Systematic review of near patient test evaluations in primary care

Frequencies and patterns of microbiology test requests from primary care in Oxfordshire, UK, 2008-2018: a retrospective cohort study of electronic health records to inform point-of-care testing

OBJECTIVES

To inform point-of-care test (POCT) development, we quantified the primary care demand for laboratory microbiology tests by describing their frequencies overall, frequencies of positives, most common organisms identified, temporal trends in testing and patterns of cotesting on the same and subsequent dates.

DESIGN

Retrospective cohort study.

SETTING

Primary care practices in Oxfordshire.

PARTICIPANTS

393 905 patients (65% female; 49% aged 18-49).

PRIMARY AND SECONDARY OUTCOME MEASURES

The frequencies of all microbiology tests requested between 2008 and 2018 were quantified. Patterns of cotesting were investigated with heat maps. All analyses were done overall, by sex and age categories.

RESULTS

1 596 752 microbiology tests were requested. Urine culture±microscopy was the most common of all tests (n=673 612, 42%), was mainly requested without other tests and was the most common test requested in follow-up within 7 and 14 days. Of all urine cultures, 180 047 (27%) were positive and 172 651 (26%) showed mixed growth, and Escherichia coli was the most prevalent organism (132 277, 73% of positive urine cultures). Antenatal urine cultures and blood tests in pregnancy (hepatitis B, HIV and syphilis) formed a common test combination, consistent with their use in antenatal screening.

CONCLUSIONS

The greatest burden of microbiology testing in primary care is attributable to urine culture ± microscopy; genital and routine antenatal urine and blood testing are also significant contributors. Further research should focus on the feasibility and impact of POCTs for these specimen types.

C-reactive protein and neutrophil count laboratory test requests from primary care: what is the demand and would substitution by point-of-care technology be viable?

AIMS : C-reactive protein (CRP) and neutrophil count (NC) are important diagnostic indicators of inflammation. Point-of-care (POC) technologies for these markers are available but rarely used in community settings in the UK. To inform the potential for POC tests, it is necessary to understand the demand for testing. We aimed to describe the frequency of CRP and NC test requests from primary care to central laboratory services, describe variability between practices and assess the relationship between the tests.

METHODS

We described the number of patients with either or both laboratory tests, and the volume of testing per individual and per practice, in a retrospective cohort of all adults in general practices in Oxfordshire, 2014-2016.

RESULTS

372 017 CRP and 776 581 NC tests in 160 883 and 275 093 patients, respectively, were requested from 69 practices. CRP was tested mainly in combination with NC, while the latter was more often tested alone. The median (IQR) of CRP and NC tests/person tested was 1 (1-2) and 2 (1-3), respectively. The median (IQR) tests/practice/week was 36 (22-52) and 72 (50-108), and per 1000 persons registered/practice/week was 4 (3-5) and 8 (7-9), respectively. The median (IQR) CRP and NC concentrations were 2.7 (0.9-7.9) mg/dL and 4.1 (3.1-5.5)×10⁹/L, respectively.

CONCLUSIONS

The high demand for CRP and NC testing in the community, and the range of results falling within the reportable range for current POC technologies highlight the opportunity for laboratory testing to be supplemented by POC testing in general practice.

Matching diagnostics development to clinical need: Target product profile development for a point of care test for community-acquired lower respiratory tract infection

Background

Point of care tests (POCTs) are increasingly being promoted for guiding the primary medical care of community acquired lower respiratory tract infections (CA-LRTI). POCT development has seldom been guided by explicitly identified clinical need and requirements of the intended users. Approaches for identifying POCT priorities and developing target product profiles (TPPs) for POCTs in primary medical care are not well developed, and there is no published TPP for a CA-LRTI POCT aimed at developed countries.

Methods

We conducted workshops with expert stakeholders and a survey with primary care clinicians to produce a target product profile (TPP) to guide the development of a clinically relevant and technologically feasible POCT for CA-LRTI.

Results

Participants with clinical, academic, industrial, technological and basic scientific backgrounds contributed to four expert workshops, and 45 practicing primary care clinicians responded to an online survey and prioritised community-acquired pneumonia (CAP) as the CA-LRTI where a new POCT was most urgently needed. Consensus was reached on a TPP document that included information on the intended niche in the clinical pathway in primary medical care; diagnostic product specification (intended use statement and test concept), and minimum and ideal user specifications. Clinicians minimum requirements of a CA-LRTI POCT included the use of minimally invasive samples, a result in less than 30 minutes, no more than a single preparation step, minimum operational requirements, and detection of common respiratory pathogens and their resistance to commonly prescribed antibiotics.

