1
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David SP, Dunnenberger HM, Choi S, DePersia A, Ilbawi N, Ward C, Wake DT, Khandekar JD, Shannon Y, Hughes K, Miller N, Mangold KA, Sabatini LM, Helseth DL, Xu J, Sanders A, Kaul KL, Hulick PJ. Personalized medicine in a community health system: the NorthShore experience. Front Genet 2023; 14:1308738. [PMID: 38090148 PMCID: PMC10713750 DOI: 10.3389/fgene.2023.1308738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/06/2023] [Indexed: 02/01/2024] Open
Abstract
Genomic and personalized medicine implementation efforts have largely centered on specialty care in tertiary health systems. There are few examples of fully integrated care systems that span the healthcare continuum. In 2014, NorthShore University HealthSystem launched the Center for Personalized Medicine to catalyze the delivery of personalized medicine. Successful implementation required the development of a scalable family history collection tool, the Genetic and Wellness Assessment (GWA) and Breast Health Assessment (BHA) tools; integrated pharmacogenomics programming; educational programming; electronic medical record integration; and robust clinical decision support tools. To date, more than 225,000 patients have been screened for increased hereditary conditions, such as cancer risk, through these tools in primary care. More than 35,000 patients completed clinical genetic testing following GWA or BHA completion. An innovative program trained more than 100 primary care providers in genomic medicine, activated with clinical decision support and access to patient genetic counseling services and digital healthcare tools. The development of a novel bioinformatics platform (FLYPE) enabled the incorporation of genomics data into electronic medical records. To date, over 4,000 patients have been identified to have a pathogenic or likely pathogenic variant in a gene with medical management implications. Over 33,000 patients have clinical pharmacogenomics data incorporated into the electronic health record supported by clinical decision support tools. This manuscript describes the evolution, strategy, and successful multispecialty partnerships aligned with health system leadership that enabled the implementation of a comprehensive personalized medicine program with measurable patient outcomes through a genomics-enabled learning health system model that utilizes implementation science frameworks.
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Affiliation(s)
- Sean P. David
- Department of Family Medicine, NorthShore University HealthSystem, Evanston, IL, United States
- Department of Family Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, United States
- Outcomes Research Network, NorthShore University HealthSystem, Evanston, IL, United States
| | - Henry M. Dunnenberger
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, United States
| | - Sarah Choi
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, United States
| | - Allison DePersia
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, United States
- Outcomes Research Network, NorthShore University HealthSystem, Evanston, IL, United States
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL, United States
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
| | - Nadim Ilbawi
- Department of Family Medicine, NorthShore University HealthSystem, Evanston, IL, United States
- Department of Family Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
| | - Christopher Ward
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, United States
| | - Dyson T. Wake
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, United States
| | - Janardan D. Khandekar
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL, United States
- Kellogg Cancer Center, NorthShore University HealthSystem, Evanston, IL, United States
| | - Yvette Shannon
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, United States
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL, United States
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
| | - Kristen Hughes
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, United States
| | - Nicholas Miller
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, United States
| | - Kathy A. Mangold
- Department of Pathology, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
| | - Linda M. Sabatini
- Department of Pathology, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
| | - Donald L. Helseth
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, United States
| | - Jianfeng Xu
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, United States
| | - Alan Sanders
- Center for Psychiatric Genetics, Department of Psychiatry and Behavioral Sciences, NorthShore University HealthSystem, Evanston, IL, United States
- Departments of Psychiatry and Behavioral Neuroscience, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
| | - Karen L. Kaul
- Outcomes Research Network, NorthShore University HealthSystem, Evanston, IL, United States
- Department of Pathology, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
- Department of Pathology, NorthShore University HealthSystem, Evanston, IL, United States
| | - Peter J. Hulick
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, United States
- Outcomes Research Network, NorthShore University HealthSystem, Evanston, IL, United States
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL, United States
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
