers need to lead and coordinate effort among stakeholders and consider cultural and faith perspectives to ensure success. It is essential that policymakers integrate PM approaches into national strategies to improve health and health care for all, and to drive towards the future of medicine precision health.
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Affiliation(s)
- M. Walid Qoronfleh
- Research & Policy Department, World Innovation Summit for Health (WISH), Qatar Foundation, P.O. Box 5825, Doha, Qatar
| | - Lotfi Chouchane
- Departments of Genetic Medicine and Microbiology and Immunology, Weill Cornell Medicine, Qatar, Doha, Qatar
| | - Borbala Mifsud
- College of Health and Life Sciences, Hamad Bin Khalifa University (HBKU), Doha, Qatar
| | - Maryam Al Emadi
- Clinical Operations, Primary Health Corporation (PHCC), Doha, Qatar
| | - Said Ismail
- Qatar Genome Program, Qatar Foundation, Doha, Qatar
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15
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Procop GW, Weathers AL, Reddy AJ. Operational Aspects of a Clinical Decision Support Program. Clin Lab Med 2020; 39:215-229. [PMID: 31036276 DOI: 10.1016/j.cll.2019.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Clinical decision support tools that involve improving test utilization should be jointly overseen by a laboratory stewardship committee and the hospital informatics team. The roles of these groups vary by institution and may overlap. This is a team effort and collaboration is a must. The effectiveness of these efforts in an institution depends on the receptiveness of leadership and providers, as well as the effectiveness of the associated committees. Examples of the challenges and successes of laboratory stewardship interventions that have been operationalized at the Cleveland Clinic that use clinical decision support tools, as well as associated literature, are reviewed.
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Affiliation(s)
- Gary W Procop
- Molecular Microbiology, Mycology, Parasitology and Virology Laboratories, Enterprise Laboratory Stewardship Committee, Department of Medical Operations, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue/ LL2-131, Cleveland, OH 44195, USA.
| | - Allison L Weathers
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 25900 Science Park Drive, AC220 Beechwood, OH 44122, USA
| | - Anita J Reddy
- Respiratory Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue/ G6-156, Cleveland, OH 44195, USA
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16
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Thorn CF, Whirl-Carrillo M, Hachad H, Johnson JA, McDonagh EM, Ratain MJ, Relling MV, Scott SA, Altman RB, Klein TE. Essential Characteristics of Pharmacogenomics Study Publications. Clin Pharmacol Ther 2019; 105:86-91. [PMID: 30406943 DOI: 10.1002/cpt.1279] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/02/2018] [Indexed: 12/17/2022]
Abstract
Pharmacogenomics (PGx) can be seen as a model for biomedical studies: it includes all disease areas of interest and spans in vitro studies to clinical trials, while focusing on the relationships between genes and drugs and the resulting phenotypes. This review will examine different characteristics of PGx study publications and provide examples of excellence in framing PGx questions and reporting their resulting data in a way that maximizes the knowledge that can be built on them.
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Affiliation(s)
- Caroline F Thorn
- Department of Biomedical Data Sciences, Stanford University, Stanford, California, USA
| | | | - Houda Hachad
- Translational Software, Bellevue, Washington, USA
| | - Julie A Johnson
- College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | | | - Mark J Ratain
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Mary V Relling
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Stuart A Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Sema4, a Mount Sinai Venture, Stamford, Connecticut, USA
| | - Russ B Altman
- Department of Genetics, Department of Computer Science, Department of Biomedical Engineering, Stanford University, Stanford, California, USA.,Department of Medicine, Stanford University, Stanford, California, USA
| | - Teri E Klein
- Department of Biomedical Data Sciences, Stanford University, Stanford, California, USA
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17
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Mills R, Haga SB. Qualitative user evaluation of a revised pharmacogenetic educational toolkit. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2018; 11:139-146. [PMID: 30214267 PMCID: PMC6128278 DOI: 10.2147/pgpm.s169648] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction Pharmacogenetic (PGx) testing is a leading application for personalized and precision medicine; however, there are barriers, including limited provider and patient understanding, which affect its uptake. There is a need for tools that can enhance the patient and provider experience with testing and promoting the shared and informed decision-making. Materials and methods In this study, we sought to gather additional feedback on a PGx toolkit comprised of four educational tools that had been previously evaluated through an online survey by pharmacists. Specifically, we conducted semi-structured interviews with pharmacists and members of the public regarding their understanding and utility of the toolkit and its individual components. Results Participants found three of the four toolkit components, a test information sheet, flipbook, and results sheet, to be useful and important. The fourth component, results card, was viewed less favorably. Participants differed in their preference for medical jargon and detailed results nomenclature (namely star * alleles). Conclusion User input during the development of educational materials is essential for optimizing utilization, effectiveness, and comprehension.