Conclusions

This multidisciplinary, multistage partnership approach generated a clinically-driven TPP for guiding the development of a new POCT, and this approach as well as the TPP itself may be useful to others developing a new POCT.

Reducing antibiotic prescribing in Australian general practice: time for a national strategy

In Australia, the antibiotic resistance crisis may be partly alleviated by reducing antibiotic use in general practice, which has relatively high prescribing rates - antibiotics are mostly prescribed for acute respiratory infections, for which they provide only minor benefits. Current surveillance is inadequate for monitoring community antibiotic resistance rates, prescribing rates by indication, and serious complications of acute respiratory infections (which antibiotic use earlier in the infection may have averted), making target setting difficult. Categories of interventions that may support general practitioners to reduce prescribing antibiotics are: regulatory (eg, changing the default to "no repeats" in electronic prescribing, changing the packaging of antibiotics to facilitate tailored amounts of antibiotics for the right indication and restricting access to prescribing selected antibiotics to conserve them), externally administered (eg, academic detailing and audit and feedback on total antibiotic use for individual GPs), interventions that GPs can individually implement (eg, delayed prescribing, shared decision making, public declarations in the practice about conserving antibiotics, and self-administered audit), supporting GPs' access to near-patient diagnostic testing, and public awareness campaigns. Many unanswered clinical research questions remain, including research into optimal implementation methods. Reducing antibiotic use in Australian general practice will require a range of approaches (with various intervention categories), a sustained effort over many years and a commitment of appropriate resources and support.

Towards elimination of visceral leishmaniasis in the Indian subcontinent-Translating research to practice to public health

BACKGROUND

The decade following the Regional Strategic Framework for Visceral Leishmaniasis (VL) elimination in 2005 has shown compelling progress in the reduction of VL burden in the Indian subcontinent. The Special Programme for Research and Training in Tropical Diseases (TDR), hosted by the World Health Organization (WHO) and other stakeholders, has coordinated and financed research for the development of new innovative tools and strategies to support the regional VL elimination initiative. This paper describes the process of the TDR's engagement and contribution to this initiative.

METHODOLOGY/PRINCIPAL FINDINGS

Multiple databases were searched to identify 152 scientific papers and reports with WHO funding or authorship affiliation around the following 3 framework strategies: detection of new cases, morbidity reduction, and prevention of infection. TDR has played a critical role in the evaluation and subsequent use of the 39-aminoacid-recombinant kinesin antigen (rK39) rapid diagnostic test (RDT) as a confirmatory test for VL in the national program. TDR has supported the clinical research and development of miltefosine and single-dose liposomal amphotericin B as a first-line treatment against VL. TDR has engaged with in-country researchers, national programme managers, and partners to generate evidence-based interventions for early detection and treatment of VL patients. TDR evaluated the quality, community acceptance, and cost effectiveness of indoor residual spraying, insecticide-treated bed nets, insecticide-impregnated durable wall linings, insecticidal paint, and environmental management as tools for integrated vector management in reducing sandfly density.

CONCLUSIONS/SIGNIFICANCE

TDR's engagement with country policy makers, scientists, and clinicians in the development of effective diagnosis, treatment, case detection, and vector control represents an important example of TDR's stewardship toward the elimination of VL in the Indian subcontinent.

Implementation of point-of-care testing in a general internal medicine practice: A confirmation study

BACKGROUND

In a previous study we reported on the impact of point-of-care testing (POCT) on practice efficiency in an academic primary care practice that was established to develop new models of care delivery. Here we report a follow-on confirmation study in a more typical primary care practice in the community.

METHODS

In this observational study with a retrospective comparison analysis we measured metrics of practice efficiency on two patient cohorts: those that did not receive POCT and those that did.

RESULTS

In the patient cohort that received POCT there was a 99% reduction in letters to patients (p<0.001), a 75% decrease in calls to patients (not significant due to small numbers), a 50% reduction in follow-up tests per visit (p=0.044) and a 38% reduction in follow-up visits due to abnormal test results (p=0.178). Financial analysis including testing costs, revenues and efficiency gains to the practice demonstrated a net financial benefit of $11.90-14.74 per patient visit.

