Tag: General Practice

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The role of general practice in cancer care

The incidence of cancer has risen in Australia and globally over the past few decades. Fortunately, advances in medicine have enabled cancer patients to live longer. We now have the means to provide better healthcare and support for this group of ‘survivors’. However, this situation also poses unique challenges to the healthcare system as resources are limited but healthcare professionals are required to do more. In recent years, there has been a call for an expansion of the role of general practitioners (GPs) in cancer care. Such a primary care-based approach allows GPs to pursue their interests in cancer management and enables diversification of healthcare resources. This article will attempt to examine how general practice can be involved in cancer care in Australia.

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Introduction

Cancer is a chronic disease on the global scale. In Australia, cancer accounts for approximately a quarter of all deaths. [1] By the age of 75, one in three males and one in four females will be expected to be diagnosed with cancer. [1] These figures may be attributed to higher population growth and an ageing population. [2] As patients are diagnosed earlier and receive better treatment, more cancer patients transit into survivorship. [3] Consequently, the immediate demands of cancer care extend beyond diagnosis and treatment and towards multi-disciplinary care, which focuses on providing support and improving the quality of life of patients. This article will briefly examine the factors influencing the involvement of primary care physicians in cancer care in Australia and reference initiatives implemented by other countries.

Patterns of cancer care and areas of GP involvement

Cancer management is complex and involves different healthcare providers. According to Norman et al., cancer care patterns may be sequential, parallel or shared. [4] In sequential care, patients are mainly cared for by oncology teams while parallel care requires general practice (GP) management of non-cancer problems. Shared care has the greatest GP involvement and requires joint management of cancer care by GP and oncology teams. GPs in Australia are mostly involved in screening and diagnosis of cancer and, eventually, referral to specialists who take over treatment and patient follow-up. GPs also play a role in managing the side effects of treatment as well as education (including prevention measures) of patients and their families. Depending on the treatment outcome, supportive or palliative care may also be provided by GPs.

In the future, it is expected that GPs will need to accept responsibilities outside their remit. This is due to a limited number of specialists in rural and remote areas and the need to diversify and expand the healthcare workforce. [5] Furthermore, health systems that include strong primary medical care were shown to be more efficient and have better health outcomes. [6] Therefore, there is a gradual move towards shared care models with GPs playing a central role alongside other healthcare providers. In this context, it will be important to understand the factors influencing the involvement of GPs in cancer care and how to maximize their involvement throughout the spectrum of cancer care.

Factors influencing GP involvement in cancer care

Location of GPs

The degree of involvement of GPs may depend on where they are based. [7] Out of necessity, GPs in rural and remote areas could be involved in coordination of cancer care and also some aspects of treatment (e.g. pre-chemotherapy checks) and follow-up of side effects. Conversely, GPs working in urban settings were more likely to refer patients upon diagnosis.

Studies have shown that indigenous Australians and other minority groups living in rural or remote areas have higher cancer mortality rates due to reduced access to healthcare. [8] GPs working in these settings could reduce this inequality through better prevention and diagnosis,  timely  referrals  as  well  as  treatment  of  co-morbidities- areas which are traditionally within the remit of primary care. [9] Although the cancer curriculum in Australian GP training focuses on these areas, it is estimated that GPs only encounter about four new cancer cases each year with cases exhibiting huge variability in cancer types and treatment requirements. [7] Such a scenario necessitates opportunities for GPs to improve their skills and experience through case-based learning and seminars. [7] Online learning modules offered by Cancer Australia are a good starting point but more effort will be required to promote these learning opportunities as GPs may not be aware of such resources. [7,10]

In recent years, the rise of telemedicine has provided an important tool in connecting rural GPs and specialists. This has enabled rural GPs to be more involved in cancer care as they can easily gain access to specialist knowledge. In Queensland, medical oncology services via videoconferencing were trialed and provided to remote and rural communities. [11] Satisfaction levels were high among both patients and rural health workers with such benefits as reduced time and money,  improved  communication between specialists  and  patients and greater access to specialist support by rural GPs. [11]

