Experimental Therapeutics Department, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA.
Clinical Pharmacology Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.
Mil Med. 2021 Dec 30;187(Suppl 1):9-17. doi: 10.1093/milmed/usab481.
Clinical utilization of pharmacogenomics (PGx) testing is highly institutionally dependent, and little information is known about provider practices of PGx testing in the Military Health System (MHS). In this study, we aimed to characterize Clinical Pharmacogenetics Implementation Consortium (CPIC) actionable prescription (Rx) patterns and their temporal relationship with PGx testing in the MHS.
Using data from the Military Health System Management Analysis and Reporting Tool (M2) database, this retrospective cohort study included all patients receiving at least one PGx test and at least one CPIC actionable Rx from January 2015 to August 2020 (845 patients, 1,471 PGx, 7,725 index CPIC actionable Rxs). Rx patterns and temporal relationships with PGx testing were characterized via descriptive statistics. Binomial regression was used to determine which patient and provider characteristics were associated with a patient receiving a PGx test within 30 days of an index Rx.
Patients had a median of 9 index CPIC actionable Rx's (range 1-26). Pain medications were most commonly prescribed (N = 794, 94% patients with at least 1 Rx). However, pain medication had the lowest Rx-PGx match rate (40%) compared to an average of 62% Rx-PGx match rate for all CPIC drugs. Antidepressants were also commonly prescribed (N = 668, 79.1% patients with at least 1 Rx), and antidepressants had the highest Rx-PGx match rate of 86.7%. A minority of providers (20%, N = 249) ordered the majority of PGx tests (86.1%, N = 1,266) and only 8.3% of PGx tests (N = 398) matched to a CPIC actionable drug within 30 days of the test (defined by Rxs ordered within 30 days before or after the PGx test). However, approximately 39.8% of patients (N = 317) had at least one drug match to a PGx test within 30 days. The largest predictor of whether a patient received a PGx test within 30 days of any index Rx was whether or not a specific psychiatry provider ordered the PGx test (odds ratio; OR 3.7, 95% CI 2.13-6.54, P < 0.001). Neither the CPIC level of evidence nor FDA PGx actionable or informative labels had a significant effect on PGx test timing.
PGx testing was generally limited to high Rx-drug users and was found to be an under-utilized resource. PGx testing did not typically follow CPIC guidelines. Implementing PGx testing protocols, simplifying PGx test-ordering by incorporating at minimum CYP2D6, CYP2C19, and CYP2C9 into PGx-testing panels, and unifying providers' PGx knowledgebase in the MHS are feasible and would improve the clinical utilization of PGx tests in the MHS.
临床药理学基因组学（PGx）检测的应用高度依赖于机构，关于医疗保健系统（MHS）中提供者进行 PGx 检测的实践知之甚少。在这项研究中，我们旨在描述临床药物遗传学实施联盟（CPIC）的可操作处方（Rx）模式及其与 MHS 中 PGx 检测的时间关系。
本回顾性队列研究使用来自军事健康系统管理分析和报告工具（M2）数据库的数据，纳入了 2015 年 1 月至 2020 年 8 月期间至少接受过一次 PGx 检测和至少一次 CPIC 可操作 Rx 的所有患者（845 例患者，1471 次 PGx，7725 次 CPIC 可操作 Rx）。通过描述性统计来描述 Rx 模式及其与 PGx 检测的时间关系。使用二项式回归确定哪些患者和提供者特征与患者在接受索引 Rx 后 30 天内接受 PGx 检测相关。
患者的中位数为 9 个索引 CPIC 可操作 Rx（范围为 1-26）。最常开具的是止痛药（N=794，94%的患者至少有 1 种 Rx）。然而，与所有 CPIC 药物平均 62%的 Rx-PGx 匹配率相比，止痛药的 Rx-PGx 匹配率最低（40%）。抗抑郁药也常被开（N=668，79.1%的患者至少有 1 种 Rx），抗抑郁药的 Rx-PGx 匹配率最高（86.7%）。只有少数（20%，N=249）提供者开具了大多数 PGx 检测（86.1%，N=1266），只有 8.3%的 PGx 检测（N=398）在测试后 30 天内（定义为在 PGx 测试前或后 30 天内开具的 Rx）与 CPIC 可操作药物匹配。然而，大约 39.8%的患者（N=317）在 30 天内至少有一种药物与 PGx 检测相匹配。患者在接受任何索引 Rx 后 30 天内接受 PGx 检测的最大预测因素是是否有特定的精神科提供者开具了 PGx 检测（比值比；OR 3.7，95%CI 2.13-6.54，P<0.001）。CPIC 证据水平和 FDA PGx 可操作或信息性标签都没有对 PGx 检测时间产生显著影响。
PGx 检测通常仅限于高 Rx 药物使用者，且被认为是一种未充分利用的资源。PGx 检测通常不符合 CPIC 指南。在 MHS 中实施 PGx 检测方案，通过将 CYP2D6、CYP2C19 和 CYP2C9 至少纳入 PGx 检测组，简化 PGx 检测的开具，以及统一提供者的 PGx 知识库是可行的，这将提高 MHS 中 PGx 检测的临床应用。