CONCLUSIONS

Our data confirm the earlier published findings that POCT can improve metrics of practice efficiency in a primary care practice.

Factors predicting antibiotic prescription and referral to hospital for children with respiratory symptoms: secondary analysis of a randomised controlled study at out-of-hours services in primary care

OBJECTIVES

Acute respiratory infections and fever among children are highly prevalent in primary care. It is challenging to distinguish between viral and bacterial infections. Norway has a relatively low prescription rate of antibiotics, but it is still regarded as too high as the antimicrobial resistance is increasing. The aim of the study was to identify predictors for prescribing antibiotics or referral to hospital among children.

DESIGN

Secondary analysis of a randomised controlled study.

SETTING

4 out-of-hours services and 1 paediatric emergency clinic in Norwegian primary care.

PARTICIPANTS

401 children aged 0-6 years with respiratory symptoms and/or fever visiting the out-of-hours services.

OUTCOMES

2 main outcome variables were registered: antibiotic prescription and referral to hospital.

RESULTS

The total prescription rate of antibiotics was 23%, phenoxymethylpenicillin was used in 67% of the cases. Findings on ear examination (OR 4.62; 95% CI 2.35 to 9.10), parents' assessment that the child has a bacterial infection (OR 2.45; 95% CI 1.17 to 5.13) and a C reactive protein (CRP) value >20 mg/L (OR 3.57; 95% CI 1.43 to 8.83) were significantly associated with prescription of antibiotics. Vomiting in the past 24 hours was negatively associated with prescription (OR 0.26; 95% CI 0.13 to 0.53). The main predictors significantly associated with referral to hospital were respiratory rate (OR 1.07; 95% CI 1.03 to 1.12), oxygen saturation <95% (OR 3.39; 95% CI 1.02 to 11.23), signs on auscultation (OR 5.57; 95% CI 1.96 to 15.84) and the parents' assessment before the consultation that the child needs hospitalisation (OR 414; 95% CI 26 to 6624).

CONCLUSIONS

CRP values >20 mg/L, findings on ear examination, use of paracetamol and no vomiting in the past 24 hours were significantly associated with antibiotic prescription. Affected respiration was a predictor for referral to hospital. The parents' assessment was also significantly associated with the outcomes.

TRIAL REGISTRATION NUMBER

NCT02496559; Results.

A rapid MZI-IDA sensor system for EGFR mutation testing in non-small cell lung cancer (NSCLC)

Epidermal growth factor receptor (EGFR) is a non-small-cell lung cancer biomarker, based on which several near-patient-testing methods have been developed and applied to predict treatment response on individual patients. Existing methods for detection of EGFR mutation are costly, labor-intensive and time-consuming. In this paper, we report a novel EGFR mutation testing system, which is based on Mach-Zehnder Interferometer (MZI) sensor and isothermal solid-phase DNA amplification (IDA) technique, called MZI-IDA sensor system. The system can deliver results within 30 min and shows high sensitivity to detect trace amounts of genomic DNA (<1 copy). In addition, the system is able to detect a L858R mutation in a 99:1 mixture of wild-type and mutant cells. In a pilot clinical study, the system is compared with conventional methods (PCR and direct sequencing) by using tissue biopsy samples from NSCLC patients. The MZI-IDA sensor system is proved to be capable of fast and accurate detection of the L858R mutation of EGFR gene in clinical samples. This may greatly help the clinicians develop an appropriate treatment plan.

Implementation of point-of-care testing in an ambulatory practice of an academic medical center

OBJECTIVES

Point-of-care laboratory testing (POCT) offers reduced turnaround time and may promote improved operational efficiency. Few studies have been reported that document improvements from implementing POCT in primary care.

METHODS

We measured metrics of practice efficiency in a primary care practice before and after implementation of POCT, including the total number of tests ordered, letters and phone calls to patients, and revisits due to abnormal test results. We performed a cost and revenue analysis.

RESULTS

Following implementation of POCT, there was a 21% decrease in tests ordered per patient (P < .0001); a decrease in follow-up phone calls and letters by 89% and 85%, respectively (P < .0001 and P < .0001); and a 61% decrease in patient revisits (P = .0002). Estimated testing revenues exceeded expenses by $6.62 per patient, and potential cost savings from improved efficiency were $24.64 per patient.

