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J. Pers. Med., Volume 4, Issue 2 (June 2014), Pages 115-296

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Research

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Open AccessArticle Formative Evaluation of Clinician Experience with Integrating Family History-Based Clinical Decision Support into Clinical Practice
J. Pers. Med. 2014, 4(2), 115-136; doi:10.3390/jpm4020115
Received: 10 December 2013 / Revised: 1 March 2014 / Accepted: 3 March 2014 / Published: 26 March 2014
Cited by 8 | PDF Full-text (1039 KB) | HTML Full-text | XML Full-text
Abstract
Family health history is a leading predictor of disease risk. Nonetheless, it is underutilized to guide care and, therefore, is ripe for health information technology intervention. To fill the family health history practice gap, Cleveland Clinic has developed a family health history [...] Read more.
Family health history is a leading predictor of disease risk. Nonetheless, it is underutilized to guide care and, therefore, is ripe for health information technology intervention. To fill the family health history practice gap, Cleveland Clinic has developed a family health history collection and clinical decision support tool, MyFamily. This report describes the impact and process of implementing MyFamily into primary care, cancer survivorship and cancer genetics clinics. Ten providers participated in semi-structured interviews that were analyzed to identify opportunities for process improvement. Participants universally noted positive effects on patient care, including increases in quality, personalization of care and patient engagement. The impact on clinical workflow varied by practice setting, with differences observed in the ease of integration and the use of specific report elements. Tension between the length of the report and desired detail was appreciated. Barriers and facilitators to the process of implementation were noted, dominated by the theme of increased integration with the electronic medical record. These results fed real-time improvement cycles to reinforce clinician use. This model will be applied in future institutional efforts to integrate clinical genomic applications into practice and may be useful for other institutions considering the implementation of tools for personalizing medical management. Full article
(This article belongs to the Special Issue Bringing Personalized Medicine into Clinical Practice 2013)
Open AccessArticle Genetically Guided Statin Therapy on Statin Perceptions, Adherence, and Cholesterol Lowering: A Pilot Implementation Study in Primary Care Patients
J. Pers. Med. 2014, 4(2), 147-162; doi:10.3390/jpm4020147
Received: 19 December 2013 / Revised: 4 March 2014 / Accepted: 17 March 2014 / Published: 27 March 2014
Cited by 3 | PDF Full-text (654 KB) | HTML Full-text | XML Full-text | Supplementary Files
Abstract
Statin adherence is often limited by side effects. The SLCO1B1*5 variant is a risk factor for statin side effects and exhibits statin-specific effects: highest with simvastatin/atorvastatin and lowest with pravastatin/rosuvastatin. The effects of SLCO1B1*5 genotype guided statin therapy (GGST) are unknown. Primary [...] Read more.
Statin adherence is often limited by side effects. The SLCO1B1*5 variant is a risk factor for statin side effects and exhibits statin-specific effects: highest with simvastatin/atorvastatin and lowest with pravastatin/rosuvastatin. The effects of SLCO1B1*5 genotype guided statin therapy (GGST) are unknown. Primary care patients (n = 58) who were nonadherent to statins and their providers received SLCO1B1*5 genotyping and guided recommendations via the electronic medical record (EMR). The primary outcome was the change in Beliefs about Medications Questionnaire, which measured patients’ perceived needs for statins and concerns about adverse effects, measured before and after SLCO1B1*5 results. Concurrent controls (n = 59) were identified through the EMR to compare secondary outcomes: new statin prescriptions, statin utilization, and change in LDL-cholesterol (LDL-c). GGST patients had trends (p = 0.2) towards improved statin necessity and concerns. The largest changes were the “need for statin to prevent sickness” (p < 0.001) and “concern for statin to disrupt life” (p = 0.006). GGST patients had more statin prescriptions (p < 0.001), higher statin use (p < 0.001), and greater decrease in LDL-c (p = 0.059) during follow-up. EMR delivery of SLCO1B1*5 results and recommendations is feasible in the primary care setting. This novel intervention may improve patients’ perceptions of statins and physician behaviors that promote higher statin adherence and lower LDL-c. Full article
(This article belongs to the Special Issue Bringing Personalized Medicine into Clinical Practice 2013)
Open AccessArticle Personalized Medicine’s Bottleneck: Diagnostic Test Evidence and Reimbursement
J. Pers. Med. 2014, 4(2), 163-175; doi:10.3390/jpm4020163
Received: 25 November 2013 / Revised: 8 March 2014 / Accepted: 26 March 2014 / Published: 4 April 2014
Cited by 8 | PDF Full-text (735 KB) | HTML Full-text | XML Full-text | Supplementary Files
Abstract
Background: Personalized medicine is gradually emerging as a transformative field. Thus far, seven co-developed drug-diagnostic combinations have been approved and several dozen post-hoc drug-diagnostic combinations (diagnostic approved after the drug). However, barriers remain, particularly with respect to reimbursement. Purpose, methods: This study [...] Read more.