Communication pathways

Communication between GPs and hospital-based services is regarded as a major challenge facing general practice in Australia. The main form of communication from hospitals to GPs is the discharge summary and specialist letter with GPs receiving information mainly from  hospital  medical  officers.  [5]  The  variable  quality  and  poor

timeliness of information received has been shown to impede quality communication between GPs and hospitals. These factors were attributed to poor understandings of GP roles in cancer care and their information needs, as well as inexperience of medical officers. [5] It was found that hospital communications to GPs tend to omit social information about the patient. As cancer patients have been shown to be dependent on GPs for psychosocial support, the social needs of cancer patients may not be addressed adequately by GPs if poor communication persists. [1]

 

It was also shown that GPs preferred to receive a multi-disciplinary discharge summary containing input from all health professionals involved. [5] The creation of electronic health records may facilitate the  development  of  such  a  discharge  summary.  In  Canada,  the British Columbia (BC) e-health initiative allows authorized health professionals working in BC to access complete patient records when and where they were required. [12] This initiative was shown to reduce patient delays and costs to healthcare providers and patients and is a great demonstration of how improved communication via improved access to patient records may improve healthcare outcomes of cancer patients. Nonetheless, it is important that such electronic platforms are developed for and with healthcare practitioners to allow them to tackle the patient’s needs without being burdened by technology. [12]

Regular  meetings  may  also  improve  communication  between  GPs and specialists. Mitchell et al. suggested that GPs should be regularly involved in hospital-based multi-disciplinary team (MDT) meetings. [13] It is heartening that a national survey found that 84% of GPs would consider taking part in MDT meetings should the opportunity arise. [14] This suggests that formalization of MDT meetings is highly feasible. Cancer patients may benefit from the sharing of experiences between members of a formalized MDT team and this could be crucial to patients who suffer from low-incidence cancers where experience of the team matters and also to GPs, who would otherwise have little awareness about which specialists to approach for specific cancers. [13]

Remuneration and financial incentives

Inadequate remuneration may also deter GPs from accepting additional responsibilities.  A recent study found an increasing proportion of Australian GPs are not involved in palliative care (25%) as compared to previous rates of 5% and 8% in 1993 and 1998 respectively. [15] Poor remuneration in relation to the time and knowledge required for palliative care may be a deterring factor. There is currently no requirement for GPs to provide after-hour services for palliative care and some GPs also reflect that they are not confident enough to manage the technical and psychosocial aspects of palliative care. [15]

Financial incentives may be helpful as the workload of GPs has increased but their incomes have decreased relative to specialist incomes. [6] In the United Kingdom, the Gold Standards Framework for palliative care rewards GPs who are interested in palliative care and demonstrate quality care through regular meetings and maintenance of a patient register. [16] Such a scheme may attract GPs to be more involved in palliative care. In addition, to increase involvement of GPs in population-based screening programs, the current payment scheme in Australia should be revised to reward service not just based on service to symptomatic patients but also asymptomatic cancer patients who approach GPs for counseling and other psychosocial issues. [8]

Role of healthcare providers

The  roles  of  healthcare  providers  are  often  unclear.  Holmberg  et al. reported that while some people understand the role of GPs in cancer care, others felt that their roles were not stated explicitly in guidelines. [17] The varying perception of GP roles may hinder GPs from expressing their information needs and prevent their expanded involvement in treatment and follow-ups.  It has been shown that patients prefer to know who is in charge and parallel care may provide a clearer definition of GP and specialist roles. [18] Moreover, parallel care is not as demanding as shared care in terms of the level of communication required to facilitate coordination of cancer care and may therefore be favoured by both GPs and specialists. [18] While it is important to align patients’ perception with the preferences of healthcare providers, a parallel pattern of care may not be necessarily be the most effective. This explains why there is now a gradual move towards multi-disciplinary care based on shared care models, which was highlighted in Australia’s 2009 report on ‘A healthier future for all Australians’. [19]

A shared care model would require clarity of roles and a need to recognize and expand the role of primary care without compromising healthcare outcomes. Two randomized control trials in the United Kingdom (UK) and Canada showed that follow-up of breast cancer patients by GPs was as safe as follow-up by specialists while an Australian study showed no difference in recurrence rates of colorectal cancer patient after follow up by GPs or specialists. [20,21] These studies imply that GPs may undertake a greater role in the follow- up phase. Similarly, there may also be a growing role for GPs in the treatment phase,  in  terms of  management of toxicity episodes or pre-chemotherapy checks, as new oral chemotherapeutic agents are developed. [13]