CONCLUSIONS

POCT can significantly improve clinical operations with cost reductions through improved practice efficiency.

Point-of-care tests in general practice: hope or hype?

Point-of-care tests are biomedical tests on patients' specimens like blood, saliva, urine or faeces, which can be used near the patient, without interference of a laboratory. The use of these tests, many of which have been recently developed, is increasing in general practice, where they add to the GP's set of diagnostic instruments. The question is, however, whether they always contribute to an effective and high-quality diagnostic process by GPs. We present a set of criteria that can be used by guideline developers, regional primary care organizations and individual GPs to evaluate a new point-of-care test in a practice setting. These criteria do not relate only to their use and quality. A point-of-care test needs to be evaluated in the right population and for the right indications, and GPs then need to use them for the indications for which they were evaluated. Expanding the range of indications can lead to an increase in false-positive and false-negative test results.

Measurement of the new anticoagulants

New oral anticoagulants are given at fixed daily doses without laboratory dose adjustment for prevention of venous thromboembolism following elective total knee- and hip replacement, for treatment and prevention of recurrent events of acute venous thromboembolism, and for prevention of embolic events in atrial fibrillation. However, it may be necessary to determine the anticoagulant effect of new oral anticoagulants in special patient populations such as in elderly, for renal impairment, before operation, bleeding or thrombotic episodes and to monitor self-compliance. Oral factor Xa and oral thrombin inhibitors influence dose dependently global and specific coagulation assays. Standardization of assays is currently undertaken. Determination of the new oral anticoagulants in serum samples would facilitate blood sampling and analysis from samples taken and stored for creatinine or other biochemical parameters. Point of care methods from plasma or urine for the new oral anticoagulants would improve patient care. First data demonstrate the feasibility of such assays in urine.

Decision-making in general practice: the effect of financial incentives on the use of laboratory analyses

This paper examines the reaction of general practitioners (GPs) to a reform in 2004 in the remuneration system for using laboratory services in general practice. The purpose of this paper is to study whether income motivation exists regarding the use of laboratory services in general practice, and if so, the degree of income motivation among general practitioners (GPs) in Norway. We argue that the degree of income motivation is stronger when the physicians are uncertain about the utility of the laboratory service in question. We have panel data from actual physician-patient encounters in general practices in the years 2001-2004 and use discrete choice analysis and random effects models. Estimation results show that an increase in the fees will lead to a small but significant increase in use. The reform led to minor changes in the use of laboratory analyses in GPs' offices, and we argue that financial incentives were diluted because they were in conflict with medical recommendations and existing medical practice. The patient's age has the most influence and the results support the hypothesis that the impact of income increases with increasing uncertainty about diagnosis and treatment. The policy implication of our results is that financial incentives alone are not an effective tool for influencing the use of laboratory services in GPs' offices.

A multi-country qualitative study of clinicians' and patients' views on point of care tests for lower respiratory tract infection

BACKGROUND

Point of care tests (POCTs) are being promoted to better target antibiotic prescribing with the aim of improving outcomes and containing antibiotic resistance.

OBJECTIVE

We aimed to explore clinician and patient views about POCTs to assist with the diagnosis and management of lower respiratory tract infection (LRTI) in primary care.

METHODS

Multi-country European qualitative interview study with 80 primary care clinicians and 121 adult patients in nine primary care networks who had recently consulted with symptoms of acute cough/LRTI. Transcripts were subjected to a five-stage analytic framework approach (familiarization, developing a thematic framework from the interview questions and the themes emerging from the data, indexing, charting, and mapping to search for interpretations in the data), with local network facilitators commenting on preliminary reports.

RESULTS

Clinicians who did not routinely use POCTs for acute cough/LRTI felt that the tests' advantages included managing patient expectations for antibiotics. Perceived disadvantages included questionable test performance, problems interpreting results, a detraction from clinical reasoning, costs, time and patients not wanting, or demanding, the tests. Clinicians who routinely used POCTs echoed these disadvantages. Almost all patients would be happy to be managed with the addition of a POCT. Patients with experience of POCTs accepted it as part of routine care.

