scholarly journals Preemptive pharmacogenetic testing to guide chemotherapy dosing in patients with gastrointestinal malignancies: a qualitative study of barriers to implementation

BMC Cancer ◽  
2022 ◽  
Vol 22 (1) ◽  
Author(s):  
Kelsey S. Lau-Min ◽  
Lisa A. Varughese ◽  
Maria N. Nelson ◽  
Christine Cambareri ◽  
Nandi J. Reddy ◽  
...  
Keyword(s):  
Qualitative Study ◽  
Medical Center ◽  
Clinical Care ◽  
Insurance Coverage ◽  
Academic Medical Center ◽  
Clinical Effectiveness ◽  
Structured Interview ◽  
Evidence Base ◽  
Routine Practice ◽  
Gastrointestinal Malignancies

Abstract Background Pharmacogenetic (PGx) testing for germline variants in the DPYD and UGT1A1 genes can be used to guide fluoropyrimidine and irinotecan dosing, respectively. Despite the known association between PGx variants and chemotherapy toxicity, preemptive testing prior to chemotherapy initiation is rarely performed in routine practice. Methods We conducted a qualitative study of oncology clinicians to identify barriers to using preemptive PGx testing to guide chemotherapy dosing in patients with gastrointestinal malignancies. Each participant completed a semi-structured interview informed by the Consolidated Framework for Implementation Research (CFIR). Interviews were analyzed using an inductive content analysis approach. Results Participants included sixteen medical oncologists and nine oncology pharmacists from one academic medical center and two community hospitals in Pennsylvania. Barriers to the use of preemptive PGx testing to guide chemotherapy dosing mapped to four CFIR domains: intervention characteristics, outer setting, inner setting, and characteristics of individuals. The most prominent themes included 1) a limited evidence base, 2) a cumbersome and lengthy testing process, and 3) a lack of insurance coverage for preemptive PGx testing. Additional barriers included clinician lack of knowledge, difficulty remembering to order PGx testing for eligible patients, challenges with PGx test interpretation, a questionable impact of preemptive PGx testing on clinical care, and a lack of alternative therapeutic options for some patients found to have actionable PGx variants. Conclusions Successful adoption of preemptive PGx-guided chemotherapy dosing in patients with gastrointestinal malignancies will require a multifaceted effort to demonstrate clinical effectiveness while addressing the contextual factors identified in this study.

Clinician perspectives on preemptive pharmacogenetic testing to guide chemotherapy dosing in patients with gastrointestinal malignancies.

2021 ◽  
Vol 39 (3_suppl) ◽  
pp. 54-54
Author(s):  
Kelsey S. Lau-Min ◽  
Lisa A. Varughese ◽  
Maria N. Nelson ◽  
Christine Cambareri ◽  
Nandi J. Reddy ◽  
...  
Keyword(s):  
Electronic Health Record ◽  
Medical Center ◽  
Academic Medical Center ◽  
Structured Interview ◽  
Routine Practice ◽  
Health Record ◽  
Theory Approach ◽  
Test Results ◽  
Gastrointestinal Malignancies ◽  
Electronic Health

54 Background: Pharmacogenetic (PGx) testing for germline variants in the DPYD and UGT1A1 genes can be used to guide fluoropyrimidine and irinotecan dosing, respectively. Despite the known association between PGx variants and chemotherapy toxicity, preemptive testing prior to chemotherapy initiation is rarely performed in routine practice. Methods: We conducted a multi-site mixed-methods study to understand clinician attitudes toward PGx testing and to identify facilitators and barriers to using preemptive testing to guide chemotherapy dosing in patients with gastrointestinal malignancies. Each participant completed a demographic survey and semi-structured interview informed by the Consolidated Framework for Implementation Research. Interviews were analyzed using a modified grounded theory approach. Results: A total of 16 medical oncologists and 9 oncology pharmacists from one academic medical center and two community hospitals participated. Fifteen (60%) participants reported feeling comfortable or very comfortable with interpreting PGx test results. While clinicians expressed generally favorable attitudes toward PGx testing, many were hesitant to use it to preemptively guide chemotherapy dosing due to a perceived lack of evidence for this practice. They cited a lack of consensus chemotherapy dosing recommendations in response to PGx test results, as well as concerns about decreased drug efficacy, especially in patients treated with curative intent. Additional barriers included 1) a low prevalence of actionable PGx variants; 2) lengthy PGx test turnaround time; 3) concerns about testing costs and lack of insurance coverage; and 4) burdensome integration of PGx testing into clinical workflows. The electronic health record emerged as a potential tool for the unobtrusive integration of PGx testing into clinical practice–suggested applications included default PGx test orders for eligible patients, discrete reporting of PGx variant results, and clinical decision support to guide subsequent chemotherapy dosing. Conclusions: Successful adoption of preemptive PGx-guided chemotherapy dosing in patients with gastrointestinal malignancies will require a multi-level effort to demonstrate clinical effectiveness while addressing the contextual factors identified in this study. The electronic health record should be explored as a tool to integrate PGx testing into routine practice.

