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

Transformative impact of point-of-care testing in critical care

The advent of point-of-care testing (POCT) has revolutionized the approach to patient management, especially for pediatric care. POCT provides rapid, on-the-spot biochemical and microbiological evaluations, bypassing delays typically associated with central laboratory testing, enabling swift clinical decision-making. Additionally, POCT has proven to be a valuable prognostic tool for monitoring electrolyte, lactate, creatinine levels, often a marker of severe illness and poor outcomes. POCT enables its faster identification, allowing for prompt interventions. This capability is essential in managing conditions like sepsis, where timely treatment can significantly impact survival rates. However, the implementation of POCT is not without its challenges. Variability in sample handling, particularly with heparinized syringes, can affect the accuracy of certain measurements, such as potassium levels. The absence of comprehensive follow-up data and cost-effectiveness analyses in some studies indicate the need for continued research to optimize the use of POCT. In conclusion, POCT is a transformative tool in critical care, offering prompt and reliable assessments that significantly enhance patient management. As technology advances, the integration of POCT into emergency departments and intensive critical care units holds great promise for improving the quality of healthcare and patient survival rates.

Performance of the Flash10 COVID-19 point-of-care molecular test

After the COVID-19 pandemic, fever clinics urgently require rapid nucleic acid tests to enhance their capacity for timely pathogen detection. This study evaluated the analytical performance and clinical utility of the Flash10 SARS-CoV-2 point-of-care test (Flash10 POCT) for detecting SARS-CoV-2 in patients with fever in the adult fever clinic in Beijing Tsinghua Changgung Hospital from August 1 to August 30, 2023. The analytical performance and clinical utility of the Flash10 POCT for detecting SARS-CoV-2 were assessed in 125 patients with fever syndrome in the adult fever clinic. The Flash10 POCT demonstrated an analytical precision of 3.1% for the Ct values of the ORF1ab gene and 2.9% for the Ct values of the N gene in SARS-CoV-2 nucleic acid testing. Furthermore, the Flash10 POCT demonstrated a lower limit of detection (LoD) of 100 copies/mL, with no detected aerosol contamination leakage. Of the 125 patients (median age 61.9 years, 52% male and 48% female), both the Flash10 POCT and RT-PCR tests yielded positive results for 100 patients and negative results for 25 patients (Fisher's exact test, p < 0.0001). The median turn-around-time for the Flash10 POCT was significantly shorter, at 1.05 h, compared to 16.15 h required for RT-PCR tests (Wilcoxon signed rank test, p < 0.0001). The Flash10 POCT showed high analytical performance, achieving a 100% detection rate for SARS-CoV-2 compared to RT-PCR tests, while also exhibiting a significantly shorter turn-around-time. Implementing the Flash10 POCT had the potential to expedite the care of adults presenting with fever.

Comparative Study of Laboratory Versus Bedside High-Sensitivity Troponin I in the Emergency Medicine Department of a Tertiary Care Hospital in India

BACKGROUND

 Evaluating high-sensitivity troponin I levels in emergency medicine is critical for diagnosing acute myocardial infarction (AMI). This study aims to evaluate the central laboratory versus bedside troponin I test in the emergency department of a tertiary care center.

MATERIAL AND METHODS

 This prospective observational study was conducted at Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pune, Maharashtra, India, from October to December 2023. Patient samples were analyzed in the central laboratory using the Dimension EXL 200 (Siemens® Healthcare Diagnostics Inc., Erlangen, Germany) as the gold standard test and through point-of-care testing using the TriageTrue® (Quidel Corporation, San Diego, CA) high-sensitivity troponin I kit, which was run on the Triage® MeterPro® device (Quidel Corporation, San Diego, CA). This device quantitatively determines troponin I in ethylenediaminetetraacetic acid-anticoagulated whole blood and plasma specimens. The results were compared. Statistical analysis was performed using SPSS version 18 (SPSS Inc., Chicago, IL). An unpaired t-test was performed to compare the difference in time taken using the two testing methods.

RESULT

 The mean time for obtaining troponin I results was substantially shorter with bedside testing (14.91 minutes, standard deviation (SD) = 0.5) than with laboratory testing (119.1 minutes, SD = 5.03). Statistical analysis revealed a significant difference (t = -172.36, p < 0.001). A chi-square test was conducted to assess the disparity between the two testing methods, yielding a chi-square value of 32.64 and a p value of 0.00001, indicating a significant difference between bedside testing and laboratory testing.

CONCLUSION

The bedside high-sensitivity troponin I test offers a considerable advantage over laboratory testing regarding turnaround time within the emergency medicine department in India. This rapid diagnostic capability is crucial for timely management, which is beneficial for patients inconclusive of acute coronary syndrome-like non-ST segment elevation myocardial infarction (NSTEMI). It is also cost-effective. It also reduces the emergency boarding time and may reduce the number of unnecessary admissions in healthcare facilities.

Molecular point-of-care devices for the diagnosis of infectious diseases in resource-limited settings - A review of the current landscape, technical challenges, and clinical impact

Molecular point-of-care (POC) tests offer high sensitivity, rapid turnaround times, relative ease of use, and the convenience of laboratory-grade testing in the absence of formal laboratory spaces and equipment, making them appealing options for infectious disease diagnosis in resource-limited settings. In this review, we discuss the role and potential of molecular POC tests in resource-limited settings and their associated logistical challenges. We discuss U.S. Food and Drug Administration approval, Clinical Laboratory Improvement Amendments complexity levels, and the REASSURED criteria as a starting point for assessing options currently available inside and outside of the United States. We then present POC tests currently in research and development phases that have potential for commercialization and implementation in limited-resource settings. Finally, we review published studies that have assessed the clinical impact of molecular POC testing in limited- and moderate-resource settings.

