Design, implementation and initial assessment of the Northern Territory Point-of-Care Testing Program

Facilitators and barriers of the implementation of point-of-care devices for cardiometabolic diseases: a scoping review

BACKGROUND

Point-of-care testing (POCT) devices may facilitate the delivery of rapid and timely results, providing a clinically important advantage in patient management. The challenges and constraints in the implementation process, considering different levels of actors have not been much explored. This scoping review aimed to assess literature pertaining to implementation facilitators and barriers of POCT devices for the diagnosis or monitoring of cardiometabolic diseases.

METHODS

A scoping review of the literature was conducted. The inclusion criteria were studies on the inception, planning, or implementation of interventions with POCT devices for the diagnosis or monitoring of cardiometabolic diseases defined as dyslipidemia, cardiovascular diseases, type 2 diabetes, and chronic kidney disease. We searched MEDLINE, Embase, and Global Health databases using the OVID searching engine until May 2022. The Consolidated Framework of Implementation Research (CFIR) was used to classify implementation barriers and facilitators in five constructs. Also, patient, healthcare professional (HCP), and organization level was used.

RESULTS

Twenty studies met the eligibility criteria for data extraction. All studies except two were conducted in high-income countries. Some findings are: 1) Intervention: the most widely recognized facilitator was the quick turnaround time with which results are obtained. 2) Outer setting: at the organizational level, the lack of clear regulatory and accreditation mechanisms has hindered the adoption and sustainability of the use of POCT. 3) Inner setting: for HCP, performing POCT during the consultation was both a facilitator and a barrier in terms of time, personnel, and service delivery. 4) Individuals: the implementation of POCT may generate stress and discomfort in some HCP in terms of training and new responsibilities. 5) Process: for patients, it is highly appreciated that obtaining the sample was simple and more comfortable if venipuncture was not used.

CONCLUSION

This scoping review has described the facilitators and barriers of implementing a POCT device for cardiometabolic conditions using the CFIR. The information can be used to design better strategies to implement these devices and benefit more populations that have low access to cardiometabolic tests.

Sustained Quality and Service Delivery in an Expanding Point-of-Care Testing Network in Remote Australian Primary Health Care

CONTEXT.—

Since 2008, the Northern Territory Point-of-Care Testing Program has improved patient access to pathology testing for acute and chronic disease management for remote health services.

OBJECTIVE.—

To evaluate the analytical quality, service delivery, and clinical utility of an expanding remote point-of-care testing network.

DESIGN.—

Four years (2016-2019) of data on analytical quality, test numbers, and training statistics and 6 months of clinical point-of-care testing data from Abbott i-STATs at remote health services throughout the Northern Territory were analyzed to assess analytical performance, program growth, and clinical utility.

RESULTS.—

From 2016 to 2019, point-of-care test numbers increased, with chemistry and blood gas testing more than doubling to 8500 and 6000 tests, respectively, troponin I testing almost doubling (to 6000), and international normalized ratio testing plateauing at 8000 tests. Participation in quality control and proficiency testing was high, with quality comparable to laboratory-based analytical goals. A shift toward flexible training and communication modes was noted. An audit of point-of-care test results demonstrated elevated creatinine, associated with chronic kidney disease management, as the most common clinically actionable patient result.

CONCLUSIONS.—

The Northern Territory Point-of-Care Testing Program provides high quality point-of-care testing within remote primary health services for acute and chronic patient management and care. Clinical need, sound analytical performance, flexibility in training provision, and effective support services have facilitated the sustainability of this expanding point-of-care testing model in the remote Northern Territory during the past 11 years.

The Benefits and Challenges of Point-of-Care Testing in Rural and Remote Primary Care Settings in Australia

CONTEXT.—

Point-of-care (POC) testing has significant potential application in rural and remote Australian communities where access to laboratory-based pathology testing is often poor and the burden of chronic, acute, and infectious disease is high.

OBJECTIVE.—

To explore the clinical, operational, cultural, and cost benefits of POC testing in the Australian rural and remote health sector and describe some of the current challenges and limitations of this technology.