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Smith DM, Wake DT, Dunnenberger HM. Pharmacogenomic Clinical Decision Support: A Scoping Review. Clin Pharmacol Ther 2023; 113:803-815. [PMID: 35838358 DOI: 10.1002/cpt.2711] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/10/2022] [Indexed: 11/06/2022]
Abstract
Clinical decision support (CDS) is often cited as an essential part of pharmacogenomics (PGx) implementations. A multitude of strategies are available; however, it is unclear which strategies are effective and which metrics are used to quantify clinical utility. The objective of this scoping review was to aggregate previous studies into a cohesive depiction of the current state of PGx CDS implementations and identify areas for future research on PGx CDS. Articles were included if they (i) described electronic CDS tools for PGx and (ii) reported metrics related to PGx CDS. Twenty of 3,449 articles were included and provided data on PGx CDS metrics from 15 institutions, with 93% of programs located at academic medical centers. The most common tools in CDS implementations were interruptive post-test alerts. Metrics for clinical response and alert response ranged from 12-73% and 21-98%, respectively. Few data were found on changes in metrics over time and measures that drove the evolution of CDS systems. Relatively few data were available regarding support of optimal approaches for PGx CDS. Post-test alerts were the most widely studied approach, and their effectiveness varied greatly. Further research on the usability, effectiveness, and optimization of CDS tools is needed.
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Affiliation(s)
- D Max Smith
- MedStar Health, Columbia, Maryland, USA.,Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Dyson T Wake
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Henry M Dunnenberger
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
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3
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Socco S, Wake DT, Lee JC, Dunnenberger HM. Pharmacogenomics of medications given via nonconventional administration routes: a scoping review. Pharmacogenomics 2022; 23:933-948. [DOI: 10.2217/pgs-2022-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Pharmacogenomics (PGx) implementation has become increasingly widespread. One of the most important aspects of this implementation process is the development of appropriate clinical decision support (CDS). Major PGx resources, such as the Clinical Pharmacogenetics Implementation Consortium, provide valuable recommendations for the development of CDS for specific gene–drug pairs but do not specify whether the administration route of a drug is clinically relevant. It is also unknown if PGx alerts for nonorally and non-intravenously administered PGx-relevant medications should be suppressed to reduce alert fatigue. The purpose of this scoping review was to identify studies and their clinical, pharmacokinetic and pharmacodynamic outcomes to better determine if CDS alerts are relevant for nonorally and non-intravenously administered PGx-relevant medications. Although this scoping review identified multiple PGx studies, the results of these studies were inconsistent, and more evidence is needed regarding different routes of medication administration and PGx.
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Affiliation(s)
- Samantha Socco
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA
- Department of Precision Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Dyson T Wake
- Department of Precision Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - James C Lee
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA
| | - Henry M Dunnenberger
- Department of Precision Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
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4
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Ho TT, Bell G, Gammal RS, Gregornik D, Wake DT, Dunnenberger HM. A clinician’s guide for counseling patients on results of a multigene pharmacogenomic panel. Am J Health Syst Pharm 2022; 79:1634-1644. [DOI: 10.1093/ajhp/zxac189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
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
This article explores approaches to pharmacogenomic counseling for patients who have undergone multigene panel testing by describing the collective experience of 5 institutions.
Summary
Multigene panel pharmacogenomic testing has the potential to unlock a myriad of information about a patient’s past, present, and future drug response. The multifaceted nature of drug response coupled with the complexity of genetic results necessitates some form of patient education through pharmacogenomic counseling. Published literature regarding disclosure of pharmacogenomic test results is limited. This article compares the counseling practices of pharmacists from 5 different institutions with pharmacogenomics clinics whose experience represents perspectives ranging from academia to community clinical environments. Overarching counseling themes discussed during result disclosure center around (1) pharmacogenomic results, (2) gene-drug interactions, (3) gene-drug-drug interactions, (4) drug changes (5) future, familial, or disease-risk implications, (6) updates in the interpretation and application of pharmacogenomic results, (7) gauging patient comprehension, and (8) sharing results and supplemental information.
