United States Emergency Department Use of Medications with Pharmacogenetic Recommendations.
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IntroductionEmergency departments (ED) use many medications with a range of therapeutic efficacy and potential significant side effects, and many medications have dosage adjustment recommendations based on the patient's specific genotype. How frequently medications with such pharmaco-genetic recommendations are used in United States (US) EDs has not been studied.
MethodsWe conducted a cross-sectional analysis of the 2010-2015 National Hospital Ambulatory Medical Care Survey (NHAMCS). We reported the proportion of ED visits in which at least one medication with Clinical Pharmacogenetics Implementation Consortium (CPIC) recommendation of Level A or B evidence was ordered. Secondary comparisons included distributions and 95% confidence intervals of age, gender, race/ethnicity, ED disposition, geographical region, immediacy, and insurance status between all ED visits and those involving a CPIC medication.
ResultsFrom 165,155 entries representing 805,726,000 US ED visits in the 2010-2015 NHAMCS, 148,243,000 ED visits (18.4%) led to orders of CPIC medications. The most common CPIC medication was tramadol (6.3%). Visits involving CPIC medications had higher proportions of patients who were female, had private insurance and self-pay, and were discharged from the ED. They also involved lower proportions of patients with Medicare and Medicaid.
ConclusionAlmost one fifth of US ED visits involve a medication with a pharmacogenetic recommendation that may impact the efficacy and toxicity for individual patients. While direct application of genotyping is still in development, it is important for emergency care providers to understand and support this technology given its potential to improve individualized, patient-centered care.
Published Version (Please cite this version)
Limkakeng, Alexander T, Pratik Manandhar, Alaatin Erkanli, Stephanie A Eucker, Adam Root and Deepak Voora (2021). United States Emergency Department Use of Medications with Pharmacogenetic Recommendations. The western journal of emergency medicine, 22(6). pp. 1347–1354. 10.5811/westjem.2021.5.51248 Retrieved from https://hdl.handle.net/10161/24038.
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Dr. Alexander T. Limkakeng, Jr., MD, MHSc, FACEP is a Professor of Emergency Medicine, Vice Chair of Clinical Research, Director of the Acute Care Research Team, and Director of the Resident Research Fellowship for the Department of Emergency Medicine in the Duke University School of Medicine in Durham, North Carolina.
Dr. Limkakeng has served as chair of the American College of Emergency Physicians (ACEP) Research Committee, and been the Course Director of the ACEP Research Forum from 2016-2018, the largest emergency medical research platform in the nation. He is also the Assistant Director of ACEP’s Emergency Medicine Basic Research Skills course. He was elected to the Nominating Committee of the Society of Academic Emergency Medicine.
As a researcher, Dr. Limkakeng has led multiple clinical trials and interdepartmental sponsored projects and is author on over 100 peer-reviewed manuscripts. These include studies in emergency conditions such as COVID-19, traumatic brain injury, hypertension, heart failure, thrombosis, stroke, envenomations, and septic shock. His research has been funded by grants totaling over $5 million dollars. He has lectured internationally on acute coronary syndrome, responsible conduct of research, design of clinical trials, and precision medicine in emergency care. He has led Duke’s involvement in NIH-funded research networks and industry-funded work that led to FDA approval for multiple high-sensitivity cardiac troponin assays. He now serves as Co-PI for the Duke U24 Hub in the NIH Early Phase Pain Investigation Clinical Network (EPPIC-Net) (1U24NS114416) and a co-PI on the Duke U24 Hub award (1U24NS129498) in the NIH Strategies to Innovate Emergency Care Clinical Trials (SIREN) Network.
His personal research interest is finding new ways to diagnose acute coronary syndrome. In particular, he is interested in novel biomarkers and precision medicine approaches to this problem. The common element throughout this work is a focus on time-sensitive health conditions.
Areas of research interests include Bayesian hierarchical models for longitudinal data, Bayesian optimal designs, finite mixtures and Mixtures of Dirichlet Processes, Markov transition models, nonparametrics smoothing and density estimation, survival analysis for recurrent-event data, biomarker selection and detecting early ovarian cancer.
Stephanie Eucker, MD, PhD, FACEP is an Assistant Professor and Assistant Director of Acute Care Research in the Duke University Department of Emergency Medicine. Her primary research interest is in preventing and treating chronic pain, disability, and opioid use disorder (OUD) by incorporating innovative multimodal and nonpharmacologic pain management strategies in the Emergency Department (ED). Her broad clinical and research training includes Emergency Medicine, Bioengineering, Clinical and Translational research. Her research comprises three main synergistic areas of focus: (1) innovative nonpharmacologic ED pain care models, (2) patient-centered, personalized medicine approaches to pain care selection, and (3) transforming ED care best practices.
In the nonpharmacologic realm, Dr. Eucker is PI of a SAMHSA-funded pragmatic randomized clinical trial of acupuncture to treat acute musculoskeletal pain in the ED, to which her team has successfully recruited 599 patients with >50% identifying as African-American and/or Latinx. Her team successfully developed an approach to acupuncture that is feasible for the fast-paced ED setting, produces significantly greater pain reductions than usual care alone, and is used and rated highly acceptable by diverse ED patients with acute musculoskeletal pain.
In the patient-centered focus, she leads several ongoing studies investigating the relationship between biopsychosocial factors and pain-related outcomes in ED patients, patient expectations for ED pain management, and the relationship between post-ED care pathways and downstream opioid use.
Regarding research on improving and implementing ED best practices, Dr. Eucker is site-PI for the multi-site PROCOVAXED study aiming to improve COVID-19 vaccination rates among ED patients through multi-media informational platforms. She has been a co-investigator in a multi-center AHRQ implementation study to improve safe ED prescribing for older adults. She also leads a multi-professional quality improvement and research effort to improve naloxone and buprenorphine prescribing for ED patients with opioid overdose and OUD. She has also partnered with Durham County and other community partners to improve linkages to care through peer support specialists in the ED.
Regarding training, Dr. Eucker has mentored numerous trainees in research, including undergraduates, graduate students, medical student, resident physicians, physician assistants and junior faculty over the past several years. She is highly experienced at engaging learners at their level of understanding and interest in the research process, from novice researchers to those with extensive experience. Her mentees have coauthored numerous publications and progressed to leading projects under her mentorship.
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