Assessing the Implementation of Pharmacogenomic Panel-Testing in Primary Care in the Netherlands Utilizing a Theoretical Framework
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Setting
2.2. Study Design
2.3. Ethical Approval
2.4. Data Collection: PGx Recommendation Specific Surveys
2.5. Data collection: Pharmacist Specific Survey and Semi-Structured Interviews among Participating Pharmacists
2.6. Data Analysis
3. Results
3.1. Participant Demographics
3.2. PGx Recommendation Specific Surveys
3.3. Interview Findings
3.3.1. Interview Findings: Pharmacist Perceived Remaining Barriers
Unclear Procedures Outside Study Setting
Undetermined Reimbursement for Testing and Consulting
Insufficient Evidence of Clinical Utility for PGx Panel-Testing
Infrastructural Inefficiencies
HCP PGx Knowledge and Awareness
3.3.2. Interview Findings: Pharmacist Perceived Enablers
Perceived Role in Delivering PGx
Believed Effects of PGx
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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Characteristics Interviewed Pharmacist (n = 15) | |
---|---|
Age (years) | |
Mean (SD, range) | 38.5 (9.9, 25–59) |
Gender | |
Female | 53.3% |
Work experience (years) | |
Mean (SD, range) | 12.9 (9.0, 0.5–30.0) |
Role in pharmacy | |
Managing pharmacist | 73.3% |
Supporting pharmacist | 6.7% |
Community pharmacy specialist in training | 20.0% |
Self-reported pharmacogenomic knowledge (scale 1–5) | |
Mean (SD, range) | 3.3 (0.6, 2–4) |
Self-reported belief in effect of pre-emptive pharmacogenomic testing (scale 1–5) | |
Mean (SD, range) | 4.1 (0.6, 3–5) |
Completed PGx e-learning? | |
Yes, completely | 20% |
Yes, partly | 13.3% |
No | 66.7% |
When partly, what section of the e-learning did you complete? | |
The information videos | 13.3% |
Number of recommendations received at time of interview | |
Mean (SD, range) | 3.5 (2.5, 2–11) |
Participation in previous PGx study | |
Yes | 5 (33%) |
Pharmacy characteristics (n = 13) 1 | |
Number of patients | |
<5000 | 7.7% |
5000–7500 | - |
7500–10,000 | 46.2% |
>10,000 | 46.2% |
Full-time equivalents of pharmacists | |
≤1 FTE | 30.8% |
>1 and ≤2 FTE | 61.5% |
>2 and ≤3 FTE | 7.7% |
Pharmacy organization | |
Independent | 23.1% |
Franchise | 23.1% |
Pharmacy group | 53.8% |
Located in a healthcare center? | |
Yes | 38.5% |
Top 5 drugs for which actionable recommendations were received by interviewed pharmacists | |
Simvastatin | 25 (27.2%) |
Metoprolol | 22 (23.9%) |
Tramadol | 11 (12.0%) |
Amitriptyline | 8 (8.7%) |
Atorvastatin | 5 (5.4%) |
Shared Decision Making | |
---|---|
Did you discuss the pharmacogenomic recommendation with the treating physician? | |
Yes | 77.2% |
No | 18.5% |
Missing | 4.3% |
Do you agree to the final treatment decision/change that was made based on your PGx-guided recommendation? | |
Yes | 82.6% |
No | 2.2% |
Missing | 15.2% |
Why do you disagree? (n = 2) “I would have preferred to alter the drug but the patient had already initiated it and therefore I preferred not to alter it”; “The patient was already set on a dose of metoprolol and therefore I preferred not adjusting it” | |
Report of results to the patient | |
Who discussed the results of the PGx recommendation with the patient? | |
Pharmacist | 56.5% |
Pharmacy technician | 3.3% |
Treating physician | 15.2% |
Result was to be reported at the time of interview | 20.7% |
Missing | 4.4% |
Time allocation | |
Approximately how much time did you spend on handling this recommendation? | |
Mean number of minutes (SD) | 18.6 (13.1) |
Range | 3–90 |
Missing | 10 |
Interview Findings: Pharmacist Perceived Remaining Barriers |
---|
(1) Unclear procedures outside the study setting (individual health professional factors; capacity for organizational change) |