CONCLUSIONS

Acceptability of POCTs to clinicians is likely to be improved if tests perform well on accuracy, time to result, simplicity and cost. Including POCTs in the routine management of acute cough/LRTI is likely to be acceptable to most patients.

Patients' perspectives on self-testing of oral anticoagulation therapy: content analysis of patients' internet blogs

BACKGROUND

Patients on oral anticoagulant therapy (OAT) require regular testing of the prothrombin time (PT) and the international normalised ratio (INR) to monitor their blood coagulation level to avoid complications of either over or under coagulation. PT/INR can be tested by a healthcare professional or by the patient. The latter mode of the testing is known as patient self-testing or home testing. The objective of this study was to elicit patients' perspectives and experiences regarding PT/INR self-testing using portable coagulometer devices.

METHODS

Internet blog text mining was used to collect 246 blog postings by 108 patients, mainly from the USA and the UK. The content of these qualitative data were analysed using XSight and NVivo software packages.

RESULTS

The key themes in relation to self-testing of OAT identified were as follows: Patient benefits reported were time saved, personal control, choice, travel reduction, cheaper testing, and peace of mind. Equipment issues included high costs, reliability, quality, and learning how to use the device. PT/INR issues focused on the frequency of testing, INR fluctuations and individual target (therapeutic) INR level. Other themes noted were INR testing at laboratories, the interactions with healthcare professionals in managing and testing OAT and insurance companies' involvement in acquiring the self-testing equipment. Social issues included the pain and stress of taking and testing for OAT.

CONCLUSIONS

Patients' blogs on PT/INR testing provide insightful information that can help in understanding the nature of the experiences and perspectives of patients on self-testing of OAT. The themes identified in this paper highlight the substantial complexities involved in self-testing programmes in the healthcare system. Thus, the issues elicited in this study are very valuable for all stakeholders involved in developing effective self-testing strategies in healthcare that are gaining considerable current momentum particularly for patients with chronic illness.

Design, implementation and results of the quality control program for the Australian government's point of care testing in general practice trial

BACKGROUND

From 2005 to 2007 the Australian Government funded a multicentre, clustered randomized controlled trial to determine the clinical effectiveness, cost-effectiveness, satisfaction and safety of point of care testing (PoCT) in general practice (GP). PoC tests measured (and devices used) in the trial were haemoglobin A1c and urine albumin:creatinine ratio (DCA 2000), lipids (Cholestech LDX) and international normalized ratio (CoaguChek S).

METHODS

An internal quality control (QC) program was developed as part of a quality management framework for the trial. PoCT device operators were provided with a colour-coded QC Result Sheet and QC Action Sheet for on-site recording and interpreting of their results. Within-practice imprecision for QC testing was calculated and compared with the analytical goals for imprecision set prior to the trial.

RESULTS

The average participation rate for QC testing was 91% or greater. Median within-practice imprecision met the analytical goals for all PoC tests, except for high-density lipoprotein-cholesterol (HDL-C) where observed performance was outside the minimum goal for one level and one lot number of QC. Most practices achieved the imprecision goals for all analytes, with the principal exception of HDL-C.

CONCLUSIONS

Results from QC testing indicate that PoCT in the GP trial met the analytical goals set for the trial, with the exception of HDL-C.

A pragmatic cluster randomised controlled trial to evaluate the safety, clinical effectiveness, cost effectiveness and satisfaction with point of care testing in a general practice setting - rationale, design and baseline characteristics

BACKGROUND

Point of care testing (PoCT) may be a useful adjunct in the management of chronic conditions in general practice (GP). The provision of pathology test results at the time of the consultation could lead to enhanced clinical management, better health outcomes, greater convenience and satisfaction for patients and general practitioners (GPs), and savings in costs and time. It could also result in inappropriate testing, increased consultations and poor health outcomes resulting from inaccurate results. Currently there are very few randomised controlled trials (RCTs) in GP that have investigated these aspects of PoCT.

DESIGN/METHODS

The Point of Care Testing in General Practice Trial (PoCT Trial) was an Australian Government funded multi-centre, cluster randomised controlled trial to determine the safety, clinical effectiveness, cost effectiveness and satisfaction of PoCT in a GP setting.The PoCT Trial covered an 18 month period with the intervention consisting of the use of PoCT for seven tests used in the management of patients with diabetes, hyperlipidaemia and patients on anticoagulant therapy. The primary outcome measure was the proportion of patients within target range, a measure of therapeutic control. In addition, the PoCT Trial investigated the safety of PoCT, impact of PoCT on patient compliance to medication, stakeholder satisfaction, cost effectiveness of PoCT versus laboratory testing, and influence of geographic location.