Conclusion
Dedicating time to counseling patients on the results of a multigene pharmacogenomic panel is important given the lifelong applications of a test that is generally performed only once. The content and methods of disclosing test results shared by the experiences of pharmacists at 5 different institutions serve as guide to be further refined as research addresses effective communication strategies that enhance patient comprehension of pharmacogenomic results.
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Affiliation(s)
- Teresa T Ho
- Department of Pharmacotherapeutics & Clinical Research, University of South Florida Taneja College of Pharmacy, Tampa , FL, and Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Gillian Bell
- Genetics & Personalized Medicine Department, Mission Health, Asheville, NC, and Genome Medical, South San Francisco , CA, USA
| | | | - David Gregornik
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston , MA, USA
| | - Dyson T Wake
- Pharmacogenomics Program, Children's Minnesota, Minneapolis , MN, USA
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5
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Wake DT, Smith DM, Kazi S, Dunnenberger HM. Pharmacogenomic Clinical Decision Support: A Review, How-to Guide, and Future Vision. Clin Pharmacol Ther 2021; 112:44-57. [PMID: 34365648 PMCID: PMC9291515 DOI: 10.1002/cpt.2387] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/28/2021] [Indexed: 02/06/2023]
Abstract
Clinical decision support (CDS) is an essential part of any pharmacogenomics (PGx) implementation. Increasingly, institutions have implemented CDS tools in the clinical setting to bring PGx data into patient care, and several have published their experiences with these implementations. However, barriers remain that limit the ability of some programs to create CDS tools to fit their PGx needs. Therefore, the purpose of this review is to summarize the types, functions, and limitations of PGx CDS currently in practice. Then, we provide an approachable step‐by‐step how‐to guide with a case example to help implementers bring PGx to the front lines of care regardless of their setting. Particular focus is paid to the five “rights” of CDS as a core around designing PGx CDS tools. Finally, we conclude with a discussion of opportunities and areas of growth for PGx CDS.
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Affiliation(s)
- Dyson T Wake
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - D Max Smith
- MedStar Health, Columbia, Maryland, USA.,Georgetown University Medical Center, Washington, DC, USA
| | - Sadaf Kazi
- Georgetown University Medical Center, Washington, DC, USA.,National Center for Human Factors in Healthcare, MedStar Health Research Institute Washington, Washington, DC, USA
| | - Henry M Dunnenberger
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
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6
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Wake DT, Bell GC, Gregornik DB, Ho TT, Dunnenberger HM. Synthesis of major pharmacogenomics pretest counseling themes: a multisite comparison. Pharmacogenomics 2021; 22:165-176. [PMID: 33461326 DOI: 10.2217/pgs-2020-0168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The accessibility of pharmacogenomic (PGx) testing has grown substantially over the last decade and with it has arisen a demand for patients to be counseled on the use of these tests. While guidelines exist for the use of PGx results; objective determinants for who should receive PGx testing remain incomplete. PGx clinical services have been created to meet these screening and education needs and significant variability exists between these programs. This article describes the practices of four PGx clinics during pretest counseling sessions. A description of the major tenets of the benefits, limitations and risks of testing are compiled. Additional tools are provided to serve as a foundation for those wishing to begin or expand their own counseling service.