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Affiliation(s)
- Rachel Mills
- Duke Center for Applied Genomics and Precision Medicine, Duke University Medical Center, Durham, NC, USA,
| | - Susanne B Haga
- Duke Center for Applied Genomics and Precision Medicine, Duke University Medical Center, Durham, NC, USA,
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18
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Shankar P, Anderson N. Advances in Sharing Multi-sourced Health Data on Decision Support Science 2016-2017. Yearb Med Inform 2018; 27:16-24. [PMID: 30157504 PMCID: PMC6115214 DOI: 10.1055/s-0038-1641215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Introduction:
Clinical decision support science is expanding to include integration from broader and more varied data sources, diverse platforms and delivery modalities, and is responding to emerging regulatory guidelines and increased interest from industry.
Objective:
Evaluate key advances and challenges of accessing, sharing, and managing data from multiple sources for development and implementation of Clinical Decision Support (CDS) systems in 2016-2017.
Methods:
Assessment of literature and scientific conference proceedings, current and pending policy development, and review of commercial applications nationally and internationally.
Results:
CDS research is approaching multiple landmark points driven by commercialization interests, emerging regulatory policy, and increased public awareness. However, the availability of patient-related “Big Data” sources from genomics and mobile health, expanded privacy considerations, applications of service-based computational techniques and tools, the emergence of “app” ecosystems, and evolving patient-centric approaches reflect the distributed, complex, and uneven maturity of the CDS landscape. Nonetheless, the field of CDS is yet to mature. The lack of standards and CDS-specific policies from regulatory bodies that address the privacy and safety concerns of data and knowledge sharing to support CDS development may continue to slow down the broad CDS adoption within and across institutions.
Conclusion:
Partnerships with Electronic Health Record and commercial CDS vendors, policy makers, standards development agencies, clinicians, and patients are needed to see CDS deployed in the evolving learning health system.
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Affiliation(s)
- Prabhu Shankar
- Division of Health Informatics, Department of Public Health Sciences, School of Medicine, University of California, Davis, CA, USA
| | - Nick Anderson
- Division of Health Informatics, Department of Public Health Sciences, School of Medicine, University of California, Davis, CA, USA
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19
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Caudle KE, Keeling NJ, Klein TE, Whirl-Carrillo M, Pratt VM, Hoffman JM. Standardization can accelerate the adoption of pharmacogenomics: current status and the path forward. Pharmacogenomics 2018; 19:847-860. [PMID: 29914287 DOI: 10.2217/pgs-2018-0028] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Kelly E Caudle
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Nicholas J Keeling
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN 38105, USA.,Department of Pharmacy Administration, University of Mississippi School of Pharmacy, Oxford, MS 38655, USA
| | - Teri E Klein
- Department of Biomedical Data Science, Stanford University, Stanford, CA 94305, USA
| | | | - Victoria M Pratt
- Department of Medical & Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - James M Hoffman
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN 38105, USA.,Office of Quality & Patient Care, St Jude Children's Research Hospital, Memphis, TN 38105, USA
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20
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Billings J, Racsa PN, Bordenave K, Long CL, Ellis JJ. The impact of real-world cardiovascular-related pharmacogenetic testing in an insured population. Int J Clin Pract 2018; 72:e13088. [PMID: 29767472 DOI: 10.1111/ijcp.13088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 03/20/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pharmacogenomics is intended to help clinicians provide the right drug to the right patient at an appropriate dose. However, limited evidence of clinical utility has slowed uptake of pharmacogenomic testing (PGT). OBJECTIVE To evaluate the impact of real-world cardiovascular (CV)-related PGT on clinical outcomes, healthcare resource utilisation (HCRU) and cost in a large, heterogeneous population. METHODS Individuals with Medicare Advantage Prescription Drug, Medicaid, or commercial coverage between 1/1/2011 and 9/30/2015 and ≥1 atherosclerotic CV-related diagnosis were identified. Those with ≥1 claim for CV-related PGT were included in the test group (index date = 1st PGT claim) and matched 1:2 to controls without PGT. Individuals aged <22 or ≥90 years old on the index date, with <12 months continuous enrollment before and after the index date, or without an ASCVD-related diagnosis in the 12-month pre-index period were excluded. The primary outcome was occurrence of a major CV event during the 12-month post-index period. RESULTS After adjustment, the PGT group was significantly more likely to experience ischaemic stroke, pulmonary embolism, deep vein thrombosis or a composite event compared with controls. Adjusting for baseline characteristics, HCRU was significantly higher for the test group across all measured outcomes except all-cause and ASCVD-related inpatient admissions. Median all-cause and ASCVD-related healthcare costs were significantly higher for the test group. CONCLUSIONS Real world PGT in a large population did not improve outcomes. Tailoring medication therapy to each patient holds great promise for providing quality care but a deeper understanding of how widespread utilisation of PGT might impact objective health outcomes is needed.
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Affiliation(s)
| | - Patrick N Racsa
- Comprehensive Health Insights, Humana Inc., Louisville, KY, USA
| | | | - Charron L Long
- Research and Publications, Humana Inc., Louisville, KY, USA
| | - Jeffrey J Ellis
- Comprehensive Health Insights, Humana Inc., Louisville, KY, USA
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21
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Mills RA, Eichmeyer JN, Williams LM, Muskett JA, Schmidlen TJ, Maloney KA, Lemke AA. Patient Care Situations Benefiting from Pharmacogenomic Testing. CURRENT GENETIC MEDICINE REPORTS 2018. [DOI: 10.1007/s40142-018-0136-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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22
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Nedungadi P, Iyer A, Gutjahr G, Bhaskar J, Pillai AB. Data-Driven Methods for Advancing Precision Oncology. CURRENT PHARMACOLOGY REPORTS 2018; 4:145-156. [PMID: 33520605 PMCID: PMC7845924 DOI: 10.1007/s40495-018-0127-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE OF REVIEW This article discusses the advances, methods, challenges, and future directions of data-driven methods in advancing precision oncology for biomedical research, drug discovery, clinical research, and practice. RECENT FINDINGS Precision oncology provides individually tailored cancer treatment by considering an individual's genetic makeup, clinical, environmental, social, and lifestyle information. Challenges include voluminous, heterogeneous, and disparate data generated by different technologies with multiple modalities such as Omics, electronic health records, clinical registries and repositories, medical imaging, demographics, wearables, and sensors. Statistical and machine learning methods have been continuously adapting to the ever-increasing size and complexity of data. Precision Oncology supportive analytics have improved turnaround time in biomarker discovery and time-to-application of new and repurposed drugs. Precision oncology additionally seeks to identify target patient populations based on genomic alterations that are sensitive or resistant to conventional or experimental treatments. Predictive models have been developed for cancer progression and survivorship, drug sensitivity and resistance, and identification of the most suitable combination treatments for individual patient scenarios. In the future, clinical decision support systems need to be revamped to better incorporate knowledge from precision oncology, thus enabling clinical practitioners to provide precision cancer care. SUMMARY Open Omics datasets, machine learning algorithms, and predictive models have enabled the advancement of precision oncology. Clinical decision support systems with integrated electronic health record and Omics data are needed to provide data-driven recommendations to assist clinicians in disease prevention, early identification, and individualized treatment. Additionally, as cancer is a constantly evolving disorder, clinical decision systems will need to be continually updated based on more recent knowledge and datasets.