Background: Personalized medicine is gradually emerging as a transformative field. Thus far, seven co-developed drug-diagnostic combinations have been approved and several dozen post-hoc drug-diagnostic combinations (diagnostic approved after the drug). However, barriers remain, particularly with respect to reimbursement. Purpose, methods: This study analyzes barriers facing uptake of drug-diagnostic combinations. We examine Medicare reimbursement in the U.S. of 10 drug-diagnostic combinations on the basis of a formulary review and a survey. Findings: We found that payers reimburse all 10 drugs, but with variable and relatively high patient co-insurance, as well as imposition of formulary restrictions. Payer reimbursement of companion diagnostics is limited and highly variable. In addition, we found that the body of evidence on the clinical- and cost-effectiveness of therapeutics is thin and even less robust for diagnostics. Conclusions, discussion: The high cost of personalized therapeutics and dearth of evidence concerning the comparative clinical effectiveness of drug-diagnostic combinations appear to contribute to high patient cost sharing, imposition of formulary restrictions, and limited and variable reimbursement of companion diagnostics. Our findings point to the need to increase the evidence base supportive of establishing linkage between diagnostic testing and positive health outcomes. Full article
(This article belongs to the Special Issue Bringing Personalized Medicine into Clinical Practice 2013)
Open AccessArticle Impact of Information Technology on the Therapy of Type-1 Diabetes: A Case Study of Children and Adolescents in Germany
J. Pers. Med. 2014, 4(2), 200-217; doi:10.3390/jpm4020200
Received: 13 January 2014 / Revised: 26 March 2014 / Accepted: 1 April 2014 / Published: 16 April 2014
Cited by 1 | PDF Full-text (1244 KB) | HTML Full-text | XML Full-text
Abstract
Being able to manage and adjust insulin doses is a key part of managing type-1 diabetes. Children and adolescents with type-1 diabetes mellitus often have serious difficulties with this dosage adjustment. Therefore, this paper aims to investigate the impact of using novel [...] Read more.
Being able to manage and adjust insulin doses is a key part of managing type-1 diabetes. Children and adolescents with type-1 diabetes mellitus often have serious difficulties with this dosage adjustment. Therefore, this paper aims to investigate the impact of using novel mobile, web and communication technologies in assisting their therapy and treatment. A trial was conducted in the north-eastern part of Germany to evaluate the impact of the “Mobil Diab”, a mobile diabetes management system, on the clinical outcome. 68 subjects aged between 8 and 18 years, divided randomly into control and intervention groups, were included into the study. Metrics such as changes in the quality of metabolic control, changes in psychological parameters, usability and acceptance of the technology were used for evaluation purpose. Metabolic control was mainly assessed by the mean HbAlc. Analysis showed a good acceptance of the proposed system. An overall improvement in mean levels of HbA1c was observed, however further studies will be conducted to prove evidence of the weight and BMI improvements. Moreover, initial indications of positive impact on the improvement in psychological parameters were presumed based on the result of the conducted study. The system appeared to be an efficient and time saving tool in diabetes management. Full article
(This article belongs to the Special Issue Mobile Health)
Open AccessArticle Knowledge, Attitudes and Referral Patterns of Lynch Syndrome: A Survey of Clinicians in Australia
J. Pers. Med. 2014, 4(2), 218-244; doi:10.3390/jpm4020218
Received: 27 November 2013 / Revised: 24 April 2014 / Accepted: 25 April 2014 / Published: 12 May 2014
Cited by 1 | PDF Full-text (2408 KB) | HTML Full-text | XML Full-text
Abstract
This study assessed Australian clinicians’ knowledge, attitudes and referral patterns of patients with suspected Lynch syndrome for genetic services. A total of 144 oncologists, surgeons, gynaecologists, general practitioners and gastroenterologists from the Australian Medical Association and Clinical Oncology Society responded to a [...] Read more.