scholarly journals Physician experiences of screen-level features in a prominent electronic health record: Design recommendations from a qualitative study

2021 ◽  
Vol 27 (1) ◽  
pp. 146045822199791
Author(s):  
Saif Khairat ◽  
Cameron Coleman ◽  
Randall Teal ◽  
Salma Rezk ◽  
Victoria Rand ◽  
...  
Keyword(s):  
Information Retrieval ◽  
Qualitative Study ◽  
Medical Center ◽  
Academic Medical Center ◽  
Clinical Information ◽  
Structured Interview ◽  
Management Tool ◽  
End User ◽  
Physician Perceptions ◽  
Screen Level

The goal of this qualitative study was to assess physicians’ perceptions around features of key screens within a prominent commercial EHR, and to solicit end-user recommendations for improved retrieval of high-priority clinical information. We conducted a qualitative, descriptive study of 25 physicians in a medical ICU setting. at a tertiary academic medical center. An in-depth, semi-structured interview guide was developed to elicit physician perceptions on information retrieval as well as favorable and unfavorable features of specific EHR screens. Transcripts were independently coded in a qualitative software management tool by at least two trained coders using a common code book. We successfully obtained vendor permission to map physicians perception’s on full Epic© screenshots. Among the 25 physician participants (13 female; 5 attending physicians, 9 fellows, 11 residents), the majority of participants reported experiencing challenges finding clinical information in the EHR. We present the most favorable and unfavorable screen-level features for four central EHR screens: Flowsheet, Notes/Chart Review, Results Review, and Vital Signs. We also compiled participants’ recommendations for a comprehensive EHR dashboard screen to better support clinical workflow and information retrieval in the medical ICU through User-Centered Design. ICU physicians demonstrated a mix of positive and negative attitudes toward specific screen-level features in a major vendor-based EHR system. Physician perceptions of information overload emerged as a theme across multiple EHR screens. Our findings underscore the importance of qualitative research and end-user feedback in EHR software design and interface optimization at both the vendor and institutional level.

scholarly journals Risk factors associated with physician trainee concern over missed educational opportunities during the COVID-19 pandemic

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Sunny S. Lou ◽  
Charles W. Goss ◽  
Bradley A. Evanoff ◽  
Jennifer G. Duncan ◽  
Thomas Kannampallil
Keyword(s):  
Risk Factors ◽  
Clinical Education ◽  
Medical Center ◽  
Clinical Care ◽  
Academic Medical Center ◽  
Clinical Work ◽  
Educational Opportunities ◽  
Missed Opportunities ◽  
Physician Trainee ◽  
At Home

Abstract Background The COVID-19 pandemic resulted in a transformation of clinical care practices to protect both patients and providers. These changes led to a decrease in patient volume, impacting physician trainee education due to lost clinical and didactic opportunities. We measured the prevalence of trainee concern over missed educational opportunities and investigated the risk factors leading to such concerns. Methods All residents and fellows at a large academic medical center were invited to participate in a web-based survey in May of 2020. Participants responded to questions regarding demographic characteristics, specialty, primary assigned responsibility during the previous 2 weeks (clinical, education, or research), perceived concern over missed educational opportunities, and burnout. Multivariable logistic regression was used to assess the relationship between missed educational opportunities and the measured variables. Results 22% (301 of 1375) of the trainees completed the survey. 47% of the participants were concerned about missed educational opportunities. Trainees assigned to education at home had 2.85 [95%CI 1.33–6.45] greater odds of being concerned over missed educational opportunities as compared with trainees performing clinical work. Trainees performing research were not similarly affected [aOR = 0.96, 95%CI (0.47–1.93)]. Trainees in pathology or radiology had 2.51 [95%CI 1.16–5.68] greater odds of concern for missed educational opportunities as compared with medicine. Trainees with greater concern over missed opportunities were more likely to be experiencing burnout (p = 0.038). Conclusions Trainees in radiology or pathology and those assigned to education at home were more likely to be concerned about their missed educational opportunities. Residency programs should consider providing trainees with research or at home clinical opportunities as an alternative to self-study should future need for reduced clinical hours arise.