Access  to  protocols  such  as  The  Cancer  institute  NSW  Standard Cancer Treatment Program (CI-SCaT) may allow GPs to manage cancer patients without requiring too much reliance on specialist expertise. [13] Similarly, GPs can access wiki-based clinical practice guidelines which are developed and constantly updated by Cancer Council Australia. [22] GPs based in rural/remote areas have been relying on generic clinical skills adapted to cancer care to manage cancer patients for years and supplementation of these skills by specialized cancer information may improve the feasibility and practicality of GP-based cancer management. [23]

GP preferences and input

While there is much potential for the expansion of GP roles, GP preferences and their input in cancer plans needs to be valued. GPs generally express interest in being involved in areas that are traditionally within their remit such as prevention, diagnosis, surveillance and psychological support but less than 50% of GPs expressed a desire to undertake coordination roles in treatment and supportive care. [7] These observations may reflect underlying structural and systemic constraints (e.g. workload and payment structures) that could only be addressed effectively at a governmental level. Conversely, as mentioned previously, GPs in rural/remote areas are already actively involved in coordination of cancer and psychological care and thus they may accept expanded roles more readily.

Ultimately, there needs to be a buildup of trust and confidence in GP capabilities and increased involvement of GPs in cancer control plans will  be  necessary.  Internationally,  the  UK  National  Health  Service (NHS) has involved GPs in its cancer plan since 2000. [1] Similarly, in Australia, GPs have been involved in the National Service Improvement Framework for Cancer while a scoping exercise undertaken by the National Cancer Control Initiative in 2004 has sought to identify areas of priority to support cancer care by primary healthcare providers. [1] A result of which was the Cancer Service Networks National Demonstration Program (CanNET) which was funded by the Australia government in seven states. It was conceived as a means of identifying opportunities to improve the organization and delivery of cancer care via MDTs and managed clinical networks (MCNs) so as to improve outcomes and reduce disparities in cancer survival rates across population groups. [24]

Lessons from CanNET

The evaluation of CanNET provided valuable insights into the provision of multi-disciplinary cancer care. For example, in addition to effective communication, it was found that networking events and activities were essential  to  building  up  professional  relationships  between healthcare providers. [24] Moreover, although GPs were willing to be involved in MDT sessions, engaging GPs was found to be difficult due to constraints imposed on general practice. [24] This suggests that while examining constraints on the specialist side is important and has been researched extensively, increased focus should also be placed on alleviating constraints on the GP side.

CanNET was also found to increase the work burden for healthcare providers. [24] This has prompted a re-think of healthcare providers’ roles to incorporate more flexibility.  A number of innovative roles are found overseas and could be trialed in various CanNET networks. For example, the Uniting Primary Care and Oncology Network (UPCON) in Manitoba advocated the use of medical leaders in the form of lead family physicians (FPs). [25] These lead FPs are primary care physicians within a practice who have an interest in cancer care and constantly engage in regular education programs and meetings jointly organized by oncologists and FPs. They disseminate useful information to colleagues and also play an advisory role by raising issues pertaining to primary care during meetings with oncologists and the Manitoba cancer agency. Besides occasionally accepting referrals, lead FPs did not have to perform difficult or unfamiliar tasks and they were remunerated according to their level of involvement. [25] This program managed to improve the partnership between GPs and other healthcare providers and could potentially fit into the Australian system.

Consistent with the theme of medical leadership, it was found that the introduction of continuing professional development (CPD) was effective in promoting local champions in some CanNET networks. CPD opportunities such as mentoring and clinical placements were received positively and more than half of the healthcare providers surveyed acknowledged that these activities helped increased their knowledge and skills and provided valuable networking opportunities. [24] Nonetheless, more work is required to address potential constraints such as workload and staff shortages. This again raises the importance of tele-oncology as a possible solution as essential oncology skills may be learnt during GP sit-ins with patients, therefore reducing the need for face-to-face attendance of workshops.