“No, I don’t know how to [request a test]. There seems to be some kind of system where you can order tests electronically, but I don’t have access to it anyway.” (P3:16) “Officially, a prescriber still has to request it and that is particularly irritating. I just want to arrange [requesting tests] myself.” (P12:9) “Can the pharmacist also request [PGx tests]? I have to say that the reimbursement policy is really unknown to me.” (P15:23) “... if there was clarity about reimbursement, what does it cost, which patients are eligible—sort of practical guidelines, that would be really useful.” (P14:16) “Requesting a test wasn’t really complicated at all. However, it is still unclear what [genes] to request; do we request the full profile or are you going to request one gene specifically?” (P5:38) “Well I know I can request a gene test in Leiden. If I request in Rotterdam, then the whole panel is tested. But how to make those choices, that is unclear to me.” (P10:30) |
(2) Undetermined reimbursement for test and consult (incentives and resources; social political and legal factors) |
“I don’t mind [the lack of reimbursement] in the experimental phase, but at a certain point, if it becomes more daily practice, then I think there must be something to compensate for [our time].” (P8:43) “If it starts becoming routine practice, then yes, I would think it would be logical to receive compensation for the consultation—that our time is reimbursed by the insurance.” (P9:28) “Well, what I really find a major obstacle is that we are not compensated for the consultations. When I look at how much energy we invest here, we get nothing at all for it. I think that is really a major obstacle because that is not feasible of course.” (P12:39) |
(3) Insufficient evidence of clinical utility for PGx panel-testing (guideline factors) |
“I still think so, yes, research has to show if it is at all cost-effective.” (P1:23) “The insurer is only thinking about cost-benefit ratios. So we should show that its cost-effective or cost-saving so that patients do not receive ineffective means. But of course, we hope to demonstrate that in the PREPARE study. Nonetheless, those [genetic testing] prices really have to really go down.” (P12:21) “We are still implementing in a research context, and investigating its added value. Similarly to implementing a new drug, it has to have demonstrated added value before prescribing it in the clinic. They must first prove that first.” (P5:53) |
(4) Infrastructure inefficiencies (guideline factors; incentives and resources) |
“Well, I think it’s really important that clear and practical guidelines are incorporated into our EMR.” (P15:26) “Not all recommendations are very clearly interpretable.” (P3:2) “The DPWG recommendations really help a lot, even though they are not always very clear. So for example ‘avoid clopidogrel’, well with TIA you do not have many alternatives than clopidogrel, and dipyridamole is unavailable at the moment - sometimes I want the guidelines to be more concrete.” (P15:9) “Well, what I find the biggest obstacle is the limited automation in the pharmacy system.” (P11:37) “The best thing would be if we received the data from the LSP from the lab, of course.” (P13:32) |
(5) Healthcare Professional pharmacogenomics knowledge and awareness (professional interactions; individual health professional factors:) |
“Well, I don’t think it’s very nice to say, but the GPs don’t know anything about it” (P5:15) “I notice that the GPs are not interested in the details, they want to act upon the results but are not interested in anything with CYPs, that’s my perception” (P12:13) “It really depends on the medical specialty, whether [PGx] is of interest to them. For example, the psychiatrists know quite a bit about [PGx], but I know how generalizable this is. On the other hand, I know a patient who was very proud of their PGx profile and showed it to their cardiologist, who had absolutely no idea what it was” (P8:31) |
Interview Findings: Pharmacist Perceived Enablers |
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(1) Perceived role in delivering PGx (incentives and resources; professional interactions; capacity for organizational change; social political and legal factors) |