DISCUSSION

The paper provides an overview of the Trial Design, the rationale for the research methodology chosen and how the Trial was implemented in a GP environment. The evaluation protocol and data collection processes took into account the large number of patients, the broad range of practice types distributed over a large geographic area, and the inclusion of pathology test results from multiple pathology laboratories.The evaluation protocol developed reflects the complexity of the Trial setting, the Trial Design and the approach taken within the funding provided. The PoCT Trial is regarded as a pragmatic RCT, evaluating the effectiveness of implementing PoCT in GP and every effort was made to ensure that, in these circumstances, internal and external validity was maintained.

TRIAL REGISTRATION

12612605000272695.

General practitioners' perceptions of introducing near-patient testing for common infections into routine primary care: a qualitative study

OBJECTIVE

Near-patient tests are promoted for guiding management of common infections in primary care with a view to enhancing the effectiveness of prescribing decisions and containing antimicrobial resistance. Changes in clinical practice should be based on appraisals of the factors that might influence change, viewed from the perspective of those expected to implement the change. We therefore explored the views of general practitioners concerning the possible introduction of near-patient tests for managing common infections.

DESIGN

Qualitative semi-structured interview study. Interviews were recorded and analysed using thematic content analysis.

SETTING

General practices in south-east Wales, UK.

SUBJECTS

A total of 26 general practitioners (GPs) from high fluroquinolone antibiotics prescribing practices and 14 GPs from practices that prescribed fluroquinolones close to the south-east Wales mean.

RESULTS

There was strong enthusiasm for a hypothetical near-patient, finger-prick blood tests that could distinguish viral from bacterial infections. Many GPs emphasized that such tests would be valuable in "selling" decisions not to prescribe antibiotics to patients. Concerns included limited additional useful information to guide prescribing above clinical diagnosis alone, that patients might deteriorate even if the tests correctly identified a viral aetiology, and that GPs would need to be convinced by research evidence supporting uptake. Several indicated that tests would be useful only for a limited number of patients and they were concerned by time pressures, apparatus maintenance and quality control, cost, and possible objections from patients, especially children.

CONCLUSIONS

Despite GP enthusiasm for the concept of a rapid test to distinguish viral from bacterial infection, strategies to promote uptake would be enhanced if concerns were addressed regarding the importance and feasibility of such tests in daily practice.

Near patient testing for glycated haemoglobin in people with Type 2 diabetes mellitus managed in primary care: acceptability and satisfaction

AIMS

To assess the acceptability of and satisfaction with near patient testing for glycated haemoglobin in primary care in patients and health professionals.

METHODS

A questionnaire survey and qualitative study were nested within a randomized controlled trial conducted in eight general practices in Leicester-shire, UK. Satisfaction with diabetes care was compared in the intervention group (near patient test) and in the control subjects (usual laboratory test), using the Diabetes Clinic Satisfaction Questionnaire. Semistructured interviews were conducted with a purposive sample of patients and healthcare professionals and analysed using thematic coding and framework charting.

RESULTS

Questionnaire data for 344 patients were analysed and interviews were conducted with 15 patients and 11 health professionals. Interviews indicated that the near patient test was highly acceptable to patients and staff and confirmed that there may be potential benefits such as time saving, reduced anxiety and impact on patient management and job satisfaction. However, both the survey and the interviews identified high pre-existing levels of satisfaction with diabetes care in both intervention and control group patients and survey results failed to confirm increased patient satisfaction as a result of rapid testing. Limited patient understanding of glycated haemoglobin testing was noted.

CONCLUSIONS

We were unable to confirm actual rather than potential advantages of the near patient test. Widespread adoption in primary care cannot be recommended without further evidence of benefit.

A guide for diagnostic evaluations

Accurate diagnostic tests have a key role in patient management and the control of most infectious diseases. Unfortunately, in many developing countries, clinical care is often critically compromised by the lack of regulatory controls on the quality of these tests. The information available on the performance of a diagnostic test can be biased or flawed because of failings in the design of the studies which assessed the performance characteristics of the test. As a result, diagnostic tests are sold and used in much of the developing world without evidence of effectiveness. Misdiagnosis leading to failure to treat a serious infection or wasting expensive treatment on people who are not infected remains a serious obstacle to health.