Looking to the future- the ideal oncology curriculum

The Oncology Education Committee of Cancer Council Australia has developed an ideal oncology curriculum for medical schools with the aim of equipping students with the knowledge, skills and attitude to provide quality care to cancer patients and their caregivers. This curriculum  has  been  reviewed  recently  to  include  more  emphasis on clinical experiences such as ‘observing all components of multi- disciplinary  cancer  care’.  [26]  These  changes  reflect  the  need  for future doctors who are able to work within a multi-disciplinary cancer care setting and who can understand the role of healthcare providers (including GPs) in different phases of a cancer patient’s journey. [26] Students who are interested in becoming GPs will need to be familiar with the specific needs and requirements of cancer patients as GPs are often the first point of call. Furthermore, students who take up the Medical Rural Bonded Scholarship Scheme (MRBS) and end up in rural settings will be expected to take up more responsibility than their urban counterparts. As such, changes in medical education may pave the way for changes in future medical practice.

Conclusion

Cancer management in Australia is gradually changing toward a shared care model with a focus on multi-disciplinary care. In this context, there is an increasing demand for GPs to expand their roles to relieve the pressure on other healthcare providers. Existing constraints that impede the involvement of GP will need to be addressed. These include issues pertaining to communication, remuneration, role clarity as well as GP preferences and input. A number of initiatives such as CanNET were implemented and has helped identify areas which could promote a greater role for general practice in cancer care. Overseas healthcare initiatives such as UPCON and the BC e-health initiative will also provide further valuable lessons in our search for solutions. Currently, tele-oncology appears to be a viable approach in improving rural GP involvement in cancer care and alleviating workload and staff shortages.

In conclusion, GPs have the capacity to provide quality cancer care alongside their specialist counterparts and it would be a more efficient use of healthcare resources to involve rather than neglect them. It is unlikely that specialist cancer care will be compromised as they form the core component of the actual treatment process whereas GPs are envisioned to take up coordinating as well as diagnosis and follow-up roles. As the roles of the GP can be flexible depending on preference and expertise, this is in itself advantageous as cancer care is no longer limited by the number of specialists. Specialist care may also be enhanced due to a more focused and individualized approach afforded by the less workload taken on by the specialists.

Acknowledgements

None.

Conflict of interest

None declared.

Correspondence

K Ho: koho2292@uni.sydney.edu.au

References

[1] McAvoy BR. General practitioners and cancer control. Med J Aust 2007; 187(2):115-7.

[2] Australian Institute of Health and Welfare, Australasian Association of Cancer Registries. Cancer in Australia 2001. AIHW Cancer Series No. 28. (AIHW Cat.No. CAN 23.) Canberra: AIHW, 2004.

[3] Phillips JL, Currow DC. Cancer as a chronic disease. Collegian 2010; 17(2):47-50.

[4] Norman A, Sisler J, Hack T, Harlos M. Family physicians and cancer care.Palliative care patients’ perspectives. Can Fam Physician 2001; 47:2009-16

[5] Rowlands S, Callen J, Westbrook J. Are general practioners getting the information they need from hospitals to manage their lung cancer patients? A qualitative exploration. HIMJ 2012; 41(2)4-13.

[6] Harris MF, Harris E. Facing the challenges: general practice in 2020. Med J Aust 2006; 185(2):122-4.

[7] Johnson CE, Lizama N, Garg N, Ghosh M, Emery J, Saunders C. Australian general practitioners’ preferences for managing the care of people diagnosed with cancer. Asia Pac J Clin Oncol 2012;doi: 10.1111/ajco.12047

[8] Jiwa M, Saunders CM, Thompson SC, Rosenwax LK, Sargant S, Khong EL, et al. Timely cancer diagnosis and management as a chronic condition: opportunities for primary care. Med J Aust 2008; 189(2):78-82.

[9] Campbell NC, Macleod U, Weller D. Primary care oncology: essential if high quality cancer care is to be achieved for all. Fam Pract 2002; 19(6):577-8.

[10] Cancer Australia. Cancer learning.  2011. Available from: http://www.cancerlearning.gov.au/.

[11] Sabesan S, Simcox K, Marr J. Medical oncology clinics through videoconferencing: an  acceptable  telehealth  model  for  rural  patients and  health  workers.  Intern  Med  J 2012;42(7):780-5.