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Affiliation(s)
- Prema Nedungadi
- Center for Research in Analytics & Technology in Education, Amrita Vishwa Vidyapeetham, Amritapuri, Kollam, India
- Department of Computer Science, School of Engineering, Amrita Vishwa Vidyapeetham, Amritapuri, Kollam, India
| | - Akshay Iyer
- Center for Research in Analytics & Technology in Education, Amrita Vishwa Vidyapeetham, Amritapuri, Kollam, India
| | - Georg Gutjahr
- Center for Research in Analytics & Technology in Education, Amrita Vishwa Vidyapeetham, Amritapuri, Kollam, India
| | - Jasmine Bhaskar
- Center for Research in Analytics & Technology in Education, Amrita Vishwa Vidyapeetham, Amritapuri, Kollam, India
- Department of Computer Science, School of Engineering, Amrita Vishwa Vidyapeetham, Amritapuri, Kollam, India
| | - Asha B. Pillai
- Division of Pediatric Hematology/Oncology, Departments of Pediatrics and Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL, USA
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23
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Borobia AM, Dapia I, Tong HY, Arias P, Muñoz M, Tenorio J, Hernández R, García García I, Gordo G, Ramírez E, Frías J, Lapunzina P, Carcas AJ. Clinical Implementation of Pharmacogenetic Testing in a Hospital of the Spanish National Health System: Strategy and Experience Over 3 Years. Clin Transl Sci 2018; 11:189-199. [PMID: 29193749 PMCID: PMC5866958 DOI: 10.1111/cts.12526] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 10/27/2017] [Indexed: 01/31/2023] Open
Abstract
In 2014, we established a pharmacogenetics unit with the intention of facilitating the integration of pharmacogenetic testing into clinical practice. This unit was centered around two main ideas: i) individualization of clinical recommendations, and ii) preemptive genotyping in risk populations. Our unit is based on the design and validation of a single nucleotide polymorphism (SNP) microarray, which has allowed testing of 180 SNPs associated with drug response (PharmArray), and clinical consultation regarding the results. Herein, we report our experience in integrating pharmacogenetic testing into our hospital and we present the results of the 2,539 pharmacogenetic consultation requests received over the past 3 years in our unit. The results demonstrate the feasibility of implementing pharmacogenetic testing in clinical practice within a national health system.
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Affiliation(s)
- Alberto M. Borobia
- Clinical Pharmacology DepartmentIdiPAZ, La Paz University Hospital, School of MedicineAutonomous University of MadridMadridSpain
| | - Irene Dapia
- Medical and Molecular Genetics Institute (INGEMM)La Paz University HospitalMadridSpain
- Center for Biomedical Network Research on Rare Diseases (CIBERER)ISCIIIMadridSpain
| | - Hoi Y. Tong
- Clinical Pharmacology DepartmentIdiPAZ, La Paz University Hospital, School of MedicineAutonomous University of MadridMadridSpain
| | - Pedro Arias
- Medical and Molecular Genetics Institute (INGEMM)La Paz University HospitalMadridSpain
- Center for Biomedical Network Research on Rare Diseases (CIBERER)ISCIIIMadridSpain
| | - Mario Muñoz
- Clinical Pharmacology DepartmentIdiPAZ, La Paz University Hospital, School of MedicineAutonomous University of MadridMadridSpain
| | - Jair Tenorio
- Medical and Molecular Genetics Institute (INGEMM)La Paz University HospitalMadridSpain
- Center for Biomedical Network Research on Rare Diseases (CIBERER)ISCIIIMadridSpain
| | - Rafael Hernández
- Clinical Pharmacology DepartmentIdiPAZ, La Paz University Hospital, School of MedicineAutonomous University of MadridMadridSpain
| | - Irene García García
- Clinical Pharmacology DepartmentIdiPAZ, La Paz University Hospital, School of MedicineAutonomous University of MadridMadridSpain
| | - Gema Gordo