Stepwise Approach to Developing Point-of-Care Testing Services in the Community/Ambulatory Pharmacy Setting

OBJECTIVE

To provide a stepwise approach to development and implementation of a point-of-care testing (POCT) patient care service.

SETTING

Community and ambulatory care pharmacy practice.

PRACTICE DESCRIPTION

To provide community and ambulatory pharmacists with the steps involved in integrating POCT services into their pharmacy practice site.

PRACTICE INNOVATION

Authors used various resources to detail the process of implementing pharmaceutical care in community or ambulatory pharmacy settings in combination with individual practice experiences. The five steps involved in developing a POCT service include conducting a needs assessment, researching and organizing information, developing program materials, implementing the service, and evaluating the service. The narrative description of each step is illustrated by a case study example.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS/CONCLUSION

POCT patient care services are a valuable addition to a pharmacy's services, benefiting patients, health care providers, and the pharmacy. This article presents a structured, deliberate approach with resources that can be used to develop a successful POCT service within a community or ambulatory pharmacy setting.

Randomised controlled trial of near-patient testing for glycated haemoglobin in people with type 2 diabetes mellitus

BACKGROUND

Tight glycaemic control in people with type 2 diabetes can lead to a reduction in microvascular and possibly macrovascular complications. The use of near-patient (rapid) testing offers a potential method to improve glycaemic control.

AIM

To assess the effect and costs of rapid testing for glycated haemoglobin (HbA1c) in people with type 2 diabetes.

DESIGN OF STUDY

Pragmatic open randomised controlled trial.

SETTING

Eight practices in Leicestershire, UK.

METHOD

Patients were randomised to receive instant results for HbA1c or to routine care. The principal outcome measure was the proportion of patients with an HbA1c <7% at 12 months. We also assessed costs for the two groups.

RESULTS

Of the 681 patients recruited to the study 638 (94%) were included in the analysis. The mean age at baseline was 65.7 years (SD = 10.8 years) with a median (interquartile range) duration of diabetes of 4(1-8) years. The proportion of patients with HbA1c < 7% did not differ significantly between the intervention and control groups (37 versus 38%, odds ratio 0.95 [95% confidence interval = 0.69 to 1.31]) at 12 months follow up. The total cost for diabetes-related care was 390 UK pounds per patient for the control group and 370 UK pounds for the intervention group. This difference was not statistically significant.

CONCLUSION

Near-patient testing for HbA1c alone does not lead to outcome or cost benefits in managing people with type 2 diabetes in primary care. Further research is required into the use of rapid testing as part of an optimised patient management model including arrangements for patient review and testing.

Twelve essentials of science-based policy

This article presents a systematic framework of 12 essentials, or basic elements, of science-based policy. The 12 essentials are grouped into three categories, or areas, as follows: 1) knowledge generation, which includes credible design, accurate data, sound analysis, and comprehensive synthesis; 2) knowledge exchange, which includes relevant content, appropriate translation, timely dissemination, and modulated release; and 3) knowledge uptake, which includes accessible information, readable message, motivated user, and rewarding outcome.

Patient self-testing is a reliable and acceptable alternative to laboratory INR monitoring

SAn ageing population and the continuing expansion of clinical indications for coumadin therapy have increased pressure on hospital anticoagulant clinics. One solution is patient self-testing (PST) of the international normalized ratio (INR) using capillary blood samples on point-of-care coagulation monitors at home. We conducted a prospective study to determine whether patients can achieve accurate INR values through PST, using the CoaguChek S (Roche Diagnostics, Lewes, UK). The main outcome measurements were: comparability of INR values obtained by PST and the hospital laboratory, patient acceptability as assessed by a questionnaire and anticoagulant control. Eighty-four patients [53 men, 31 women; median age 59 years (range 26-83)], receiving long-term oral anticoagulation (warfarin), were recruited from our Anticoagulation Clinic. Patients were randomized to weekly self-testing or continuing 4-weekly hospital laboratory monitoring of INR. Comparison of INRs (n = 234) showed no significant differences between the CoaguChek (median INR 3.02) and laboratory testing (median INR 3.07). There was excellent correlation between the two methods (r = 0.95), with 85% of CoaguChek results within 0.5 INR units of the laboratory method. On four occasions, differences of >1 unit INR were obtained, but in each case the patient's anticoagulation was unstable (INR >4.5 by both methods) and the differences in INR would not have altered patient management. 87% of patients found self-testing straightforward, 87% were confident in the result they obtained and 77% preferred self-testing. We conclude that PST is a reliable alternative to hospital clinic attendance and is acceptable to the majority of suitably trained patients.