DATA SOURCES.—

Evidence-based research from established POC testing networks for chronic, acute, and infectious disease currently managed by the International Centre for Point-of-Care Testing at Flinders University are used to highlight the experience gained and the lessons learned from these networks and, where possible, describe innovative solutions to address the current barriers to the uptake of POC testing, which include governance, staff turnover, maintaining training and competency, connectivity, quality testing, sustainable funding mechanisms, and accreditation.

CONCLUSIONS.—

Point-of-care testing can provide practical and inventive opportunities to revolutionize the delivery of pathology services in rural and remote sectors where clinical need for this technology is greatest. However, many barriers to POC testing still exist in these settings, and the full potential of POC testing cannot be realized until these limitations are addressed and resolved.

Economic evaluation of point-of-care testing in the remote primary health care setting of Australia's Northern Territory

Aim

To determine the cost-effectiveness of utilizing point-of-care testing (POCT) on the Abbott i-STAT device as a support tool to aid decisions regarding the emergency medical retrievals of patients at remote health centers in the Northern Territory (NT) of Australia.

Methods

A decision analytic simulation model–based economic evaluation was conducted using data from patients presenting with three common acute conditions (chest pain, chronic renal failure due to missed dialysis session(s), and acute diarrhea) at six remote NT health centers from July to December 2015. The specific outcomes measured in this study were the number of unnecessary emergency medical retrieval prevented through POCT. Cost savings through prevented unnecessary medical retrievals for each presentation type were then determined and extrapolated to give per annum NT-wide estimates.

Results

POCT prevented 60 unnecessary medical evacuations from a total of 200 patient cases meeting the selection criteria (48/147 for chest pain, 10/28 for missed dialysis, and 2/25 for acute diarrhea). The associated cost savings were AUD $4,674, $8,034, and $786 per patient translating to NT-wide savings of AUD $13.72 million, $6.45 million, and $1.57 million per annum (AUD $21.75 million in total) for chest pain, missed dialysis, and acute diarrhea presentations, respectively.

Conclusion

This study demonstrated that POCT when used to aid decision making for acutely ill patients delivered significant cost savings for the NT health care system by preventing unnecessary emergency medical retrievals.

Point-of-care testing facilitates screening and treatment for anaemia in women and children in rural Pakistan

OBJECTIVE

To use point-of-care testing to screen and facilitate treatment for anaemia and to establish an estimate of the prevalence of anaemia in the local population.

DESIGN

An uncontrolled before and after study design was used to evaluate the effectiveness of the intervention on the anaemia status of participants.

SETTING

This study took place in a rural mountain community (population approximately 1000) in the Haripur district in northern Pakistan.

PARTICIPANTS

Women of child-bearing age (15-49 years) and children (12-14 years) were included in this study.

INTERVENTIONS

The intervention included point-of-care testing for haemoglobin, treatment with mebendazole and oral iron supplementation, and an education campaign about anaemia delivered by community health workers and medical students.

MAIN OUTCOME MEASURES

The main outcome measure was an increase in blood haemoglobin over the study period. A secondary outcome measure was a positive change in anaemia status or classification post-intervention.

RESULTS

Anaemia was initially detected in 64 (53%) women and 15 (47%) children. The mean haemoglobin concentration increased significantly (P < 0.001) from 118 to 130 g L^-1 (women) and 120 to 130 g L^-1 (children) post-intervention. Overall prevalence of anaemia in women (P < 0.001) and children (P < 0.001) decreased significantly (by 30% and 34%, respectively) post-intervention.

CONCLUSIONS

Point-of-care testing used for the detection of anaemia in this rural community helped to identify the burden of disease and to reduce this significantly by way of rapid diagnosis, education and immediate medical intervention.

Improvement in delivery of type 2 diabetes services differs by mode of care: a retrospective longitudinal analysis in the Aboriginal and Torres Strait Islander Primary Health Care setting

Background

Addressing evidence-practice gaps in primary care remains a significant public health challenge and is likely to require action at different levels of the health system. Whilst Continuous Quality Improvement (CQI) is associated with improvements in overall delivery, little is known about delivery of different types of care processes, and their relative improvement during CQI.

