By Ernie Hood
Rural U.S. residents experience a variety of disparities in healthcare compared to people who live in more urban settings, including higher mortality rates and lower life expectancy. Disadvantaged socioeconomic status, reduced access to healthcare facilities and services and higher incidence of poor health behaviors are just a few of the barriers creating those long-standing differences.
Now, according to a study published in 2014 in the journal Pharmacogenomics, access to pharmacogenetic testing may emerge as another source of inequality between the big city and the countryside. But new genetic testing services like GeneSight from Assurex Health could bring equity by reducing rural obstacles.
Researchers from the University of Montana and the University of Washington conducted focus groups aimed at exploring differences in implementation of pharmacogenetic testing between small metropolitan and rural areas and the major medical centers in large metropolitan sectors.
“There’s a huge percentage of the population that doesn’t live in these big urban areas, so for folks implementing pharmacogenetic testing in large hospitals, we’re leaving out nearly half of the U.S. population,” said Erica Woodahl, Ph.D., an associate professor from the University of Montana. “So unless we have a concerted effort to implement this in smaller areas, it could lead to more health disparities.”
Mind the Gaps
The study described several issues perceived as barriers to implementing pharmacogenetic testing in so-called diverse practice settings: small metropolitan, rural and tribal communities.
The 12 western Montana healthcare providers who participated (along with five King County, Washington providers as controls) identified testing timeframe and logistics as major concerns. With just one genetic testing laboratory in the entire state, access to testing and other genetic services and counselors is very limited, discouraging implementation due to slow turnaround times from having to send tests to external locations.
That obstacle may be receding, however, as genetic testing services such as GeneSight let you send a sample via prepaid FedEx and guarantee results within 36 hours, making implementation within rural areas more practical and potentially more attractive.
Patient receptivity to pharmacogenetic testing was seen as another barrier. The providers were concerned that patients would be reluctant to accept pharmacogenetic testing, confusing it with genetic tests to predict or diagnose disease and being suspicious of anything with a “genetic” label. They also cited the fact that rural physicians may have little or no experience in ordering or interpreting pharmacogenetic tests.
Participants also talked about problems related to cost and insurance reimbursement, and patient adherence. As Woodahl explained, “Some of the providers are really interested, but are thinking, this sounds great, but we have more important, more immediate things to deal with, such as trouble with patients taking the drug as recommended, or sometimes patients will split drugs if they live far away from a pharmacy.”
The groups discussed barriers to pharmacogenetic testing particular to tribal communities. Mistrust stemming from past abuses in genetic research certainly delays uptake in tribal areas, along with anxieties about the potential economic impacts of genetic testing. As one participant explained, “Tribal benefits are based on having [a] certain amount of tribal blood. So if a test might show that they do not have enough to meet their benefits, it means a lot to them.”
Tribal groups also face unique cost challenges stemming from limited funding available from the Indian Health Service, which finances clinics providing healthcare to many American Indian/Alaska Native people.
Acceptance and approval of pharmacogenetic testing by tribal community leaders is another necessity. “I can see there would be some barriers in terms of even getting this in the [clinic] building,” a study participant observed.
On the Brighter Side
Despite the many obstacles, Woodahl is optimistic that pharmacogenetic testing will eventually permeate diverse practice settings.
“As people hear more about pharmacogenetics and personalized medicine, there’s going to be a demand for it,” she said. “It’s important for those of us in the field to think about implementation strategies to make sure that a large portion of patients are not overlooked in this new technology, and to think about what different practice settings may require.”