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Affiliation(s)
- Dyson T Wake
- Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Gillian C Bell
- Genetics & Personalized Medicine Department, Mission Health, Asheville, NC 28803, USA
| | - David B Gregornik
- Pharmacogenomics Program, Children's Minnesota, Minneapolis, MN 55404, USA
| | - Teresa T Ho
- Department of Pharmacotherapeutics & Clinical Research, University of South Florida Taneja College of Pharmacy, Tampa, FL 33612, USA
| | - Henry M Dunnenberger
- Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
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7
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Helseth DL, Gulukota K, Miller N, Yang M, Werth T, Sabatini LM, Bouma M, Dunnenberger HM, Wake DT, Hulick PJ, Kaul KL, Khandekar JD. Flype: Software for enabling personalized medicine. Am J Med Genet C Semin Med Genet 2020; 187:37-47. [PMID: 33270363 PMCID: PMC7984435 DOI: 10.1002/ajmg.c.31867] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 02/02/2023]
Abstract
The advent of next generation DNA sequencing (NGS) has revolutionized clinical medicine by enabling wide‐spread testing for genomic anomalies and polymorphisms. With that explosion in testing, however, come several informatics challenges including managing large amounts of data, interpreting the results and providing clinical decision support. We present Flype, a web‐based bioinformatics platform built by a small group of bioinformaticians working in a community hospital setting, to address these challenges by allowing us to: (a) securely accept data from a variety of sources, (b) send orders to a variety of destinations, (c) perform secondary analysis and annotation of NGS data, (d) provide a central repository for all genomic variants, (e) assist with tertiary analysis and clinical interpretation, (f) send signed out data to our EHR as both PDF and discrete data elements, (g) allow population frequency analysis and (h) update variant annotation when literature knowledge evolves. We discuss the multiple use cases Flype supports such as (a) in‐house NGS tests, (b) in‐house pharmacogenomics (PGX) tests, (c) dramatic scale‐up of genomic testing using an external lab, (d) consumer genomics using two external partners, and (e) a variety of reporting tools. The source code for Flype is available upon request to the authors.
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Affiliation(s)
- Donald L Helseth
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Kamalakar Gulukota
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Nicholas Miller
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Mathew Yang
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Tom Werth
- Health Information Technology, NorthShore University HealthSystem, Skokie, Illinois, USA
| | - Linda M Sabatini
- Department of Pathology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Mike Bouma
- Department of Pathology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Henry M Dunnenberger
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Dyson T Wake
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Peter J Hulick
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA.,Center for Medical Genetics, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Karen L Kaul
- Department of Pathology, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Janaradan D Khandekar
- Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA.,Kellogg Cancer Center, NorthShore University HealthSystem, Evanston, Illinois, USA
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Abstract
Pharmacogenomics (PGx) is a powerful tool that can predict increased risks of adverse effects and sub-therapeutic response to medications. This article establishes the core principles necessary for a primary care provider to meaningfully and prudently use PGx testing. Key topics include in which patients PGx testing should be considered, how PGx tests are ordered, how the results are translated into clinical recommendations, and what further advancements are likely in the near future. This will provide clinicians with a foundational knowledge of PGx that can allow incorporation of this tool into their practice or support further personal investigation.
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Affiliation(s)
- Dyson T Wake
- Pharmacogenomics, Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Nadim Ilbawi
- Department of Family Medicine, NorthShore University HealthSystem, 6810 North McCormick Boulevard, Lincolnwood, IL 60712, USA
| | - Henry Mark Dunnenberger
- Pharmacogenomics, Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201, USA
| | - Peter J Hulick
- Center for Medical Genetics, Mark R. Neaman Center for Personalized Medicine, NorthShore University HealthSystem, University of Chicago, Pritzker School of Medicine, 1000 Central Street Suite 610, Evanston, IL 60201, USA.