Methods

We used data from over 15,000 clinical audit records of clients with Type 2 diabetes collected as part of a wide-scale CQI program implemented between 2005 and 2014 in 162 Aboriginal and Torres Strait Islander health centres. We abstracted data from clinical records on 15 service items recommended in clinical guidelines and categorised these items into five modes of care on the basis of the mechanism through which care is delivered: laboratory tests; generalist-delivered physical checks; specialist-delivered checks; education/counselling for nutrition and physical activity and education/counselling for high risk substance use. We calculated delivery for each patient for each of mode of care by determining the proportion of recommended services delivered for that mode. We used multilevel regression models to quantify variation attributable to health centre or client level factors and to identify factors associated with greater adherence to clinical guidelines for each mode of care.

Results

Clients on average received 43 to 60 % of recommended care in 2005/6. Different modes of care showed different patterns of improvement. Generalist-delivered physical checks (delivered by a non-specialist) showed a steady year on year increase, delivery of laboratory tests showed improvement only in the later years of the study, and delivery of counselling/education interventions showed early improvement which then plateaued. Health centres participating in CQI had increased odds of top quartile service delivery for all modes compared to baseline, but effects differed by mode. Health centre factors explained 20–52 % of the variation across jurisdictions and health centres for different modes of care.

Conclusions

Levels of adherence to clinical guidelines and patterns of improvement during participation in a CQI program differed for different modes of care. Policy and funding decisions may have had important effects on the level and nature of improvements achieved.

Review of the cultural safety of a national Indigenous point-of-care testing program for diabetes management

In Australia, Aboriginal and Torres Strait Islander people have approximately three-fold higher rates of diabetes than non-Indigenous Australians. Point-of-care testing, where pathology tests are conducted close to the patient, with results available during the patient consultation, can potentially deliver several benefits for both the Indigenous client and the health professional team involved in their care. Currently, point-of-care testing for diabetes management is being conducted in over 180 Aboriginal and Torres Strait Islander Medical Services as part of a national program called Quality Assurance for Aboriginal and Torres Strait Islander Medical Services (QAAMS). The cultural safety of the Program was reviewed by sourcing the views of the QAAMS Indigenous Leaders Team in a focus group setting and by surveying the point-of-care testing operators enrolled in QAAMS, via an electronic questionnaire. The current study confirms that QAAMS remains a culturally safe program that fills a permanent and positive niche within the Indigenous health sector. The study demonstrates that QAAMS provides a convenient and accessible ‘one-stop’ pathology service for Indigenous clients with diabetes and empowers Aboriginal Health Workers to have a direct role in the care of their diabetes clients.

A randomised trial of point-of-care tests for chlamydia and gonorrhoea infections in remote Aboriginal communities: Test, Treat ANd GO- the "TTANGO" trial protocol

BACKGROUND

High prevalence rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) have been reported in Aboriginal people in remote and regional areas of Australia for well over two decades, and repeat positivity rates are high. To interrupt disease transmission and reduce the risk of complications, early diagnosis and treatment is important. However in many remote and regional areas there are long delays between testing for these curable sexually transmissible infections and providing treatment, due to both physical distance from laboratories and difficulties when recalling patients for subsequent management once results are available. Point-of-care (POC) tests have the potential to provide more timely diagnosis, to increase treatment and contact tracing, and in turn reduce CT and NG infection rates.

METHODS/DESIGN

TTANGO (Test, Treat, ANd GO) is a cross-over cluster randomised controlled trial in 12 regional or remote Australian health services, which predominantly provide clinical services to Aboriginal people. The overall aim of TTANGO is to measure the clinical effectiveness, cost-effectiveness and cultural and operational acceptability of molecular POC testing for CT and NG infection. The primary outcome is repeat positivity at three months after treatment of an initial CT or NG infection. Participating health services will undertake the clinical management of CT and NG under two different modalities for one year each. In the first year, six health services will be randomly assigned to manage these infections under current diagnostic guidelines. The other six will supplement current diagnostic guidelines with POC testing, whereby diagnosis is made and subsequent treatment for those with positive POC tests is offered at the initial consultation. In the second year, the health services will cross over to the opposite management modality. TTANGO will be conducted over four years; 1.5 years of trial initiation and community consultation, 2 years of trial conditions and evaluation, and 6 months of data analysis and feedback.

DISCUSSION

TTANGO is the first cluster randomised trial of POC testing for CT and NG internationally. The results of this trial will provide crucial information to guide sexual health clinical practice in remote Aboriginal communities and other high prevalence settings.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12613000808741.