Primary Care Clinicians Attitudes and Knowledge of Pharmacogenetics in a Large, Multi-state, Healthcare System

  Background: Considerable progress has been made in the way of pharmacogenetic research and the development of clinical recommendations; however, its implementation into clinical practice has been slower than anticipated. We sought to better understand its lack of clinical uptake within primary care. Aim: The primary objective of this survey was to ascertain primary care clinicians’ perceptions of pharmacogenetic use and implementation in an integrated health system of metropolitan and rural settings across several states. Methods: Primary care clinicians (including MDs, DOs, NPs, and PAs) were invited to participate in a survey via email. Questions about pharmacogenetics knowledge and perceptions were presented to assess current understanding and usage of pharmacogenetics in practice. Results: The rate of response for the survey was 17%. Of the 90 respondents, 58% were female, 69% were MDs/DOs, 20% were NPs, and 11% were PAs. Fifty-eight percent of respondents received their clinical degree in or after 2000. Ninety percent of respondents noted that they were uncomfortable ordering a pharmacogenetics test, with 76% stating they were uncomfortable applying the results of a pharmacogenetic test. Notably, 78% of respondents were interested in having pharmacogenetic testing available through Medication Therapy Management (MTM) services, although PAs were significantly less interested as compared to NPs and MD/DOs. Ninety-five percent of respondents were interested in a clinical decision support tool relevant to pharmacogenetic results. Conclusions: As a whole, prescribing clinicians in primary care clinics are uncomfortable in the ordering, interpreting, and applying pharmacogenetic results to individual patients. However, favorable attitudes towards providing pharmacogenetic testing through existing MTM clinics provides the opportunity for pharmacists to advance existing practices. Conflict of Interest: We declare no conflicts of interest or financial interests that the authors or members of their immediate families have in any product or service discussed in the manuscript, including grants (pending or received), employment, gifts, stock holdings or options, honoraria, consultancies, expert testimony, patents and royalties Treatment of Human Subjects: IRB determined project was non-HSR   Type: Student Projec

Personalized treatment of women with early breast cancer: a risk-group specific cost-effectiveness analysis of adjuvant chemotherapy accounting for companion prognostic tests OncotypeDX and Adjuvant!Online

Background: Due to high survival rates and the relatively small benefit of adjuvant therapy, the application of personalized medicine (PM) through risk stratification is particularly beneficial in early breast cancer (BC) to avoid unnecessary harms from treatment. The new 21-gene assay (OncotypeDX, ODX) is a promising prognostic score for risk stratification that can be applied in conjunction with Adjuvant!Online (AO) to guide personalized chemotherapy decisions for early BC patients. Our goal was to evaluate risk-group specific cost effectiveness of adjuvant chemotherapy for women with early stage BC in Austria based on AO and ODX risk stratification. Methods: A previously validated discrete event simulation model was applied to a hypothetical cohort of 50-year-old women over a lifetime horizon. We simulated twelve risk groups derived from the joint application of ODX and AO and included respective additional costs. The primary outcomes of interest were life-years gained, quality-adjusted life-years (QALYs), costs and incremental cost-effectiveness (ICER). The robustness of results and decisions derived were tested in sensitivity analyses. A cross-country comparison of results was performed. Results: Chemotherapy is dominated (i.e., less effective and more costly) for patients with 1) low ODX risk independent of AO classification; and 2) low AO risk and intermediate ODX risk. For patients with an intermediate or high AO risk and an intermediate or high ODX risk, the ICER is below 15,000 EUR/QALY (potentially cost effective depending on the willingness-to-pay). Applying the AO risk classification alone would miss risk groups where chemotherapy is dominated and thus should not be considered. These results are sensitive to changes in the probabilities of distant recurrence but not to changes in the costs of chemotherapy or the ODX test. Conclusions: Based on our modeling study, chemotherapy is effective and cost effective for Austrian patients with an intermediate or high AO risk and an intermediate or high ODX risk. In other words, low ODX risk suggests chemotherapy should not be considered but low AO risk may benefit from chemotherapy if ODX risk is high. Our analysis suggests that risk-group specific cost-effectiveness analysis, which includes companion prognostic tests are essential in PM. Electronic supplementary material The online version of this article (10.1186/s12885-017-3603-z) contains supplementary material, which is available to authorized users

American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer

Background: Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality. Objective: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer. Methods: ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations. Results: Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer. Conclusions: Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer

Association between vitamin D deficiency and methicillin-resistant Staphylococcus aureus infection.

PURPOSE: Given that vitamin D (25(OH)D) contributes to immune defense, we sought to determine if deficiency of 25(OH)D was significantly associated with methicillin-resistant Staphylococcus aureus (MRSA) infection. METHODS: All patients with 25(OH)D determinations at the Atlanta VAMC from 2007 to 2010 were included in the analyses. These patients were cross-referenced with a prospectively collected MRSA infection database at the AVAMC (2006-2010). Patients with one or more MRSA infections during the study period were considered MRSA-infected patients. Multivariate logistic regression was used to determine the association between 25(OH)D status [deficient (<20 ng/mL) vs. non-deficient (≥20 ng/mL)] and MRSA infection. RESULTS: A total of 6405 patients with 25(OH)D determinations were included in the analyses, of which 401 (6.3 %) were MRSA-infected patients. Mean (SD) vitamin D levels, in ng/mL, were 21.1 (12.4) and 24.0 (12.6) for MRSA-infected patients and non-MRSA infected patients, respectively (p < 0.0001). The multivariate logistic regression model confirmed associations between MRSA infection and sex, race, BMI, HIV status, and 25(OH)D [odds ratio for 25(OH)D: 1.94; 95 % confidence interval: 1.51-2.49]. CONCLUSION: MRSA-infected patients had significantly lower serum vitamin D levels than non-MRSA infected patients, even when controlling for potential confounding variables

High rifaximin out-of-pocket costs are associated with decreased treatment retention among patients with hepatic encephalopathy

Background and Aims:. Hepatic encephalopathy (HE) is associated with significant morbidity and mortality for those with cirrhosis. Despite the known benefits of rifaximin use for HE, treatment retention remains low. This study aimed to evaluate the impact of out-of-pocket (OOP) rifaximin cost on treatment retention among commercially insured patients in the United States. Methods:. Adult patients with cirrhosis and HE were identified from the IBM MarketScan claims database. Those who began rifaximin treatment between January 1, 2011, and December 1, 2021 were included. Regression models were used to analyze the relationship between patients’ 30-day OOP rifaximin cost and rifaximin retention (≥80% eligible days with rifaximin supply) at 180, 360, and 540 days. Models were controlled for patient demographic and clinical characteristics including age, sex, comorbid conditions, Charlson comorbidity index (CCI), and lactulose use. Results:. A total of 6839 adult patients were included. Most patients were between 55 and 64 years (57.1%), male (60.4%), and living in urban settings (84.6%). Treatment retention was low for all time periods; retention rates for rifaximin were 42%, 25%, and 16% at 180, 360, and 540 days, respectively. In multivariable analysis, 30-day OOP costs of ≥ $150 were associated with a decreased likelihood of rifaximin retention at 180, 360, and 540 days [relative risk (RR) = 0.67, RR = 0.62, and R = 0.60, respectively]. Younger age was associated with reduced treatment retention for all time periods. Metastatic cancer and depression were associated with reduced treatment retention at 180 days (RR = 0.70 and RR = 0.87, respectively). Conclusions:. Rates of rifaximin treatment retention are low despite the known benefits of rifaximin use for breakthrough HE. High 30-day OOP cost is associated with reduced rifaximin treatment retention