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Smith DM, Weitzel KW, Elsey AR, Langaee T, Gong Y, Wake DT, Duong BQ, Hagen M, Harle CA, Mercado E, Nagoshi Y, Newsom K, Wright A, Rosenberg EI, Starostik P, Clare-Salzler MJ, Schmidt SO, Fillingim RB, Johnson JA, Cavallari LH. CYP2D6-guided opioid therapy improves pain control in CYP2D6 intermediate and poor metabolizers: a pragmatic clinical trial. Genet Med 2019; 21:1842-1850. [PMID: 30670877 PMCID: PMC6650382 DOI: 10.1038/s41436-018-0431-8] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/20/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE CYP2D6 bioactivates codeine and tramadol, with intermediate and poor metabolizers (IMs and PMs) expected to have impaired analgesia. This pragmatic proof-of-concept trial tested the effects of CYP2D6-guided opioid prescribing on pain control. METHODS Participants with chronic pain (94% on an opioid) from seven clinics were enrolled into CYP2D6-guided (n = 235) or usual care (n = 135) arms using a cluster design. CYP2D6 phenotypes were assigned based on genotype and CYP2D6 inhibitor use, with recommendations for opioid prescribing made in the CYP2D6-guided arm. Pain was assessed at baseline and 3 months using PROMIS® measures. RESULTS On stepwise multiple linear regression, the primary outcome of composite pain intensity (composite of current pain and worst and average pain in the past week) among IM/PMs initially prescribed tramadol/codeine (n = 45) had greater improvement in the CYP2D6-guided versus usual care arm (-1.01 ± 1.59 vs. -0.40 ± 1.20; adj P = 0.016); 24% of CYP2D6-guided versus 0% of usual care participants reported ≥30% (clinically meaningful) reduction in the composite outcome. In contrast, among normal metabolizers prescribed tramadol or codeine at baseline, there was no difference in the change in composite pain intensity at 3 months between CYP2D6-guided (-0.61 ± 1.39) and usual care (-0.54 ± 1.69) groups (adj P = 0.540). CONCLUSION These data support the potential benefits of CYP2D6-guided pain management.
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Affiliation(s)
- D Max Smith
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kristin W Weitzel
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Amanda R Elsey
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA
| | - Taimour Langaee
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Dyson T Wake
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Benjamin Q Duong
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Melanie Hagen
- Division of General Internal Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Christopher A Harle
- Department of Health Policy and Management, Indiana University, Indianapolis, IN, USA
| | - Elvira Mercado
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Ying Nagoshi
- Division of General Internal Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Kimberly Newsom
- University of Florida Health Pathology Laboratories, Gainesville, FL, USA
| | - Ashleigh Wright
- Division of General Internal Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Eric I Rosenberg
- Division of General Internal Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Petr Starostik
- University of Florida Health Pathology Laboratories, Gainesville, FL, USA.,Department of Pathology, Immunology & Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Siegfried O Schmidt
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Roger B Fillingim
- Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA.,Department of Community Dentistry and Behavioral Science, College of Dentistry, Gainesville, FL, USA
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA. .,Center for Pharmacogenomics, College of Pharmacy, University of Florida, Gainesville, FL, USA. .,Clinical and Translational Science Institute, University of Florida, Gainesville, FL, USA.
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10
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Lemke AA, Hulick PJ, Wake DT, Wang C, Sereika AW, Yu KD, Glaser NS, Dunnenberger HM. Patient perspectives following pharmacogenomics results disclosure in an integrated health system. Pharmacogenomics 2018; 19:321-331. [DOI: 10.2217/pgs-2017-0191] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Aim: To assess patient perceptions and utilization of pharmacogenomics (PGx) testing in an integrated community health system. Methods: Fifty-seven patients completed an online survey assessing their experiences with PGx testing offered through two methods: a designated PGx clinic or direct access in-home testing. Results: The majority of participants perceived PGx testing as helpful in their healthcare and reported understanding their results. Some had concerns about privacy and discrimination; most lacked familiarity with the Genetic Information Nondiscrimination Act. There were no significant differences in views between participants tested through either model. Conclusion: Participants reported value in both methods of PGx testing. Patient experiences, understanding and result utilization will play an important role in informing future development and implementation of PGx programs.
