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POINT OF CARE TESTINGimproving health outcomes
Christopher P PriceOutcomes Research,
Diagnostics Division,
Bayer HealthCare,
Tarrytown, USA
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Point of Care Testingwhat is it?
“the provision of a test (result) at the
point in time at which the result will
be used to make a decision and take
appropriate action which will result in
an improved health outcome”
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Point of Care Testinghas also been known as….
near patientbed-side
physicians officeextra-laboratorydecentralised
ancillaryalternate site…..testing
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Point of Care Testingchanges in healthcare: stimulus for change
quality concernscost concerns
patients expectationsnew delivery models
new diseasesnew evidence
new technologieshealth economic strategies
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transmit result
report result
validate result
review quality control*
analyse specimen*and QC sample
prepare sample
transport to laboratory
phlebotomy*
preparerequest form
patient
doctorinterpretresult*
register request
Improving Delivery of Results
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Improving Delivery of Carechanges in clinical practice
treatment close to first point of contactpatient focussed care
one stop clinicselective vs emergency care
ambulatory careprimary carehome care
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Point of Care Testingwhere?
homework and leisure place
pharmacyhealth centre (inc DTC)
paramedical vehicleemergency roomoperating roomoutpatient clinic
ward(laboratory)
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Changes in Health Care Delivery conflicts of change
In Patient Out Patient HealthCentre Home
Patient Care
Laboratory Service
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Improving Health Outcomeswhat is a health outcome?
care of individual patients
maximisation of benefit
minimisation of risk
reasonable cost
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Point of Care Testingclinical outcomes; the 5Ds
Improving on .. death
.. disease
.. disability
.. discomfort
.. dissatisfaction
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Point of Care Testingclinical outcomes:surrogates
faster decision making
earlier treatment
improved compliance
reduced complications
faster optimisation
reduced readmission
patient satisfaction
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Point of Care Testinghealth economic perspectives
test
society
clinical team
health care plan payer
hospital
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Point of Care Testingeconomic outcomes:surrogates
clinic visits
length of stay
readmission rate
intervention rate
working days lost
productive years gained
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Point of Care Testingwhy?
make a quicker decision?
instigate urgent treatment?
counsel a patient?
empower a patient?
improve a patient outcome?
save money?
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Point of Care Testing
informationdecision
action
outcome
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Point of Care Testingefficacy
informationdecision
action
outcome
good quality
evidence
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Point of Care Testingprimary care
1057 publications identified
92 extracted
“… there is little evidence to support
the introduction of NPT in primary care …”Hobbs et al. 1997
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Point of Care Testingeffectiveness
informationdecision
action
outcomegood
qualitymanagement
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Point of Care Testingchallenges
informationdecision
action
outcome
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Point of Care Testingprompting action
start
withhold
modify
stop
……treatment
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Point of Care Testingan integrated sequence
test decision action
OUTCOME
question
PATIENT
A B
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Point of Care Testingan integrated process
test decision action
OUTCOME
question
PATIENT
A B
diagnostic accuracy
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Point of Care Testingan integrated process
test decision action
OUTCOME
question
PATIENT
A B
diagnostic outcome
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decisions
cost effectiveness
technical performance
organisational impact
clinical impact• diagnostic• therapeutic• health outcome
diagnostic performance
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decisions
cost effectiveness
technical performance
organisational impact
clinical impact• diagnostic• therapeutic• health outcome
diagnostic performance
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Point of Care Testingkeys to success
organisation and management
changing clinical practice
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decisions
cost effectiveness
technical performance
organisational impact
clinical impact• diagnostic• therapeutic• health outcome
diagnostic performance
Briefly, some examples …..
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Point of Care Testingemergency room
Tsai et al. 199428% patient course altered
Sands et al. 19959% patient course altered
11% admission/discharge altered
Kendall et al. 19987% patient treatment altered
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Point of Care Testingturnaround times: before and after
Test TAT (min) TAT (min) Change
Laboratory POCT min(%)
Urinalysis 40 4 - 36 (90)
Pregnancy 78 5 - 73 (94)
Glucose 10 6 - 4 (60)
Cardiac 110 17 - 93
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Point of Care TestingED length of stay: before and after
Test ED LOS (min) ED LOS (min) Change
Pre POCT Post POCT
Urinalysis 395 358 - 37
Pregnancy 386 346 - 40
Glucose N/A N/A N/A
Cardiac 386 338 - 47
Mean 389 347 - 41
p=0.006
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Point of Care Testingthe MGH ED ‘financials’
• POCT unit cost: $19.20 per test
• Lab unit cost: $2.94 per test
• productivity: 5,162 per FTE
• total testing volume: 25,812 per year
• total POCT cost: $495,590 (7d - 16h)
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Point of Care Testingthe broader perspective: MGH
• bed minutes saved per test: 41
• bed hours saved per year: 17,638
• cost of a bed: $402,960
• cost of two beds: $805,920
• total saving: $805,920 - $495,590
= $310,330
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Impact of Point of Care Monitoring on Epilepsy Management
weeks from first visit
number of dose changes
number of drug assays
monitoring:laboratory
22.9
2.0
4.5
clinic
4.5*
1.5
2.5*
*P<0.05
(Patsalos et al., Lancet 1987; ii: 39)
for optimal control:
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-0.8
-0.6
-0.4
-0.2
00 6 12
Months
HbA
1c(%
)
p< 0.05
POCT for HbA1c in Diabetes Clinic
Cagliero et al 1999
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patient
doctor
Point of Care Testingcompliance
glucose
urinealbumin
HbA1c
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Point of Care Testingintraoperative PTH measurement
reduces reoperation rate
enables day case surgery
reduces length of stay
reduces cost per procedure
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0
1000
2000
3000
4000
5000
6000
7000
MIP BL
p<0.0011
99
8 D
OL
LA
RS
Intraoperative PTH
Chen et al. 1999
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Point of Care Testinghaematology
whole blood PT and APTT
monitor cardiopulmonary bypass
reduces erythrocyte, FFP and platelet
requirement
annual saving $265,658
Despotis et al. 1994
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Outcome Measures inIntensive Care
Admission ACR + 24 hrs Scores
0 20 40 60 80
SAP sns
APACHE sns
ACR sns
P<0.00001
P=0.0125
P=0.0002
Gosling et al 2002
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Point of Care Testingmonitoring anticoagulation therapy
primary care setting
• computerised decision support
- improvement in INR control, 23% to 86%, p>0.001
- recall time extended, p=0.033
- improvement in time spent in target range, p=0.008
- proportion of tests in target range increased, p=0.015
- ‘primary care as safe as secondary care’Fitzmaurice et al 1996, 2000, 2001, 2002
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Point of Care Testingmicroeconomic cost analysis
Lee-Lewandrowski et al., 1994
Winkelman et al., 1994
Greendyke, 1992
Nosanchuk et al., 1995
glucose: cost / test ($)
13.49
6.62
11.50
7.14
3.84
3.30
3.91
6.88
POCT laboratory
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-1000-800-600-400-200
0200
1992 1993 1994 1995 1996 1997
Wagner et al 2001
Improved Glycaemic Controlhealthcare costs
$ (i
mpr
oved
-un
impr
oved
)
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Point of Care Testingtoday’s challenges
maintaining good quality systems
CHANGING CLINICAL PRACTICE