Ensuring equity: Pharmacogenetic implementation in rural and tribal communities

Abstract

Implementation strategies for pharmacogenetic testing have been largely limited to major academic medical centers and large health systems, threatening to exacerbate healthcare disparities for rural and tribal populations. There exists a need in Montana (United States)—a state where two-thirds of the population live in rural areas and with a large proportion of tribal residents—to develop novel strategies to make pharmacogenetic testing more broadly available. We established partnerships between University of Montana (UM) and three early adopter sites providing patient-centered care to historically neglected populations. We conducted 45 semi-structured interviews with key stakeholders at each site and solicited participant feedback on the utility of a centralized pharmacogenetic service at UM offering consultations to patients and providers statewide via telehealth. For settings serving rural patients—tribal and non-tribal—participants described healthcare facilities without adequate infrastructure, personnel, and funding to implement pharmacogenetic services. Participants serving tribal communities stressed the need for ethical practices for collecting biospecimens and returning genetic results to patients, largely due to historical and contemporary traumas experienced by tribal populations with regard to genetic research. Participants expressed that pharmacogenetic testing could benefit patients by achieving therapeutic benefit sooner, reducing the risk of side effects, and improving adherence outcomes for patients with limited access to follow-up services in remote areas. Others expressed concern that financial barriers to pharmacogenetic testing for patients of lower socioeconomic status would further exacerbate inequities in care. Participants valued the role of telehealth to deliver pharmacogenetic consults from a centralized service at UM, describing the ability to connect providers and patients to resources and expertise as imperative to driving successful pharmacogenetic implementation. Our results support strategies to improve access to pharmacogenetic testing for neglected patient populations and create opportunities to reduce existing healthcare inequities. By exploring critical challenges for pharmacogenetic implementation focused on serving underserved communities, this work can help guide equitable frameworks to serve as a model for other resource-limited settings looking to initiate pharmacogenetic testing.

Addressing disparities in pharmacogenomics through rural and underserved workforce education

“… Fohner et al (2019) acknowledge several challenges in working with rural and underserved populations and provide several recommendations to overcoming these challenges. More recently, Leitch et al conducted interviews related to the utility of PGx with various healthcare stakeholders from three different institutions in Montana that serve neglected populations ( Leitch et al, 2022 ). While they expressed similar sentiments of positive perceived value of PGx and barriers to testing, they did note the potential of providing PGx integration through telehealth visits.…”

Pharmacogenomic variabilities in geo-ancestral subpopulations and their clinical implications: Results of collaborations with Hmong in the United States

“…Hmong, along with other underrepresented subpopulations ( Fohner et al, 2013 ; Woodahl et al, 2014 ; Leitch et al, 2022 ), are eager for clinicians to recognize their uniqueness when considering selection and dosing of medications, rather than being represented by the broader definition of geo-ancestral grouping ( Culhane-Pera et al, 2017a ; Culhane-Pera et al, 2017b ; Holzer et al, 2021 ). PGx has uncovered some relevant issues, but more PGx research is needed within subpopulations to identify differences in genomic biomarkers that can contribute to personalized medicine.…”

Pharmacogenomics and health disparities, are we helping?

“…While most of drug prescriptions occur within primary care settings and despite robust evidence supporting the utility of PGx in medicine optimization, extending PGx implementation into primary care settings specially within rural communities remains challenging given the current models of clinical practice ( Sudia, 2016 ; Dearing and Cox, 2018 ; Rollinson et al, 2020 ). Most PGx programs implemented to date are conducted within urban health care systems or large academic institutes ( Houwink et al, 2015 ; Dawes, 2020 ; Leitch et al, 2022 ). Adding the current limited reimbursement available for PGx testing and the lack of providers comfort or literacy with PGx ordering to already existing problems in the rural communities such as physicians and health care providers shortages, lower socio-economic standards, less insurance coverage, and limited access to specialists, and then PGx implementation would easily be seen as an unattainable endeavor ( Kogan et al, 2018 ; Johnston et al, 2019 ; Richman et al, 2019 ; Empey et al, 2021 ; Leitch et al, 2022 ).…”

“…Most PGx programs implemented to date are conducted within urban health care systems or large academic institutes ( Houwink et al, 2015 ; Dawes, 2020 ; Leitch et al, 2022 ). Adding the current limited reimbursement available for PGx testing and the lack of providers comfort or literacy with PGx ordering to already existing problems in the rural communities such as physicians and health care providers shortages, lower socio-economic standards, less insurance coverage, and limited access to specialists, and then PGx implementation would easily be seen as an unattainable endeavor ( Kogan et al, 2018 ; Johnston et al, 2019 ; Richman et al, 2019 ; Empey et al, 2021 ; Leitch et al, 2022 ). Yet the value of PGx to these resource-poor settings, in terms of improving the quality of healthcare by decreasing costs, reducing ADRs, and better management of polypharmacy should override such existing hurdles.…”