Determining the utility of diagnostic genomics: a conceptual framework

Utilisation of subsidised genetic and genomic testing in a publicly funded healthcare system 2014-2023

The Australian government subsidises medical services, including several genetic and genomic tests, through a federal funding scheme. We explore trends and variation in the utilisation of the publicly funded genetic and genomic tests over the last decade. We make use of administrative data of the listed genetic and genomic tests from financial year 2014 to 2023. In 2023, 102 genetic and nine genomic tests were publicly subsidised across 65 distinct clinical test indications, up from 32 items across 20 distinct tests in 2014. Service volumes have increased by 50% from 250,881 to 376,140, and benefits paid have risen by 83% from AU$42.0 million to AU$76.8 million. This accounts for 0.3% of the total AU$27.6 billion expenditure on publicly subsidised medical services in 2023. Somatic cancer, rare disease, and reproductive tests are the most prevalent tests. Women of childbearing ages used more services than men, however in nonchildbearing ages, men used more services than women. The current usage of publicly funded genetic and genomic testing within Australia is relatively modest, underscoring challenges in integration to routine clinical practice. However, the recent rapid expansion of subsidised items indicates that investments into genomics research are beginning to yield the evidence necessary to secure public funding for these services.

A Standardized Measurement and Valuation Scale of Genomic Utility for Policy Decisions: The GUV Scale

OBJECTIVES

The multifaceted ways in which genomics can be valuable to clinicians, patients, families, and society are important for informing prioritization decisions by policy makers. This study aims to develop a standardized, cumulative, and preference-weighted genomic utility valuation (GUV) on a scale of 0% to 100%.

METHODS

A multicriteria decision analysis was conducted with experts involved in policy, clinical, research, and consumer advocacy leadership in Australia for the valuation of policy priority indicators of genomic utility. The use of the GUV scale to support policy decisions is illustrated through a stylized example, and benchmark scoring thresholds of genomic utility were identified by mapping evidence from real-world health technology assessments leading to the public reimbursement of genomic testing in Australia onto the GUV scale.

RESULTS

In total, 33 (73%) invited experts participated in the study. Clinical utility had the highest priority, followed by societal, diagnostic, economic, and family utilities. Improving health outcomes had the highest preference value (29.5%), followed by improving equity (22.6%), Having high diagnostic yield (22.2%), improving symptom management (15.5%), being cost saving (14.3%), having average diagnostic yield (13.1%), enabling access to clinical trials (12.3%), and enabling reproductive family planning (11.5%). Genomic testing scores from real-world health technology assessments ranged from 46% for syndromic and nonsyndromic intellectual disability to about 60% for mitochondrial conditions and genetic kidney diseases.

CONCLUSIONS

Comparisons of genomic utility across different clinical contexts may seem difficult because of the multiple criteria required to be weighted to support policy decisions. This comparison is now facilitated in a standardized manner with the GUV scale.

Determining priority indicators of utility for genomic testing in rare disease: A Delphi study

PURPOSE

Determining the value of genomic tests in rare disease necessitates a broader conceptualization of genomic utility beyond diagnostic yield. Despite widespread discussion, consensus toward which aspects of value to consider is lacking. This study aimed to use expert opinion to identify and refine priority indicators of utility in rare disease genomic testing.

METHODS

We used 2 survey rounds following Delphi methodology to obtain consensus on indicators of utility among experts involved in policy, clinical, research, and consumer advocacy leadership in Australia. We analyzed quantitative and qualitative data to identify, define, and determine priority indicators.

RESULTS

Twenty-five experts completed round 1 and 18 completed both rounds. Twenty indicators reached consensus as a priority in value assessment, including those relating to prognostic information, timeliness of results, practical and health care outcomes, clinical accreditation, and diagnostic yield. Whereas indicators pertaining to discovery research, disutility, and factors secondary to primary reason for testing were considered less of a priority and were removed.

CONCLUSION

This study obtained expert consensus on different utility indicators that are considered a priority in determining the value of genomic testing in rare disease in Australia. Indicators may inform a standardized approach to evidence generation and assessment to guide future research, decision making, and implementation efforts.

Exploring the impact and utility of genomic sequencing in established CKD

Clinical genetics is increasingly recognized as an important area within nephrology care. Clinicians require awareness of genetic kidney disease to recognize clinical phenotypes, consider use of genomics to aid diagnosis, and inform treatment decisions. Understanding the broad spectrum of clinical phenotypes and principles of genomic sequencing is becoming increasingly required in clinical nephrology, with nephrologists requiring education and support to achieve meaningful patient outcomes. Establishment of effective clinical resources, multi-disciplinary teams and education is important to increase application of genomics in clinical care, for the benefit of patients and their families. Novel applications of genomics in chronic kidney disease include pharmacogenomics and clinical translation of polygenic risk scores. This review explores established and emerging impacts and utility of genomics in kidney disease.

Genetic Testing of Movements Disorders: A Review of Clinical Utility

Currently, pathogenic variants in more than 500 different genes are known to cause various movement disorders. The increasing accessibility and reducing cost of genetic testing has resulted in increasing clinical use of genetic testing for the diagnosis of movement disorders. However, the optimal use case(s) for genetic testing at a patient level remain ill-defined. Here, we review the utility of genetic testing in patients with movement disorders and also highlight current challenges and limitations that need to be considered when making decisions about genetic testing in clinical practice.

Highlights

The utility of genetic testing extends across multiple clinical and non-clinical domains. Here we review different aspects of the utility of genetic testing for movement disorders and the numerous associated challenges and limitations. These factors should be weighed on a case-by-case basis when requesting genetic tests in clinical practice.