Publications

Cost-effectiveness analysis is a widely used tool to assess the value of healthcare interventions. Our objective was to conduct a systematic review of the literature on the cost effectiveness of pharmacogenomic interventions. We found 11 studies that met our inclusion criteria. The most commonly examined disease was deep vein thrombosis (n=4), followed by cancer (n=3) and viral infections (n=3); the most frequently examined mutation was factor V Leiden (n=5); and the majority of the mutations examined were inherited mutations (n=7), although several studies looked at acquired (tumor or viral) mutations (n=4). The majority of the studies reported a favorable cost-effectiveness ratio for the pharmacogenomic-based strategy (n=7), while two studies reported that the pharmacogenomic-based strategy was not cost effective and two were equivocal. We conclude that there have been few evaluations of the economic costs and benefits of pharmacogenomic interventions and they have covered a limited number of conditions. Further analyses that can be used to guide the use of pharmacogenomics in clinical practice and in developing health policies are urgently needed.

INTRODUCTION

Few Americans follow recommendations regarding nutrition or physical activity, and few physicians provide nutritional counseling (NC) or physical activity counseling (PAC) to patients. Clinical, systems-based, and institutional barriers to teaching and providing NC and PAC exist, but theoretical models of behavior change and principles of adult learning theory (ALT) can enable medical educators to overcome these barriers.

METHODS

We developed an educational intervention consisting of interactive lectures and two standardized patient experiences to provide first-year medical students with practical experience in PAC and NC. Students completed pre and post educational assessments of attitudes, knowledge, and self-efficacy with the counseling techniques.

RESULTS

Knowledge scores increased from 6.1 to 8.5 (p<.001) on a 13-item test. Self-confidence scores for NC increased from 45 to 78 (p<.001), and self-confidence scores for PAC increased from 51 to 82 (p<.001). While overall attitudes regarding the necessity and utility of counseling with specific disease states were not different pre/ post test (necessity pre/post 6.3 to 6.2 p= .71; utility pre/post 5.8 to 5.7 p=.88), necessity and utility scores for disease states treated primarily with counseling were different compared to disease states students perceive to be primarily pharmacologically treated (counseling vs. pharmacological necessity 5.9 vs. 6.6 p<.001; utility 5.4 vs. 6.1 p<.001).

CONCLUSION

An educational intervention based on theoretical models of behavior change and ALT can increase knowledge and self confidence scores regarding counseling for NC and PAC.

BACKGROUND

In the United States, Puerto Ricans and Mexicans have the highest and lowest asthma prevalence, morbidity, and mortality, respectively. Ethnic-specific differences in the response to drug treatment may contribute to differences in disease outcomes. Genetic variants at the beta(2)-adrenergic receptor (beta(2)AR) may modify asthma severity and albuterol responsiveness. We tested the association of beta(2)AR genotypes with asthma severity and bronchodilator response to albuterol in Puerto Ricans and Mexicans with asthma.

METHODS

We used both family-based and cross-sectional tests of association with 8 beta(2)AR single nucleotide polymorphisms in 684 Puerto Rican and Mexican families. Regression analyses were used to determine the interaction between genotype, asthma severity, and bronchodilator drug responsiveness.

RESULTS

Among Puerto Ricans with asthma, the arginine (Arg) 16 allele was associated with greater bronchodilator response using both family-based and cross-sectional tests (p = 0.00001-0.01). We found a strong interaction of baseline FEV(1) with the Arg16Glycine (Gly) polymorphism in predicting bronchodilator response. Among Puerto Ricans with asthma with baseline FEV(1) < 80% of predicted, but not in those with FEV(1) > 80%, there was a very strong association between the Arg16 genotype and greater bronchodilator responsiveness. No association was observed between Arg16Gly genotypes and drug responsiveness among Mexicans with asthma.

CONCLUSIONS

Ethnic-specific pharmacogenetic differences exist between Arg16Gly genotypes, asthma severity, and bronchodilator response in Puerto Ricans and Mexicans with asthma. These findings underscore the need for additional research on racial/ethnic differences in asthma morbidity and drug responsiveness.