- Medical and Molecular Genetics Institute (INGEMM)La Paz University HospitalMadridSpain
- Center for Biomedical Network Research on Rare Diseases (CIBERER)ISCIIIMadridSpain
| | - Elena Ramírez
- Clinical Pharmacology DepartmentIdiPAZ, La Paz University Hospital, School of MedicineAutonomous University of MadridMadridSpain
| | - Jesús Frías
- Clinical Pharmacology DepartmentIdiPAZ, La Paz University Hospital, School of MedicineAutonomous University of MadridMadridSpain
| | - Pablo Lapunzina
- Medical and Molecular Genetics Institute (INGEMM)La Paz University HospitalMadridSpain
- Center for Biomedical Network Research on Rare Diseases (CIBERER)ISCIIIMadridSpain
| | - Antonio J. Carcas
- Clinical Pharmacology DepartmentIdiPAZ, La Paz University Hospital, School of MedicineAutonomous University of MadridMadridSpain
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24
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Mukherjee C, Sweet KM, Luzum JA, Abdel-Rasoul M, Christman MF, Kitzmiller JP. Clinical pharmacogenomics: patient perspectives of pharmacogenomic testing and the incidence of actionable test results in a chronic disease cohort. Per Med 2017; 14:383-388. [PMID: 29181084 DOI: 10.2217/pme-2017-0022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 07/04/2017] [Indexed: 02/06/2023]
Abstract
Aim This study aimed to examine pharmacogenomic test results and patient perspectives at an academic cardiovascular medicine clinic. Patients & methods Test results for three common cardiovascular drug-gene tests (warfarin-CYP2C9-VKORC1, clopidogrel-CYP2C19 and simvastatin-SLCO1B1) of 208 patients in the Ohio State University-Coriell Personalized Medicine Collaborative were examined to determine the incidence of potentially actionable test results. A post-hoc, anonymous, patient survey was also conducted. Results Potentially actionable test results for at least one of the three drug-gene tests were determined in 170 (82%) patients. Survey responses (n = 134) suggested that patients generally considered their test results to be important (median of 7.5 on a 10-point scale of importance) and were interested (median of 7.3 on a 10-point scale of interest) in a Clinical Pharmacogenomic Service. Conclusion Attitudes toward pharmacogenomic testing were generally favorable, and potentially actionable test results were not uncommon in this cardiovascular medicine cohort.
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Affiliation(s)
- Chandrama Mukherjee
- Department of Biological Chemistry & Pharmacology, Ohio State University, Columbus, OH 43210, USA.,Department of Biological Chemistry & Pharmacology, Ohio State University, Columbus, OH 43210, USA
| | - Kevin M Sweet
- Division of Human Genetics, Ohio State University, Columbus, OH 43210, USA.,Division of Human Genetics, Ohio State University, Columbus, OH 43210, USA
| | - Jasmine A Luzum
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA.,Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, College of Medicine, Ohio State University, 1800 Cannon Drive Columbus, OH 43210, USA.,Center for Biostatistics, College of Medicine, Ohio State University, 1800 Cannon Drive Columbus, OH 43210, USA
| | - Michael F Christman
- Coriell Institute for Medical Research, Camden, NJ 08103, USA.,Coriell Institute for Medical Research, Camden, NJ 08103, USA
| | - Joseph P Kitzmiller
- Department of Biological Chemistry & Pharmacology, Ohio State University, Columbus, OH 43210, USA.,Center for Pharmacogenomics, College of Medicine, Ohio State University, 5086 Graves Hall, 333 West 10th Avenue Columbus, OH 43210, USA.,Department of Biological Chemistry & Pharmacology, Ohio State University, Columbus, OH 43210, USA.,Center for Pharmacogenomics, College of Medicine, Ohio State University, 5086 Graves Hall, 333 West 10th Avenue Columbus, OH 43210, USA
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