[12] British Columbia eHealth Steering Committee. eHealth Strategic Framework. British Columbia Ministry of Health, Vancouver 2005.

[13] Mitchell, G. (2008). The role of the general practice in cancer care. Australian Family Physician 2008; 37(9):698-702.

[14] Australia Government: Cancer Australia. CanNET national evaluation (final report-phase  1).  2009.  Available  from:  http://canceraustralia.gov.au/publications-resources/cancer-australia-publications/cannet-national-evaluation-final-report-phase-1

[15] Rhee JJ, Zwar N, Vagholkar S, Dennis S, Broadbent AM, Mitchell G. Attitudes and barriers to involvement in palliative care by Australian urban general practitioners. J Palliat Med 2008; 11(7):980-5.

[16] Munday D, Mahmood K, Dale J, King N. Facilitating good processes in primary palliative care: does the Gold Standards Framework enable quality performance? Fam Pract 2007:1-9.

[17]  Holmberg,  L.  The  role  of  the  primary-care  physician  in  oncology care.  Primary healthcare and specialist cancer services. The Lancet Oncology 2005;6:121-122.

[18] Aubin M, Vezina L, Verreault R, Fillion L, HudonE, Lehmann F, et al. Family physician involvement in cancer care follow up: the experience of a cohort of patients with lung cancer. Ann Fam Med 2010; 8(6):526-32

[19]  National  Health  and  Hospitals  Reform  Commission.  A  Healthier  Future  for  All Australians  –  Final  Report  of  the  National Health  and  Hospitals  Reform  Commission. Canberra, 2009:107.

[20] Grunfeld E. Cancer survivorship: a challenge for primary care physicians. Br J Gen Pract 2005; 55(519):741-742

[21] Esterman A, Wattchow D, Pilotto L, Weller D, McGorm K,Hammett Z. Randomised controlled trial of general practitioner compared to surgical specialist follow up of patients with colorectal cancer. 2004. Paper presented at the GP & PHC Research Conference. http://www.phcris.org.au/conference/2004/index.php

[22] Cancer Council Australia. Cancer council Australia wiki platform. 2012. Available from: http://wiki.cancer.org.au/australia/Main_Page

[23] Mitchell GK, Burridge LH, Colquist SP, Love A. General practitioners’ perceptions of their role in cancer care and factors which influence this role. Health Soc Care Community 2012; 20(6):607-16.

[24] Australia Government: Cancer Australia. CanNET national evaluation (final report-phase  1).  2009.  Available  from:  http://canceraustralia.gov.au/publications-resources/cancer-australia-publications/cannet-national-evaluation-final-report-phase-1

[25] Sisler J, McCormack-Speak P. Bridging the gap between primary care and the cancer system: the UPCON network of CancerCare Manitoba. Cam Fam Physician 2009; 55(3):273-8.

[26]  Cancer  Council  Australia.  Ideal  oncology  curriculum  for  medical  schools.  2012. Available from: http://www.cancer.org.au/health-professionals/oncology-education/ideal-oncology-curriculum-for-medical-schools.html

Categories
Original Research Articles

General practitioner awareness of pharmacogenomic testing and drug metabolism activity status amongst the Black-African population in the Greater Western Sydney region

Background:  Individuals  of  black-African  background  have  a high variability in drug metabolising enzyme polymorphisms. Consequently, unless these patients are tested for these polymorphisms, it becomes difficult to predict which patients may have a sub-therapeutic response to medications (such as anti- depressants) or experience an adverse drug reaction. Given the increasing population of black-Africans in Australia, GPs are on the front line of this issue, especially in Greater Western Sydney (GWS) – one of the country’s rapidly increasing populations due to migration. Aim: To ascertain the awareness of GPs regarding drug metabolising enzyme polymorphisms in the black-African population and pharmacogenomic testing in the GWS community. Methods:  A  descriptive,  cross-sectional  study  was  conducted in GWS by analysing GP responses to a questionnaire consisting of closed and open-ended questions. Results: A total of 46 GPs completed the questionnaire. It was found that 79.1% and 79.5% of respondents were unaware of: the high variability in drug metabolism enzyme activity in the black-African population and pharmacogenomic testing (respectively). No respondents had ever utilised pharmacogenomic testing. Only a small proportion of GPs “always” considered a patient’s genetic factors (13.9%) and enzyme metaboliser status (11.1%) in clinical practice. Preferred education media for further information included written material, direct information from other health professionals (such as pharmacists) and verbal teaching sessions. Conclusion: There was a low level of awareness of enzyme metaboliser status and pharmacogenomic testing amongst GPs in GWS. A future recommendation to ameliorate this includes further education provision through a variety of media noted in the study.