scholarly journals Preparing Clinical Text for Use in Biomedical Research

2011 ◽  
pp. 2085-2095
Author(s):  
John P. Pestian ◽  
Lukasz Itert ◽  
Charlotte Andersen
Keyword(s):  
Language Processing ◽  
Medical Center ◽  
Clinical Care ◽  
Academic Medical Center ◽  
Clinical Text ◽  
Delivery Of Care ◽  
Radiology Reports ◽  
Academic Medical ◽  
Textual Data ◽  
Regulatory Actions

Approximately 57 different types of clinical annotations construct a patient’s medical record. These annotations include radiology reports, discharge summaries, and surgical and nursing notes. Hospitals typically produce millions of text-based medical records over the course of a year. These records are essential for the delivery of care, but many are underutilized or not utilized at all for clinical research. The textual data found in these annotations is a rich source of insights into aspects of clinical care and the clinical delivery system. Recent regulatory actions, however, require that, in many cases, data not obtained through informed consent or data not related to the delivery of care must be made anonymous (as referred to by regulators as harmless), before they can be used. This article describes a practical approach with which Cincinnati Children’s Hospital Medical Center (CCHMC), a large pediatric academic medical center with more than 761,000 annual patient encounters, developed open source software for making pediatric clinical text harmless without losing its rich meaning. Development of the software dealt with many of the issues that often arise in natural language processing, such as data collection, disambiguation, and data scrubbing.

Development of an Abstraction Tool to Assess Palliative Care Components

2021 ◽  
pp. 104990912110617
Author(s):  
Meredith A. MacMartin ◽  
Amber E. Barnato
Keyword(s):  
Palliative Care ◽  
Qualitative Content Analysis ◽  
Medical Center ◽  
Clinical Care ◽  
Academic Medical Center ◽  
Physical Symptoms ◽  
Future Research ◽  
Clinical Documentation ◽  
Cohen’S Kappa ◽  
Cohen's Kappa

Background: Little is known regarding the fidelity of delivery of guideline-recommended components of palliative care in “real world” encounters. Objective: To develop a qualitative coding framework to identify components of clinical palliative care in clinical documentation across care settings. Design: Retrospective review of palliative care clinical documentation from medical providers, with directed qualitative content analysis to identify components of clinical care documented. Setting/Subjects: Purposively sampled deceased patients seen by palliative care at a US academic medical center between 7/1/2011–7/1/2018. Main Outcomes and Measures: The outcome of this work is a coding framework for use in future research. We assessed the robustness of the framework using Cohen’s kappa. Results: We reviewed sixty-two encounters from twenty-six patients. We identified 7 major themes in documentation: (1) addressing physical symptoms, (2) addressing psychological symptoms, (3) establishing illness understanding, (4) supporting decision making, (5) end-of-life planning, (6) understanding psychosocial context, and (7) care coordination. Interrater reliability varied widely between components, with Cohen’s kappa ranging from −.51 to 1. Conclusions: This pilot study provides a coding framework to measure documentation of clinical palliative care components. Several components could not be reliably identified using this framework, suggesting the need for additional measurement strategies.

Patient Involvement in Anesthesia Decision-making: A Qualitative Study of Knee Arthroplasty

2021 ◽  
Author(s):  
Veena Graff ◽  
Justin T. Clapp ◽  
Sarah J. Heins ◽  
Jamison J. Chung ◽  
Madhavi Muralidharan ◽  
...  
Keyword(s):  
Decision Making ◽  
Qualitative Study ◽  
Shared Decision Making ◽  
Knee Arthroplasty ◽  
Patient Involvement ◽  
Medical Center ◽  
Academic Medical Center ◽  
Shared Decision ◽  
Structured Interviews ◽  
Primary Knee Arthroplasty

