Operational implementation of prospective genotyping for personalized medicine: the design of the Vanderbilt PREDICT project

The promise of "personalized medicine" guided by an understanding of each individual's genome has been fostered by increasingly powerful and economical methods to acquire clinically relevant information. We describe the operational implementation of prospective genotyping linked to an advanced clinical decision-support system to guide individualized health care in a large academic health center. This approach to personalized medicine entails engagement between patient and health-care provider, identification of relevant genetic variations for implementation, assay reliability, point-of-care decision support, and necessary institutional investments. In one year, approximately 3,000 patients, most of whom were scheduled for cardiac catheterization, were genotyped on a multiplexed platform that included genotyping for CYP2C19 variants that modulate response to the widely used antiplatelet drug clopidogrel. These data are deposited into the electronic medical record (EMR), and point-of-care decision support is deployed when clopidogrel is prescribed for those with variant genotypes. The establishment of programs such as this is a first step toward implementing and evaluating strategies for personalized medicine.

Modeling the supply of nurse labor. Life-cycle activity patterns of registered nurses in one Canadian delivery system

Using 1980 membership data made available by the provincial nurses' association, a simple, age-specific projection model was developed that comprised two submodels: a Markovian one to monitor yearly movements from one membership state to another and a linear submodel for the infusion of new members. The model assumes that the likelihood of moving to any membership state depends only on the nurse's current age and membership state. A comparison of actual/projected data for 1981-1984 indicates a fairly high level of accuracy, despite the oscillatory pattern of the nurse labor market in the Province of British Columbia since 1982. The details of the projections of labor force over time show a particular age cohort's characteristic behavior and delineate the effect of childbearing and aging on the supply of nurses. As well as projecting future manpower, the age-specific transition matrices were used to estimate the professional life expectancy of registered nurses. This information includes the average number of continuous years of practice for each age, as well as the average total number of years of practice until being deleted from the system at the age of 75. The forecasting capability developed from this work attempts to address two questions central to manpower planning: how many nurses will there be in the province in the next 5 years? and what is the time-frame involved in nurses' life-cycle activity patterns?