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Introduction

Depression accounts for 13% of Australia’s total disease burden, making it an important health issue in the current context. [1] General Practitioners (GPs) are usually the first point of contact for patients seeking help for depression. [2,3] Antidepressant prescription is the most common treatment form for depression in Australia with GPs prescribing an antidepressant to treat up to 40% of all psychological problems. [2] This makes GP awareness of possible treatment resistance or adverse drug reactions (ADRs) to these medications vital.

Binder et al. [4] described pharmacogenomics as “the use of genome- wide approaches to elucidate individual differences in the outcome of drug therapy”. Detecting clinically relevant polymorphisms in genetic expression can potentially be used to identify susceptibility to ADRs. [4] This would foster the application of personalised medicine by  encouraging  an  inter-individual  approach  to  medication  and dose prescriptions based on an individual’s predicted response to medications. [4,5]

Human DNA contains genes that code for 57 cytochrome (CYP) P450 isoenzymes; these are a clinically important family of hepatic and gastrointestinal isoenzymes responsible for the metabolism of over 70% of clinically prescribed drugs. [5-10] The CYP family of enzymes are susceptible to polymorphisms as a result of genetic variations, influenced by factors such as ethnicity. [6,5,10] Research has shown that polymorphisms in certain CYP drug metabolising enzymes can result in phenotypes that class individuals as “ultrarapid metabolisers (UMs), extensive metabolisers (EMs), intermediate metabolisers (IMs) and poor metabolisers (PMs).”[6,10] These categories are clinically important as they determine whether or not a drug stays within the therapeutic range. Individuals with PM status may be susceptible to experiencing ADRs as a result of toxicity, and conversely, those with UM status may not receive a therapeutic effect. [5,6,10,11]

When considering the metabolism of antidepressants, the highly polymorphic CYP enzymes: CYP2C19 and CYP2D6 are known to be involved. [5,10,12] A study by Xie et al. [13] has shown that for the CYP2D6 enzyme alone, allelic variations induce polymorphisms that result in a PM phenotype of “~1%” in Asian populations, “0-5%” among Caucasians and a variation of between “0-19%” in black- African populations. This large disparity of polymorphism phenotypes was reproduced in a recent study, which also showed that the variation is not exclusive to the CYP2D6 enzyme. [6] It has been reported that the incidence of ADRs among PMs treated with drugs such as antidepressants is 44% compared to 21% in other patients. [5,14] Consequently, increased costs have been associated with the management of UM or PM patients. [5]

The black-African population in Australia and specifically Sydney (where GWS is one of the fastest growing regions) continues to rise through migration and humanitarian programs. [15-18] Almost 30% of Africans settling in Australia in the decade leading to the year 2007 did so under humanitarian programs including under refugee status. [15-17] As refugees are at a higher risk of having mental health problems including depression  due  to  their  traumatic  histories  and  post-migratory difficulties, GPs in GWS face increased clinical interactions with  black-Africans  at  risk  of  depression.  [19,20]  Considering  the high  variability of enzyme   polymorphisms   in   this   population, pharmacogenomic testing may play a role in the primary care of these patients. We therefore conducted a study to assess GP awareness of pharmacogenomic testing and the differences in enzyme metaboliser status (drug metabolism phenotypes). We also investigated the GP preferences of media for future education on these topics.

Methodology

Study Design and Setting

This is a descriptive, cross-sectional study. Ethics approval was granted by the Human Research Ethics Committee.

Considering GWS is the fastest growing region in Sydney, we focussed on particular suburbs in GWS (Blacktown, Parramatta and Holroyd Local Government Areas). [17-20] Using geographical cluster sampling, a list of GP practices were identified with the aim of recruiting 50 participants.