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Affiliation(s)
- Amy A Lemke
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
| | - Peter J Hulick
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
| | - Dyson T Wake
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
| | - Chi Wang
- Biostatistics & Research Informatics, NorthShore University HealthSystem, 1001 University Place, Suite 146, Evanston, IL 60201, USA
| | - Annette W Sereika
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
| | - Kristen Dilzell Yu
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
| | - Nicole S Glaser
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
| | - Henry M Dunnenberger
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
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11
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Weitzel KW, Smith DM, Elsey AR, Duong BQ, Burkley B, Clare-Salzler M, Gong Y, Higgins TA, Kong B, Langaee T, McDonough CW, Staley BJ, Vo TT, Wake DT, Cavallari LH, Johnson JA. Implementation of Standardized Clinical Processes for TPMT Testing in a Diverse Multidisciplinary Population: Challenges and Lessons Learned. Clin Transl Sci 2018; 11:175-181. [PMID: 29351371 PMCID: PMC5867028 DOI: 10.1111/cts.12533] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 12/03/2017] [Indexed: 01/11/2023] Open
Abstract
Although thiopurine S‐methyltransferase (TPMT) genotyping to guide thiopurine dosing is common in the pediatric cancer population, limited data exist on TPMT testing implementation in diverse, multidisciplinary settings. We established TPMT testing (genotype and enzyme) with clinical decision support, provider/patient education, and pharmacist consultations in a tertiary medical center and collected data over 3 years. During this time, 834 patients underwent 873 TPMT tests (147 (17%) genotype, 726 (83%) enzyme). TPMT tests were most commonly ordered for gastroenterology, rheumatology, dermatology, and hematology/oncology patients (661 of 834 patients (79.2%); 580 outpatient vs. 293 inpatient; P < 0.0001). Thirty‐nine patients had both genotype and enzyme tests (n = 2 discordant results). We observed significant differences between TPMT test use and characteristics in a diverse, multispecialty environment vs. a pediatric cancer setting, which led to unique implementation needs. As pharmacogenetic implementations expand, disseminating lessons learned in diverse, real‐world environments will be important to support routine adoption.
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Affiliation(s)
- Kristin W Weitzel
- University of Florida Health Personalized Medicine Program, Gainesville, Florida, USA.,University of Florida College of Pharmacy Center for Pharmacogenomics, Gainesville, Florida, USA
| | - D Max Smith
- University of Florida Health Personalized Medicine Program, Gainesville, Florida, USA.,University of Florida College of Pharmacy Center for Pharmacogenomics, Gainesville, Florida, USA
| | - Amanda R Elsey
- University of Florida Health Personalized Medicine Program, Gainesville, Florida, USA.,University of Florida College of Pharmacy Center for Pharmacogenomics, Gainesville, Florida, USA.,University of Florida Clinical and Translational Science Institute, Gainesville, Florida, USA
| | - Benjamin Q Duong
- University of Florida Health Personalized Medicine Program, Gainesville, Florida, USA.,University of Florida College of Pharmacy Center for Pharmacogenomics, Gainesville, Florida, USA
| | - Benjamin Burkley
- University of Florida College of Pharmacy Center for Pharmacogenomics, Gainesville, Florida, USA
| | - Michael Clare-Salzler
- UF Department of Immunology, Pathology, and Laboratory Medicine, Gainesville, Florida, USA.,UF Health Pathology Laboratories, Gainesville, Florida, USA
| | - Yan Gong
- University of Florida College of Pharmacy Center for Pharmacogenomics, Gainesville, Florida, USA
| | - Tara A Higgins
- UF Health Shands Hospital Department of Pharmacy, Gainesville, Florida, USA
| | - Benjamin Kong
