Evolution of pharmacogenomic services and implementation of a multi-state pharmacogenomics clinic across a large rural healthcare system

Introduction: Pharmacogenomics (PGx) aims to maximize drug benefits while minimizing risk of toxicity. Although PGx has proven beneficial in many settings, clinical uptake lags. Lack of clinician confidence and limited availability of PGx testing can deter patients from completing PGx testing. A few novel PGx clinic models have been described as a way to incorporate PGx testing into the standard of care.Background: A PGx clinic was implemented to fill an identified gap in provider availability, confidence, and utilization of PGx across our health system. Through a joint pharmacist and Advanced Practice Provider (APP) collaborative clinic, patients received counseling and PGx medication recommendations both before and after PGx testing. The clinic serves patients both in-person and virtually across four states in the upper Midwest.Results: The majority of patients seen in the PGx clinic during the early months were clinician referred (77%, n = 102) with the remainder being self-referred. Patients were, on average, taking two medications with Clinical Pharmacogenetics Implementation Consortium guidelines. Visits were split almost equally between in-person and virtual visits.Conclusion: Herein, we describe the successful implementation of an interdisciplinary PGx clinic to further enhance our PGx program. Throughout the implementation of the PGx clinic we have learned valuable lessons that may be of interest to other implementors. Clinicians were actively engaged in clinic referrals and early adoption of telemedicine was key to the clinic’s early successes

Groundwater contamination from waste-management sites : the interaction between risk-based engineering design and regulatory policy

This dissertation puts in place a risk-cost-benefit analysis for waste management facilities that explicitly recognizes the adversarial relationship that exists in a regulated market economy between the owner-operator of the facility and the government regulatory agency under whose terms the facility must be licensed. The risk-cost-benefit analysis is set up from the perspective of the owner-operator. It can be used directly by the owner-operator to assess alternative design strategies. It can also be used by the regulatory agency to assess alternative regulatory policies, but only in an indirect manner, by examining the response of an owner-operator to the stimuli of various policies. The objective function is written in terms of a discounted stream of benefits, costs, and risks over an engineering time horizon. Benefits are in terms of revenues for services provided; costs are those of construction and operation of the facility. Risk is defined as the expected cost associated with failure, with failure defined as a groundwater contamination event that violates the licensing requirements set forth by the regulatory agency. Failure requires a breach of the containment structure and contaminant migration through the hydrogeological environment to a compliance surface. Reliability theory is used to estimate the probability of breaching and Monte Carlo finite-element simulations are used to simulate advective contaminant transport. The hydraulic conductivity values in the hydrogeological environment are defined stochastically. The probability of failure is reduced by the presence of a monitoring network established by the owner-operator. The level of reduction in the probability of failure can be calculated from the stochastic contaminant transport simulations. While the framework is quite general, the development in this dissertation is specifically suited for a landfill in which the primary design feature is one or more synthetic liners and in which contamination is brought about by the release of a single, nonreactive species in an advective, steady-state, horizontal flow field. The risk cost benefit analysis is applied to 1) an assessment of the relative worth of alternative containment-construction activities, site-investigation activities, and monitoring activities available to the owner-operator, 2) an assessment of alternative policy options available to the regulatory agency, and 3) two case histories. Sensitivity analyses designed to address the first issue show that the allocation of resources by the owner-operator is sensitive to the stochastic parameters that describe the hydraulic conductivity field at a site. For the cases analyzed, the installation of a dense monitoring network is of less value to the owner-operator than a more conservative containment design. Sensitivity analyses designed to address the second issue suggest that from a regulatory perspective, design standards should be more effective than performance standards in reducing risk, and design specifications on the containment structure should be more effective than those on the monitoring network. Performance bonds posted before construction have a greater potential to influence design than prospective penalties to be imposed at the time of failure. Sitting on low-conductivity deposits is a more effective method of risk reduction than any form of regulatory influence. Results of the case histories indicate that the methodology can be successfully applied at field sites, and that the risks associated with groundwater contamination may be small when compared to the owner-operators' benefits and costs.Science, Faculty ofEarth, Ocean and Atmospheric Sciences, Department ofGraduat

Development and early evaluation of clinical decision support for long QT syndrome population screening

Aim: Long QT syndrome (LQTS) is an inherited condition that predisposes individuals to prolongation of the QT interval and increased risk for Torsade de Pointes. Pathogenic variants in three genes - KCNH2, KCNQ1 and SCN5A - are responsible for most cases of LQTS, and recent advances in genetic testing have improved knowledge of the disease, increased access to follow-up, and reduced adverse cardiovascular outcomes. Methods: Based around our preemptive genetic screening platform which includes the three long QT genes listed above, we developed and implemented a clinical decision support (CDS) module that alerts prescribers whenever a QT-prolonging medication is ordered for patients with a genetic predisposition to LQTS. Results: Of the 13,777 individuals screened, twenty-seven tested positive for a pathogenic or likely pathogenic variant of KCNH2, KCNQ1 or SCN5A. In a subsequent early evaluation of the CDS and clinical processes, the number of QT-prolonging medications in this cohort decreased by 20% and new QT-prolonging medications were avoided in approximately 1/3 of new prescription orders. Conclusions: While long-term evaluation is needed, early data support the benefit of utilizing CDS in expanded roles, such as drug-gene-disease interactions where rare genetic variants intersect with everyday prescribing

Patient Satisfaction with Return of Pharmacogenomic Results Utilizing a Patient Portal Message - supplementary material

Supporting Materials: Table 1: List of all questions and answer options included in this survey. Figure Supporting Materials 2: Answers to the question: Who contacted you about your Pharmacogenomics (PGx) results? Figure Supporting Materials 3: Answers to the question I was given written information explaining what the results mean to me. Figure Supporting Materials 4: Answers to the question: I was given access to a video explaining what the results mean to me. Figure Supporting Materials 5: Answers to the question: If a friend was interested in having Pharmacogenomics (PGx) testing, how likely are you to recommend they have it done? Figure Supporting Materials 6: Discrete answers to the question: How do you prefer to be contacted with Pharmacogenomics (PGx) results? (Please select all that apply) Figure Supporting Materials 7: Comparison of the text of the PRM sent prior to adjusting the process of sending the message to all panel-based testing patients.</p