Study tool

Data was collected using a questionnaire validated by university supervisors and designed to elicit the level of understanding and awareness among GPs. The main themes of the questionnaire involved: questions regarding basic demographic information; questions aimed at determining the level of GP awareness regarding differences in drug metabolising phenotypes and pharmacogenomic testing; and open- ended questions eliciting the preferred methods of education with respect to pharmacogenomic testing.

Data Collection

We invited 194 GPs between April and May 2014 to participate in the study. The questionnaire and participant information sheet were either given to the practice managers or to the GPs in person. Questionnaires were collected in person within the following two weeks.

Data Analysis

Data was analysed using SPSS (version 22, IBM Australia). Descriptive statistics were used to summarise findings, with p-values calculated using Chi-square analysis (with Yates correction) to compare two sets of data. A p-value of <0.05 indicated statistical significance.

Results

The overall response rate was 23.7% (46/194). Our respondents included: 27 females and 19 males. The mean number of years of experience in general practice was 13.9 and most GPs (93.4%, 43/46) had received some form of training in antidepressant prescription in the last 5 years. The number of patients of black-African background seen in the last 6 months ranged from 0 to greater than 100. Only

26.1% (12/46) of GPs reported no consultations with a patient of black- African background within this timeframe. Of the 73.9% (34/46) of GPs who had seen at least one patient from this cohort, 55.9% (19/34) had treated at least one patient for depression with antidepressants.

GPs experience of ADRs in patients of black-African background treated for depression

From 46 participants, 19 had treated a patient of black-African background with antidepressants, 18/19 reported having identified at least one ADR (Figure 1).

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GP awareness and consideration of drug metabolism activity status and genetic factors

Awareness amongst GPs of the different drug metabolism activity phenotypes in black-Africans was low with 79.1% (34/43) being unaware. Patients’ genetic factors and enzyme metaboliser status were “always” considered by only 13.9% (5/36) and 11.1% (4/36) of GPs, respectively. There was no statistically significant difference regarding awareness between GPs who had treated black-African patients and those who had not (21.1% vs 13.3% respectively, p=0.89).

GP awareness and use of pharmacogenomic testing

The awareness of methods for testing a patient’s key drug metabolising enzymes, also known  as  pharmacogenomic testing, was extremely low with 79.5% (35/44) of GPs being unaware of the testing methods available in Australia. Of the 20.5% of GPs (9/44) who were aware, none had utilised pharmacogenomic testing for their black-African patients. These nine GPs then nominated factors that would influence their utilisation of pharmacogenomic testing on these individuals. Three main categories of influence emerged (Table 1). When specifically asked whether they would be more inclined to utilise pharmacogenomic testing on black-African patients who had previously experienced ADRs, 88.9% (8/9) GPs stated that they would be more inclined.

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Preferred education media

GPs that were aware of pharmacogenomic testing were asked, through an open-ended question, how they obtained information regarding these  methods.  Three  main  categories  were  identified  based  on their responses (Table 2). All GPs were then asked to note down their preferred medium of education for pharmacogenomic testing (Table 3). Multiple responses were allowed.

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Discussion

This study showed that there is a low level of awareness regarding pharmacogenomic testing and the differences in drug metabolism phenotypes among GPs. Additionally, we identified the preferred education media for providing information to GPs (Table 3). Awareness of pharmacogenomic testing and of the differences in drug enzyme metaboliser status (phenotype) could be valuable in the clinical setting. Improved patient outcomes have been noted when doctors are able to personalise management based on information from pharmacogenomic testing,[21] with Hall-Flavin et al. [21] noting significantly improved baseline depression scores amongst patients with depression whose doctors were provided with information on pharmacogenomics.

A previous study reported that a high proportion (97.6%) of physicians agreed that differences in genetic factors play a major role in drug responses.  [22]  Whilst  it  is  arguable  that  knowledge  of  genetic factors holistically playing a role in drug response may be universal, our study specifically focussed on the knowledge of differences in enzyme metaboliser status. It was found that 79.1% of GPs (34/43) were unaware, with only a small number of GPs “always” considering enzyme metaboliser status (11.1%) in their management. Given the aforementioned  importance  of  genetic  factors  and  the  potential to reduce ADRs using personalised medicine, this is an area for improvement.