- Oregon Health and Science University, Portland, Oregon, USA
| | - Taimour Langaee
- University of Florida College of Pharmacy Center for Pharmacogenomics, Gainesville, Florida, USA
| | - Caitrin W McDonough
- University of Florida College of Pharmacy Center for Pharmacogenomics, Gainesville, Florida, USA
| | - Benjamin J Staley
- UF Health Shands Hospital Department of Pharmacy, Gainesville, Florida, USA
| | - Teresa T Vo
- University of South Florida Health College of Pharmacy, Tampa, Florida, USA
| | - Dyson T Wake
- NorthShore University Health System, Evanston, Illinois, USA
| | - Larisa H Cavallari
- University of Florida Health Personalized Medicine Program, Gainesville, Florida, USA.,University of Florida College of Pharmacy Center for Pharmacogenomics, Gainesville, Florida, USA
| | - Julie A Johnson
- University of Florida Health Personalized Medicine Program, Gainesville, Florida, USA.,University of Florida College of Pharmacy Center for Pharmacogenomics, Gainesville, Florida, USA
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12
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Cavallari LH, Lee CR, Beitelshees AL, Cooper-DeHoff RM, Duarte JD, Voora D, Kimmel SE, McDonough CW, Gong Y, Dave CV, Pratt VM, Alestock TD, Anderson RD, Alsip J, Ardati AK, Brott BC, Brown L, Chumnumwat S, Clare-Salzler MJ, Coons JC, Denny JC, Dillon C, Elsey AR, Hamadeh IS, Harada S, Hillegass WB, Hines L, Horenstein RB, Howell LA, Jeng LJB, Kelemen MD, Lee YM, Magvanjav O, Montasser M, Nelson DR, Nutescu EA, Nwaba DC, Pakyz RE, Palmer K, Peterson JF, Pollin TI, Quinn AH, Robinson SW, Schub J, Skaar TC, Smith DM, Sriramoju VB, Starostik P, Stys TP, Stevenson JM, Varunok N, Vesely MR, Wake DT, Weck KE, Weitzel KW, Wilke RA, Willig J, Zhao RY, Kreutz RP, Stouffer GA, Empey PE, Limdi NA, Shuldiner AR, Winterstein AG, Johnson JA. Multisite Investigation of Outcomes With Implementation of CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2017; 11:181-191. [PMID: 29102571 DOI: 10.1016/j.jcin.2017.07.022] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 01/14/2023]
Abstract
OBJECTIVES This multicenter pragmatic investigation assessed outcomes following clinical implementation of CYP2C19 genotype-guided antiplatelet therapy after percutaneous coronary intervention (PCI). BACKGROUND CYP2C19 loss-of-function alleles impair clopidogrel effectiveness after PCI. METHODS After clinical genotyping, each institution recommended alternative antiplatelet therapy (prasugrel, ticagrelor) in PCI patients with a loss-of-function allele. Major adverse cardiovascular events (defined as myocardial infarction, stroke, or death) within 12 months of PCI were compared between patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy. Risk was also compared between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy. Cox regression was performed, adjusting for group differences with inverse probability of treatment weights. RESULTS Among 1,815 patients, 572 (31.5%) had a loss-of-function allele. The risk for major adverse cardiovascular events was significantly higher in patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy (23.4 vs. 8.7 per 100 patient-years; adjusted hazard ratio: 2.26; 95% confidence interval: 1.18 to 4.32; p = 0.013). Similar results were observed among 1,210 patients with acute coronary syndromes at the time of PCI (adjusted hazard ratio: 2.87; 95% confidence interval: 1.35 to 6.09; p = 0.013). There was no difference in major adverse cardiovascular events between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy (adjusted hazard ratio: 1.14; 95% confidence interval: 0.69 to 1.88; p = 0.60). CONCLUSIONS These data from real-world observations demonstrate a higher risk for cardiovascular events in patients with a CYP2C19 loss-of-function allele if clopidogrel versus alternative therapy is prescribed. A future randomized study of genotype-guided antiplatelet therapy may be of value.
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Affiliation(s)
- Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida.