This study assessed Australian clinicians’ knowledge, attitudes and referral patterns of patients with suspected Lynch syndrome for genetic services. A total of 144 oncologists, surgeons, gynaecologists, general practitioners and gastroenterologists from the Australian Medical Association and Clinical Oncology Society responded to a web-based survey. Most respondents demonstrated suboptimal knowledge of Lynch syndrome. Male general practitioners who have been practicing for ≥10 years were less likely to offer genetic referral than specialists, and many clinicians did not recognize that immunohistochemistry testing is not a germline test. Half of all general practitioners did not actually refer patients in the past 12 months, and 30% of them did not feel that their role is to identify patients for genetic referral. The majority of clinicians considered everyone to be responsible for making the initial referral to genetic services, but a small preference was given to oncologists (15%) and general practitioners (13%). Patient information brochures, continuing genetic education programs and referral guidelines were favoured as support for practice. Targeted education interventions should be considered to improve referral. An online family history assessment tool with built-in decision support would be helpful in triaging high-risk individuals for pathology analysis and/or genetic assessment in general practice. Full article
(This article belongs to the Special Issue Bringing Personalized Medicine into Clinical Practice 2013)
Open AccessArticle Differential Transcriptome Profile of Peripheral White Cells to Identify Biomarkers Involved in Oxaliplatin Induced Neuropathy
J. Pers. Med. 2014, 4(2), 282-296; doi:10.3390/jpm4020282
Received: 25 March 2014 / Revised: 21 May 2014 / Accepted: 28 May 2014 / Published: 5 June 2014
Cited by 1 | PDF Full-text (693 KB) | HTML Full-text | XML Full-text | Supplementary Files
Abstract
Anticancer chemotherapy (CT) produces non-desirable effects on normal healthy cells and tissues. Oxaliplatin is widely used in the treatment of colorectal cancer and responsible for the development of sensory neuropathy in varying degrees, from complete tolerance to chronic neuropathic symptoms. We studied [...] Read more.
Anticancer chemotherapy (CT) produces non-desirable effects on normal healthy cells and tissues. Oxaliplatin is widely used in the treatment of colorectal cancer and responsible for the development of sensory neuropathy in varying degrees, from complete tolerance to chronic neuropathic symptoms. We studied the differential gene expression of peripheral leukocytes in patients receiving oxaliplatin-based chemotherapy to find genes and pathways involved in oxaliplatin-induced peripheral neuropathy. Circulating white cells were obtained prior and after three cycles of FOLFOX or CAPOX chemotherapy from two groups of patients: with or without neuropathy. RNA was purified, and transcriptomes were analyzed. Differential transcriptomics revealed a total of 502 genes, which were significantly up- or down-regulated as a result of chemotherapy treatment. Nine of those genes were expressed in only one of two situations: CSHL1, GH1, KCMF1, IL36G and EFCAB8 turned off after CT, and CSRP2, IQGAP1, GNRH2, SMIM1 and C5orf17 turned on after CT. These genes are likely to be associated with the onset of oxaliplatin-induced peripheral neuropathy. The quantification of their expression in peripheral white cells may help to predict non-desirable side effects and, consequently, allow a better, more personalized chemotherapy. Full article
(This article belongs to the Special Issue Personalized Cancer Therapy)
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Review

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Open AccessReview Human Centred Design Considerations for Connected Health Devices for the Older Adult
J. Pers. Med. 2014, 4(2), 245-281; doi:10.3390/jpm4020245
Received: 20 February 2014 / Revised: 23 April 2014 / Accepted: 6 May 2014 / Published: 4 June 2014
Cited by 6 | PDF Full-text (1960 KB) | HTML Full-text | XML Full-text
Abstract
Connected health devices are generally designed for unsupervised use, by non-healthcare professionals, facilitating independent control of the individuals own healthcare. Older adults are major users of such devices and are a population significantly increasing in size. This group presents challenges due to [...] Read more.
