Genetic code or ZIP code? Equitable pharmacogenetics accounts for both

Precision medicine is a new frontier in healthcare, offering a simple promise: to match the right patients to the right therapies at the right time. While that promise leans heavily on scientific advances in genomics, precision medicine works best when it’s contextualized with other factors—notably, social determinants of health.

But what does that mean for pharmacists, whose influence is steadily moving toward the heart of primary care? Speakers of a recent Wolters Kluwer webinar tackled that question, discussing the implications of evolving genomics amid ongoing healthcare disparities. Titled ”Pharmacy Next: Safer, Affordable and Personalized”, the insights-packed event covered topics of interest to pharmacists, including the nuances of pharmacogenetics that extend well beyond genetics alone.

One trend panelists emphasized was that of social factors: With consumer trust in pharmacists headed up, according to a new survey commissioned by Wolters Kluwer, many pharmacists are reevaluating their role in this rapidly changing universe of precision medicine—and that absolutely should account for social and environmental factors, the speakers noted.

So which determinants matter most and where do pharmacists fit in?

Emerging demand for personalized medicine

Consumers are ready for genomic testing. Wolters Kluwer’s survey found that roughly 7 in 10 Americans said they’d be willing to give a blood sample if doing so could help personalize their care.

An expanding market of genomic testing has helped meet those demands head-on: A study from 2018 counted about 75,000 genetic tests, with hundreds more added each month. Pharmacogenetic testing in particular has become more prevalent as the list of known gene-drug interactions steadily grows.

These developments take place as pharmacists find themselves interacting with patients more than ever before, such that much of primary care could someday be delivered at a drugstore. About 60% of respondents said they expected pharmacies—not doctors—to provide most primary care services within five years.

As pharmacists assume these new roles and expectations, they’ll need to consider more context. With social factors driving as much as 80% of healthcare outcomes, that increasingly means making visible all the factors they cannot see.

Data interoperability and digital transformation have helped enable that seemingly impossible task, such as applications that uncover key insights from provider notes, audio messages, and other areas of unstructured clinical data. Dr. David Bates of Brigham and Women’s Hospital and Harvard Medical School added that even AI could have a much more pronounced role in those efforts as the sprawl of data widens.

“Dr. Eric Topol [founder of the Scripps Research Translational Institute] has put forward a vision in which when a clinician is thinking about what to do for a patient, they could factor in all the various things about that individual,” he said. “Not just their genetic information, but all the clinical things that have happened to them, all the drugs they're taking now, and what their prior experiences with drugs have been. Bringing all that together at the same time is something that the human mind can't do but artificial intelligence can do.”

Reaching beyond biometrics alone

While pharmacogenetic science has advanced, genomic tests still exist in a continuum wrought with inequities that cause uneven access to them. Disparities call for a more measured look at precision medicine that balances those realities—and, importantly, one that goes beyond biometrics alone.

One obvious factor to consider is financial toxicity, which can happen when the expense of novel testing becomes cost prohibitive. Webinar moderator Dan Streetman, Associate Director, Clinical Content - Referential Drug Interactions and Pharmacogenomics, explains:

“Using genetics, kidney function, and drug interactions to identify what we think is the best drug for a patient isn't a lot of value if the drug we recommend isn't covered by their insurance, is just too expensive, or if it causes some side effect that we may consider to be relatively minor but is something that has a substantial impact on that individual because it directly affects their work,” he said. “The goal of identifying the best medication for an individual cannot be reached without considering all relevant patient-focused factors, and that absolutely includes social determinants of health.”

In an era where medical debt affects one in five Americans and some 58 million people say they can’t afford their prescribed meds, consideration of financial factors for pharmacogenetics is essential—not just in the obvious ways (like out-of-pocket cost) but also the more insidious, like the ability to work. If expected side effects could keep people from their paycheck, they’re an obvious barrier.

Accordingly, the Wolters Kluwer survey found cost to be a dominant factor driving consumer trust in pharmacies. If seeing a provider other than their doctor meant lower costs, 56% of Americans said they’d trust a pharmacist as their prescriber.

Accounting for a diversity of social determinants of health

Although costs are a sizeable barrier, social determinants of health extend well beyond financial toxicity. When it comes to precision medicine, panelists encouraged a more robust approach, particularly for pharmacists:

“Your ZIP code is more important than your genetic code as it relates to health outcomes,” said Daniel Knecht, MD, MBA, of CVS Caremark. “It’s exciting to focus on genomics and its promise. But at the end of the day, the bigger driver determinant here is the social behavioral determinants of health…access to healthy food, access to fresh water and clean air, and employment and crime. Those are really important determinants, and we need to stay focused on that. And investing in that.”

Other lifestyle-related factors that may be interrelated with socioeconomics—or not—include poor eating habits and sedentary behaviors. These and other behaviors can stem from many different contributors, such as a patient’s own culture or the loneliness of a recently widowed person, for example. These many nuances represent opportunities for pharmacists to create more personalized impact even outside the genomics itself.

“I think about preemptive testing, screening, preventive care, and lifestyle management as ways that we can save money across the system and things that pharmacists can do,” said Natasha Petry, PharmD, MPH, BCACP, of Sanford Health and NDSU. “I’m looking at community and ambulatory care pharmacists. They are very well positioned to perform certain point-of-care screenings and testing along with making lifestyle recommendations.”

Making precision medicine even more precise

Pharmacists are entering an exciting era in patient care as trust in their profession coincides with a renaissance of pharmacogenetic achievements. But care can’t be delivered in a vacuum, of course—which underscores the need for pharmacists to consider more context with every patient encounter.

“As we continue to learn more, I am really excited to see how we can combine things like disease predisposition, pharmacogenomics, the microbiome, proteomics, epigenetics—multiple areas of this precision medicine movement,” Dr. Petry said. “But also, [to consider these] in combination with social determinants of health and other factors so that we can precisely care for our patients in a manner that they’re hoping for, and wanting, and that we’ve never been able to do before.”