Request PGx test “Now and then GPs call me to ask whether requesting a PGx test for particular patients is useful.” (P1:17) “The GPs are just really busy, so I think they appreciate that we take PGx upon us.” (P12:12) “I notice that the GPs really want the [PGx] information but they think it is fine if we request the tests. They have even provided us with a signed empty [requesting] form, and let us fill in what [PGx] tests we need. That has happened twice now.” (P12:14) Acting upon PGx test and reporting to patients “We have a very important role because we should know most about it, at least in primary care.” (P4:37) “[PGx testing] really is the task of the pharmacist because we are in the world of contraindications, interactions, and medication surveillance” (P10:26) “The collaboration [with the GPs] is really good, but they think ‘this has something to do with the liver and can cause intoxications or ineffective plasma levels, you know what‒this is your thing.” (P11:19) “I feel that when I have done all the preparatory work, then its fun to report the results to the patient. Especially when its something simple like “you will be getting another statin.” (P2:11) Follow-up “I feel the follow-up should be a shared responsibility between pharmacist and GP. If the pharmacotherapy has changed as a result of PGx, then both GP and pharmacist should be monitoring how things are going.” (P3:10) |
(2) Believed effects of PGx (individual health professional factors; patient factors) |
Pharmacotherapy improvement “Being able to select those patients at higher risk for adverse drug events before initiating the drug, that is very beneficial” (P13:17) “I think [PGx] may improve drug adherence, I think so.” (P6:25) “I think [PGx] will prevent a lot of healthcare costs related to hospital admissions.” (P15:31) “[testing diagnostically] may not always give a definitive answer, but at least we will be able to cross-out genetics as being the cause [of the adverse event].” (P5:31) “We are now able to fine-tune pharmacotherapy.” (P3:20) “I don’t know if we are saving lives with it, but [PGx] is beneficial and fun.” (P2:50) Pharmacist added value and learning by doing “[PGx] is a great opportunity for pharmacists to show what we can do because a lot of people really don’t know that” (P8:38) “[PGx] makes [pharmacist value] transparent for patients: What does the pharmacist actually do? What is the value of a pharmacy?” (P6:5) “[PGx] gives a really good feeling. This is what I do this profession for.” (P11:15) “This [added value] is the reason why I wanted to participate in this study because I want some experience with PGx testing, for the GPs too” (P7:33) “The more [actionable PGx] interactions you encounter, the easier it becomes.” (P7:20) Professional interaction improvement “[PGx] brings you closer to patients, which really is an added value, and also to the GPs. So I really enjoy doing it.” (P2:56) “[PGx] can give patients a certain feeling of trust in their medication when we say we are going to test your DNA to see if the medication fits your profile, then patients trust it more to start taking it.” (P6:26) “[PGx] confirms what the patient most of the time already knows.” (P1:24) |
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van der Wouden, C.H.; Paasman, E.; Teichert, M.; Crone, M.R.; Guchelaar, H.-J.; Swen, J.J. Assessing the Implementation of Pharmacogenomic Panel-Testing in Primary Care in the Netherlands Utilizing a Theoretical Framework. J. Clin. Med. 2020, 9, 814. https://doi.org/10.3390/jcm9030814
van der Wouden CH, Paasman E, Teichert M, Crone MR, Guchelaar H-J, Swen JJ. Assessing the Implementation of Pharmacogenomic Panel-Testing in Primary Care in the Netherlands Utilizing a Theoretical Framework. Journal of Clinical Medicine. 2020; 9(3):814. https://doi.org/10.3390/jcm9030814
Chicago/Turabian Stylevan der Wouden, Cathelijne H., Ellen Paasman, Martina Teichert, Matty R. Crone, Henk-Jan Guchelaar, and Jesse J. Swen. 2020. "Assessing the Implementation of Pharmacogenomic Panel-Testing in Primary Care in the Netherlands Utilizing a Theoretical Framework" Journal of Clinical Medicine 9, no. 3: 814. https://doi.org/10.3390/jcm9030814