Connected health devices are generally designed for unsupervised use, by non-healthcare professionals, facilitating independent control of the individuals own healthcare. Older adults are major users of such devices and are a population significantly increasing in size. This group presents challenges due to the wide spectrum of capabilities and attitudes towards technology. The fit between capabilities of the user and demands of the device can be optimised in a process called Human Centred Design. Here we review examples of some connected health devices chosen by random selection, assess older adult known capabilities and attitudes and finally make analytical recommendations for design approaches and design specifications. Full article
(This article belongs to the Special Issue Mobile Health)

Other

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Open AccessCommentary Ethics, Evidence and Economics in the Pursuit of “Personalized Medicine”
J. Pers. Med. 2014, 4(2), 137-146; doi:10.3390/jpm4020137
Received: 2 December 2013 / Revised: 17 February 2014 / Accepted: 21 February 2014 / Published: 27 March 2014
Cited by 2 | PDF Full-text (502 KB) | HTML Full-text | XML Full-text
Abstract
Despite enthusiastic advocacy for what personalized medicine might be able to deliver and major investments into the development of this, there remain disappointingly few examples of personalized medicine in routine clinical practice today, particularly in high areas of unmet need such as [...] Read more.
Despite enthusiastic advocacy for what personalized medicine might be able to deliver and major investments into the development of this, there remain disappointingly few examples of personalized medicine in routine clinical practice today, particularly in high areas of unmet need such as cancer. We believe that this is because personalized medicine challenges the moral, economic and epistemological foundations of medicine. In this article, we briefly describe the scientific premises underpinning personalized medicine, contrast these with traditional paradigms of drug development, and then consider the ethical, economic and epistemological implications of this approach to medicine. Full article
(This article belongs to the Special Issue Bringing Personalized Medicine into Clinical Practice 2013)
Open AccessConcept Paper A Proposed Clinical Decision Support Architecture Capable of Supporting Whole Genome Sequence Information
J. Pers. Med. 2014, 4(2), 176-199; doi:10.3390/jpm4020176
Received: 11 December 2013 / Revised: 22 February 2014 / Accepted: 14 March 2014 / Published: 4 April 2014
Cited by 4 | PDF Full-text (629 KB) | HTML Full-text | XML Full-text
Abstract
Whole genome sequence (WGS) information may soon be widely available to help clinicians personalize the care and treatment of patients. However, considerable barriers exist, which may hinder the effective utilization of WGS information in a routine clinical care setting. Clinical decision support [...] Read more.
Whole genome sequence (WGS) information may soon be widely available to help clinicians personalize the care and treatment of patients. However, considerable barriers exist, which may hinder the effective utilization of WGS information in a routine clinical care setting. Clinical decision support (CDS) offers a potential solution to overcome such barriers and to facilitate the effective use of WGS information in the clinic. However, genomic information is complex and will require significant considerations when developing CDS capabilities. As such, this manuscript lays out a conceptual framework for a CDS architecture designed to deliver WGS-guided CDS within the clinical workflow. To handle the complexity and breadth of WGS information, the proposed CDS framework leverages service-oriented capabilities and orchestrates the interaction of several independently-managed components. These independently-managed components include the genome variant knowledge base, the genome database, the CDS knowledge base, a CDS controller and the electronic health record (EHR). A key design feature is that genome data can be stored separately from the EHR. This paper describes in detail: (1) each component of the architecture; (2) the interaction of the components; and (3) how the architecture attempts to overcome the challenges associated with WGS information. We believe that service-oriented CDS capabilities will be essential to using WGS information for personalized medicine. Full article
(This article belongs to the Special Issue Bringing Personalized Medicine into Clinical Practice 2013)

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