Clinician Perspectives on Using Pharmacogenomics in Clinical Practice

Abstract

Aim To describe the knowledge and attitudes of clinicians participating in a large pharmacogenomics implementation program. Materials & methods Semi-structured interviews with 15 physicians and nurse practitioners were conducted. Results Three categories of themes were identified: preparation and knowledge, pharmacogenomics usage in practice, and future management of genomic variants. Providers expressed an inability to keep up with the rapid pace of evidence generation and indicated strong support for clinical decision support to assist with genotype-tailored therapies. Concerns raised by clinicians included effectively communicating results, long-term responsibility for actionable results and hand-offs with providers outside the implementation program. Conclusions Clinicians identified their own knowledge deficits, workflow integration, and longitudinal responsibility as challenges to successful usage of pharmacogenomics in clinical practice.

Physician response to implementation of genotype‐tailored antiplatelet therapy

“…Clinicians were likely cautioned by the increased number of serious bleeding events in the prasugrel arm of TRITON‐TIMI 38 among patients 75 and older, which was also reinforced by the program's communication of relative contraindications to prasugrel when present. Other physician‐specific factors have been elicited using survey and interview data published separately but obtained from the same population of clinicians . In these studies, some cardiologists expressed uncertainty around the clinical significance of the intermediate metabolizer status and the lack of randomized controlled trial data to support the use of CYP2C19 to tailor antiplatelet therapy.…”

“…Clinician barriers to following program advice have been previously reported using both survey and qualitative methodologies. Clinicians expressed difficulties with understanding the established pharmacogenomics nomenclature, concerns for patient noncompliance related to the higher out‐of‐pocket costs for prasugrel or ticagrelor compared to clopidogrel, and confusion surrounding the clinical responsibility for the diverse components of a pharmacogenomics panel test …”

“…Other physician-specific factors have been elicited using survey and interview data published separately but obtained from the same population of clinicians. 27,28 In these studies, some cardiologists expressed uncertainty around the clinical significance of the intermediate metabolizer status and the lack of randomized controlled trial data to support the use of CYP2C19 to tailor antiplatelet therapy. Additionally, physicians cited the cost of ticagrelor and prasugrel as a barrier to switching patients who could not afford the higher copay.…”

“…Clinicians expressed difficulties with understanding the established pharmacogenomics nomenclature, concerns for patient noncompliance related to the higher out-of-pocket costs for prasugrel or ticagrelor compared to clopidogrel, and confusion surrounding the clinical responsibility for the diverse components of a pharmacogenomics panel test. 27,28 As a quality improvement program, prescription alterations were determined from electronic records and, when absent due to loss of follow-up, the patient was censored at the time of the last record. Rates of genotype-tailored therapy may be underestimated, as prescription changes that occurred outside of the VUMC electronic prescribing system were not recorded.…”

A Review of Consent Practices and Perspectives for Pharmacogenetic testing

“…For example, a discussion about testing may not be viewed by patients with the same gravitas as a signed consent form, or patients may fail to recognize it as part of the consent process [62]. Also, the information disclosed in patient-provider discussion may vary substantially due to providers' knowledge [63][64][65][66], so provider education is essential and discussion tips may help standardize discussions. We identified only one guideline on the use of the HER-2 testing that included talking points for discussing test results, but it did not address pretesting communication and consent [67].…”