A comparison of Bayesian and maximum likelihood methods to determine the performance of a point of care test for Helicobacter pylori in the office setting

OBJECTIVE

Evaluations of point of care tests (PCT) are often hampered by a lack of appropriate gold standards. This study aimed to compare the results of a Bayesian statistical analysis and a maximum likelihood method to evaluate the performance of a PCT for Helicobacter pylori in primary care.

METHODS

The Helisal Rapid Blood Test (Cortecs Diagnostics) was performed in 311 patients from 6 primary care centers, and a concurrent venous sample was taken for 2 enzyme-linked immunosorbent assays (ELISA) performed at the laboratory, blind to the PCT result. The Bayesian analysis was conducted using Markov Chain Monte Carlo methods (WinBUGS). The performance characteristics of the PCT and the 2 ELISA tests were estimated together with 95% credible intervals (95% CIs).

RESULTS

The estimate of prevalence of H. pylori in this population was 64% (95% CI, 59% to 70%), the sensitivity and specificity of the PCT were 89% (84% to 94%) and 84% (77% to 91%), respectively (likelihood ratios positive 5.6, negative 0.13). The equivalent maximum likelihood results were prevalence, 65%; sensitivity, 90%; and specificity, 83%.

CONCLUSIONS

The Helisal Rapid Blood Test performed as well as laboratory-based ELISA tests in this cohort of patients. The Bayesian analysis and the maximum likelihood method gave similar results, the Bayesian method also simultaneously estimating 95% CIs.

Proactive health computing

In an analysis departing from the global health situation, the foundation for a change of paradigm in health informatics based on socially embedded information infrastructures and technologies is identified and discussed. It is shown how an increasing computing and data transmitting capacity can be employed for proactive health computing. As a foundation for ubiquitous health promotion and prevention of disease and injury, proactive health systems use data from multiple sources to supply individuals and communities evidence-based information on means to improve their state of health and avoid health risks. The systems are characterised by: (1) being profusely connected to the world around them, using perceptual interfaces, sensors and actuators; (2) responding to external stimuli at faster than human speeds; (3) networked feedback loops; and (4) humans remaining in control, while being left outside the primary computing loop. The extended scientific mission of this new partnership between computer science, electrical engineering and social medicine is suggested to be the investigation of how the dissemination of information and communication technology on democratic grounds can be made even more important for global health than sanitation and urban planning became a century ago.

Randomised controlled trial of Helicobacter pylori testing and endoscopy for dyspepsia in primary care

OBJECTIVE

To determine the cost effectiveness of a strategy of near patient Helicobacter pylori testing and endoscopy for managing dyspepsia.

DESIGN

Randomised controlled trial.

SETTING

31 UK primary care centres.

PARTICIPANTS

478 patients under 50 years old presenting with dyspepsia of longer than four weeks duration.

INTERVENTIONS

Near patient testing for H pylori and open access endoscopy for patients with positive results. Control patients received acid suppressing drugs or specialist referral at general practitioner's discretion.

MAIN OUTCOME MEASURES

Cost effectiveness based on improvement in symptoms and use of resources at 12 months; quality of life.

RESULTS

40% of the study group tested positive for H pylori. 45% of study patients had endoscopy compared with 25% of controls. More peptic ulcers were diagnosed in the study group (7.4% v 2.1%, P=0.011). Paired comparison of symptom scores and quality of life showed that all patients improved over time with no difference between study and control groups. No significant differences were observed in rates of prescribing, consultation, or referral. Costs were higher in the study group ( 367.85 pound sterling v 253.16 pound sterling per patient).

CONCLUSIONS

The test and endoscopy strategy increases endoscopy rates over usual practice in primary care. The additional cost is not offset by benefits in symptom relief or quality of life.