Background Calls to better involve patients in decisions about anesthesia—e.g., through shared decision-making—are intensifying. However, several features of anesthesia consultation make it unclear how patients should participate in decisions. Evaluating the feasibility and desirability of carrying out shared decision-making in anesthesia requires better understanding of preoperative conversations. The objective of this qualitative study was to characterize how preoperative consultations for primary knee arthroplasty arrived at decisions about primary anesthesia. Methods This focused ethnography was performed at a U.S. academic medical center. The authors audio-recorded consultations of 36 primary knee arthroplasty patients with eight anesthesiologists. Patients and anesthesiologists also participated in semi-structured interviews. Consultation and interview transcripts were coded in an iterative process to develop an explanation of how anesthesiologists and patients made decisions about primary anesthesia. Results The authors found variation across accounts of anesthesiologists and patients as to whether the consultation was a collaborative decision-making scenario or simply meant to inform patients. Consultations displayed a number of decision-making patterns, from the anesthesiologist not disclosing options to the anesthesiologist strictly adhering to a position of equipoise; however, most consultations fell between these poles, with the anesthesiologist presenting options, recommending one, and persuading hesitant patients to accept it. Anesthesiologists made patients feel more comfortable with their proposed approach through extensive comparisons to more familiar experiences. Conclusions Anesthesia consultations are multifaceted encounters that serve several functions. In some cases, the involvement of patients in determining the anesthetic approach might not be the most important of these functions. Broad consideration should be given to both the applicability and feasibility of shared decision-making in anesthesia consultation. The potential benefits of interventions designed to enhance patient involvement in decision-making should be weighed against their potential to pull anesthesiologists’ attention away from important humanistic aspects of communication such as decreasing patients’ anxiety. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

scholarly journals Understanding Debriefing: A Qualitative Study of Event Reconstruction at an Academic Medical Center

2019 ◽  
Vol 95 (7) ◽  
pp. 1089-1097
Author(s):  
Rachel E. Sweeney ◽  
Justin T. Clapp ◽  
Alexander F. Arriaga ◽  
Madhavi Muralidharan ◽  
Randall C. Burson ◽  
...  
Keyword(s):  
Qualitative Study ◽  
Medical Center ◽  
Academic Medical Center ◽  
Event Reconstruction ◽  
Academic Medical

Factors associated with physician attitude and management of financial toxicity.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e18300-e18300
Author(s):  
Katrina Fischer ◽  
Anne Margaret Walling ◽  
John A. Glaspy
Keyword(s):  
Quality Improvement ◽  
Medical Center ◽  
Point Of Care ◽  
Insurance Coverage ◽  
Academic Medical Center ◽  
Financial Stress ◽  
Care Practice ◽  
Financial Toxicity ◽  
Perceived Knowledge ◽  
Financial Issues

e18300 Background: Little is known about the attitudes and knowledge of oncologists who discuss financial toxicity with patients compared with those who do not. We assessed perceptions of the oncologists’ role in discussing out of pocket (OOP) costs and financial stress (FS) to inform quality improvement strategies in the management of financial toxicity. Methods: We surveyed 45 practicing medical oncologists at a large academic medical center in 2019 using Likert scale responses. Questions covered three domains; self-perceived knowledge of financial issues related to care, practice of cost discussions with patients, and perceived ability to navigate toward solutions related to FS. Results: Fifty-three percent of oncologists felt comfortable discussing OOP costs, but only 42.5% discussed FS with patients. Over half (55%) lacked confidence they could help patients experiencing FS from treatment. These providers were less likely to ask about FS than those who were confident (r0.416, p0.004). Perceived knowledge among many was low: 48% felt they had little to no knowledge of OOP treatment costs, 33-37% had little to no understanding of how private or public insurance covers treatment respectively, and 60% reported low knowledge of point of care (POC) resources. Those who ask patients about FS reported higher perceived knowledge of insurance (public r0.47, p < 0.001, private r0.452, p 0.002) and POC resources (r0.392, p 0.007), but not more knowledge of OOP cost. Three factors were associated with increased confidence in the ability to help patients; higher knowledge of POC resources (r 0.379, p 0.01); having changed a treatment because of cost within the past year (r 0.395, p 0.047), and years in practice (r 0.329, p 0.047). Conclusions: Many oncologists lack confidence that they can help patients with financial issues, particularly early on in their career. Providers who lack confidence that they can help their patients appear less likely to ask patients about financial stress. Those who do ask about financial stress report higher self-perceived knowledge of insurance coverage and POC resources. This suggests that quality improvement efforts aimed at improving education and resources for providers to help navigate financial toxicity are needed.