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida; Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Julio D Duarte
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Deepak Voora
- Department of Medicine, Center for Applied Genomics & Precision Medicine, Duke University, Durham, North Carolina
| | - Stephen E Kimmel
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Caitrin W McDonough
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Yan Gong
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Chintan V Dave
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida
| | - Victoria M Pratt
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - R David Anderson
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Jorge Alsip
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amer K Ardati
- Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Brigitta C Brott
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lawrence Brown
- Veterans Administration Medical Center, Baltimore, Maryland
| | - Supatat Chumnumwat
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Michael J Clare-Salzler
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - James C Coons
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joshua C Denny
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chrisly Dillon
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amanda R Elsey
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Issam S Hamadeh
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Shuko Harada
- Department of Pathology and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - William B Hillegass
- Heart South Cardiovascular Group, Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lindsay Hines
- Department of Neuropsychology, University of North Dakota, Fargo, North Dakota
| | | | - Lucius A Howell
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Linda J B Jeng
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Mark D Kelemen
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Yee Ming Lee
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Oyunbileg Magvanjav
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - May Montasser
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - David R Nelson
- College of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida
| | - Edith A Nutescu
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois; Department of Pharmacy Systems, Outcomes and Policy and Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Devon C Nwaba
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Ruth E Pakyz
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Kathleen Palmer
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Josh F Peterson
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Toni I Pollin
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Alison H Quinn
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Shawn W Robinson
- Department of Medicine, University of Maryland, Baltimore, Maryland; Veterans Administration Medical Center, Baltimore, Maryland
| | - Jamie Schub
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Todd C Skaar
- Department of Medicine, Krannert Institute of Cardiology & Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - D Max Smith
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Vindhya B Sriramoju
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Petr Starostik
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Tomasz P Stys
- Department of Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - James M Stevenson
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Nicholas Varunok
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mark R Vesely
- Department of Medicine, University of Maryland, Baltimore, Maryland; Veterans Administration Medical Center, Baltimore, Maryland
| | - Dyson T Wake
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Karen E Weck
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kristin W Weitzel
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida
| | - Russell A Wilke
- Department of Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - James Willig
- Division of Cardiovascular Sciences, Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard Y Zhao
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rolf P Kreutz
- Department of Medicine, Krannert Institute of Cardiology & Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Nita A Limdi
- Department of Neurology and Hugh Kaul Personalized Medicine Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alan R Shuldiner
- Department of Medicine, University of Maryland, Baltimore, Maryland
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida; Department of Epidemiology, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Julie A Johnson
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, Florida; Department of Medicine, Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
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13
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Lemke AA, Hutten Selkirk CG, Glaser NS, Sereika AW, Wake DT, Hulick PJ, Dunnenberger HM. Primary care physician experiences with integrated pharmacogenomic testing in a community health system. Per Med 2017; 14:389-400. [DOI: 10.2217/pme-2017-0036] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Aim: To explore primary care physicians’ views of the utility and delivery of direct access to pharmacogenomics (PGx) testing in a community health system. Methods: This descriptive study assessed the perspectives of 15 healthcare providers utilizing qualitative individual interviews. Results: Three main themes emerged: perceived value and utility of PGx testing; challenges to implementation in practice; and provider as well as patient needs. Conclusion: While providers in this study viewed benefits of PGx testing as avoiding side effects, titrating doses more quickly, improving shared decision-making and providing psychological reassurance, challenges will need to be addressed such as privacy concerns, cost, insurance coverage and understanding the complexity of PGx test results.
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Affiliation(s)
- Amy A Lemke
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
| | - Christina G Hutten Selkirk
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
| | - Nicole S Glaser
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
| | - Annette W Sereika
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
| | - Dyson T Wake
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
| | - Peter J Hulick
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
| | - Henry M Dunnenberger
- Center for Personalized Medicine, NorthShore University HealthSystem, 1001 University Place, Suite 160, Evanston, IL 60201, USA
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