When considering pharmacogenomic testing, we found 79.5% (35/44) of GPs to be unaware of testing methods. No GP had ever utilised pharmacogenomic testing, this low rate of utilisation is also reported previously in other several studies. [22-24] A lack of utilisation and awareness arguably forms a barrier against the effective incorporation of personalised medicine in the primary care setting. These low figures represent a lack of education regarding pharmacogenomics and its clinical applications. This is an issue that has been recognised since the arrival of these testing methods. [25] McKinnon et al. [25] highlighted that this lack of education across healthcare professionals is significant enough to be considered a “barrier to the widespread uptake of pharmacogenomics”. To ameliorate the situation, the International Society of Pharmacogenomics has issued recommendations in 2005 for  pharmacogenomics  to  be  incorporated  into  medical  curricula. [26]  Another  contributing  factor  to  the  low  utilisation  of  testing could include the lack of subsidised tests available through Medicare. Currently, pathology labs do provide pharmacogenomic testing (such as Douglas Hanley Moir and Healthscope), however this is largely done so through the patient’s expenses as only two methods are subsidised by Medicare. [23,27,28]

Amongst those aware of pharmacogenomic testing, eight out of nine GPs answered that they would be more likely to utilise pharmacogenomic testing in black-African patients who had previously experienced ADRs; this is consistent with findings noted by van Puijenbroek et al. [29]. Among these GPs, factors that were noted to be potential influences in their utilisation of testing included: patient factors such as compliance and the reliability of the test, and, factors affecting the clinical picture (as described in Table 1). This is consistent with findings by studies that have also identified cost and a patient’s individual response to drugs as influential factors in a physician’s decision making. [29,30]

Considering that the majority of information regarding enzyme metabolism and pharmacogenomic testing was published in pharmacological journals,[6,8-14,30-32] much of this knowledge may not have been passed on to GPs. In order to understand the preferred media of information for GPs, we posed open-ended questions and discovered that the majority of GPs who answered the question (32/39), would prefer information in the form of writing (Table 3). This could be either in the form of online sources (such as guidelines, summaries, the National Prescribing Service or the Monthly Index of Medical Specialities) or peer reviewed journal articles. Current literature also reflects this preference for GPs to gain education regarding pharmacogenomics through journal articles. [22] The other preferred medium of education was through verbal teachings, peer discussions and presentations (Table 3), with there being specific interest in information being disseminated by clinical pathology laboratories; this is also reflected in the literature. [22,29]

Strengths and limitations

Small sample size is a limitation of this study with possible contributing factors including: the short amount of time allowed for data collection and the low response rate due to GP time constraints. Strengths of the study include the use of a validated questionnaire catered to our target population and open-ended questions which gave us further insight into GP preferences.

Implications and future research

Currently, anti-coagulants provide an example of the clinical applications of considering enzyme polymorphisms in patient management. [33,34] Warfarin is a particular example where variability in INR has been associated with enzyme polymorphisms, leading to the utilisation of dosage algorithms to optimise clinical outcomes. [34] Similarly, when using antidepressants, pharmacogenomic testing could play a role in clinical decision making with Samer et al. [5] suggesting dose reductions and serum monitoring for those with known PM status. However, as identified in our study, there is an overall lack of awareness regarding the differences in enzyme metaboliser status and the methods available for pharmacogenomic testing.

Future studies should focus on the clinical practicality of utilising these tests. Additionally, future studies should determine the effectiveness of the identified GP preferred modalities of education in raising awareness.

Conclusion

There is a low awareness among GPs regarding both the differences in enzyme metaboliser status in the black-African community, and the methods of pharmacogenomic testing.

To optimise clinical outcomes in black-African patients with depression, it  may  be  useful  to  inform  GPs  of  the  availability  and  application of pharmacogenomic testing. We have highlighted the preferred education modalities through which this may be possible.

Acknowledgements

We would like to acknowledge and thank Dr. Irina Piatkov for her support as a supervisor during this project.

Conflict of interest

None declared.

Correspondence

Y Joshi: 17239266@student.uws.edu.au

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