scholarly journals How preceptors develop trust in continuity clinic residents and how trust influences supervision: A qualitative study

2021 ◽  
Author(s):  
John C. Penner ◽  
Karen E. Hauer ◽  
Katherine A. Julian ◽  
Leslie Sheu
Keyword(s):  
Internal Medicine ◽  
Qualitative Study ◽  
Medical Center ◽  
Academic Medical Center ◽  
The United States ◽  
Care Physician ◽  
Inpatient Setting ◽  
Continuity Clinic ◽  
Clinic Setting ◽  
And Task

Abstract Introduction To advance in their clinical roles, residents must earn supervisors’ trust. Research on supervisor trust in the inpatient setting has identified learner, supervisor, relationship, context, and task factors that influence trust. However, trust in the continuity clinic setting, where resident roles, relationships, and context differ, is not well understood. We aimed to explore how preceptors in the continuity clinic setting develop trust in internal medicine residents and how trust influences supervision. Methods In this qualitative study, we conducted semi-structured interviews with faculty preceptors from two continuity clinic sites in an internal medicine residency program at an urban academic medical center in the United States from August 2018–June 2020. We analyzed transcripts using thematic analysis with sensitizing concepts related to the theoretical framework of the five factors of trust. Results Sixteen preceptors participated. We identified four key drivers of trust and supervision in the continuity clinic setting: 1) longitudinal resident-preceptor-patient relationships, 2) direct observations of continuity clinic skills, 3) resident attitude towards their primary care physician role, and 4) challenging context and task factors influencing supervision. Preceptors shared challenges to determining trust stemming from incomplete knowledge about patients and limited opportunities to directly observe and supervise between-visit care. Discussion The continuity clinic setting offers unique supports and challenges to trust development and trust-supervision alignment. Maximizing resident-preceptor-patient continuity, promoting direct observation, and improving preceptor supervision of residents’ provision of between-visit care may improve resident continuity clinic learning and patient care.

scholarly journals Adoption and utilization of NGS-based molecular profiling in community-based oncology practices: Insights from Sarah Cannon.

2019 ◽  
Vol 5 (suppl) ◽  
pp. 34-34
Author(s):  
Howard A. Burris III ◽  
Daniel Schlauch ◽  
Andrew McKenzie ◽  
Yasha Sharma ◽  
David R. Spigel ◽  
...  
Keyword(s):  
Medical Center ◽  
Clinical Care ◽  
Academic Medical Center ◽  
Community Setting ◽  
Standard Of Care ◽  
Molecular Profiling ◽  
Community Based ◽  
Primary Tumors ◽  
Sequencing Technologies ◽  
Tumor Types

34 Background: The price of NGS-based sequencing technologies is falling, and the adoption of NGS-based testing is increasing in oncology practices. To date, a survey of the adoption and utilization of NGS-based technologies as a part routine oncology clinical care has not been performed. Thus, a comprehensive analysis of physician adoption and utilization of commercial NGS testing in the non-academic medical center, community-setting between 2012 and 2018 was performed. Methods: Medical Oncologists in the Sarah Cannon Research Institute network ordered commercially-available NGS-based molecular profiling for their patients as standard of care. Data use agreements were initiated between SCRI, affiliated medical oncology practices, and commercial NGS testing providers, and patient NGS data was subsequently analyzed starting in 2012. Results: Community-based NGS testing rates with the Sarah Cannon network were 5.75/month in 2012 and 440/month in 2018. Plasma-based NGS testing began in 2014 and comprised 4.9% of total testing compared to 40.1% in 2018. The number of oncologist ordering molecular profiles increased from 11 in 2012 to 269 in 2018. Physician test utilization grew from an average of 6 tests/physician to 22 tests/physician in 2012 and 2018, respectively. NGS tests were performed on 34 different tumor types and biopsies were taken from both primary tumors (~40%) and metastatic sites (~60%). Tissue-based tests averaged 14 mutations/sample while plasma-based tests averaged 4 mutations/sample. There was a 74% decrease in median time between biopsy collection and NGS test results between 2012 and 2018 (131 and 34 days, respectively), indicating a shift toward the use of fresh – non-archival – tissue in recent years. Conclusions: These data establish NGS-based testing trends in community oncology practices and show that NGS-based tumor testing utilization has increased in the community-setting between 2012 and 2018. NGS testing is performed on a wide array of tumor types and oncologists order tests earlier and utilize fresher biopsies.

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