The convergence of traditional and digital biomarkers through AI-assisted biosensing: A new era in translational diagnostics?

Advances in consumer electronics, alongside the fields of microfluidics and nanotechnology have brought to the fore low-cost wearable/portable smart devices. Although numerous smart devices that track digital biomarkers have been successfully translated from bench-to-bedside, only a few follow the same fate when it comes to track traditional biomarkers. Current practices still involve laboratory-based tests, followed by blood collection, conducted in a clinical setting as they require trained personnel and specialized equipment. In fact, real-time, passive/active and robust sensing of physiological and behavioural data from patients that can feed artificial intelligence (AI)-based models can significantly improve decision-making, diagnosis and treatment at the point-of-procedure, by circumventing conventional methods of sampling, and in person investigation by expert pathologists, who are scarce in developing countries. This review brings together conventional and digital biomarker sensing through portable and autonomous miniaturized devices. We first summarise the technological advances in each field vs the current clinical practices and we conclude by merging the two worlds of traditional and digital biomarkers through AI/ML technologies to improve patient diagnosis and treatment. The fundamental role, limitations and prospects of AI in realizing this potential and enhancing the existing technologies to facilitate the development and clinical translation of "point-of-care" (POC) diagnostics is finally showcased.

Impact of Albumin-to-Creatinine Ratio Point-of-Care Testing on the Diagnosis and Management of Diabetic Kidney Disease

BACKGROUND

For the diagnosis of diabetic kidney disease (DKD), quantitative albuminuria measurement using the albumin-to-creatinine ratio (ACR) is recommended according to various guidelines. It can be measured either in specialized laboratories or using ACR point-of-care testing (POCT). This observational study aims at evaluating the effect of ACR POCT utilization on the DKD diagnosis and treatment management for glycemic control and blood pressure.

METHOD

Data of 717 patients with diabetes (type 1 diabetes: n = 236; type 2 diabetes: n = 463; other diabetes forms: n = 18) were assessed in three centers. The impact of ACR POCT on DKD diagnosis and treatment management for glycemic control and blood pressure was assessed using a case report form. The assessment of ACR POCT utilization purpose and relevance for physicians was documented using a questionnaire.

RESULTS

Of all participants (n = 717), 39.1% had a confirmed/suspected DKD diagnosis. Hereof, 8.6% were newly diagnosed with DKD, and 9.9% were suspected with DKD based on the actual ACR POCT values. Within the group of patients with confirmed/suspected DKD (n = 280), treatment modification was performed in 46.1% of participants. A drug initiation with GLP-1 receptor agonists or SGLT2 inhibitors was performed in 11.1% or 8.9% of patients with confirmed/suspected DKD, respectively. Regarding the utilization purposes of ACR POCT, 100% of the physicians (n = 8) indicated using it to examine patients with diabetes with or without hypertension; 75% considered it very important for patients with diabetes.

CONCLUSIONS

The implementation of ACR POCT may positively affect DKD diagnosis and subsequently allow better management of patients with diabetes.

Associations between elevated high-sensitive cardiac troponin t and outcomes in patients with acute abdominal pain

PURPOSE

The purpose of this study was to determine outcomes in patients presenting to emergency department (ED) with acute abdominal pain and suspected occult myocardial injury [OMI (high-sensitive cardiac troponin T, hs-cTnT level > 14 ng/L)] without clinical signs of myocardial ischaemia. We hypothesized that OMI is a common entity associated with poor outcomes.

METHODS

After institutional research ethics committee approval, a retrospective review was performed on patients subjected to extended use of hs-cTnT measurements during two months period in patients admitted to ED with a chief complaint of abdominal pain, aged 30 years or older and triaged to red, orange, or yellow categories. Primary outcomes were 30-day, six-month, and one-year mortality, respectively. Adjusted mortality rates were compared using the Cox proportional hazard regression model.

RESULTS

Overall, 1000 consecutive patients were screened. A total of 375 patients were subjected to hs-cTnT measurement and 156 of them (41.6%) experienced OMI. None of the patients had acute myocardial infarction diagnosed in the ED. Patients with OMI had a significantly higher 30-day, six-month and one-year mortality compared to the normal hs-cTnT level group [12.8% (20/156) vs. 3.7% (8/219), p = 0.001, 34.0% (53/156) vs. 6.9% (15/219), p < 0.001 and 39.1% (61/156) vs. 9.1 (20/219), p < 0.001, respectively]. OMI was an independent risk factor for mortality at every time point analyzed.

CONCLUSION

Our investigation noted OMI in older patients with co-morbidities and in higher triage category presenting with abdominal pain to ED, respectively. OMI is an independent risk factor for poor outcomes that warrants appropriate screening and management strategy. Our results support the use of hs-cTnT as a prognostication tool in this subgroup of ED patients.

Utilizing point-of-care A1c to impact outcomes - can we make it happen in primary care?

PURPOSE OF REVIEW

Hemoglobin A1c testing provides a marker of glycemic control and is the standard for diabetes risk assessment. According to the Centers for Disease Control (CDC), only 67.3-71.4% of diabetic patients between 2011 and 2016 had at least two A1c levels tested per year. Moreover, 27.8% had uncontrolled diabetes with an A1c of ≥8.0%, increasing the risk of microvascular complications. Lack of monitoring presents a significant barrier, and improving ease of testing could improve glycemic control.

RECENT FINDINGS

Point-of-care (POC) A1c testing, obtained via capillary blood with results provided in 5-6 min, is available and used frequently in endocrine clinics. However, POC A1c testing is not standard in primary care, where 90% of type 2 diabetes patients are treated. Barriers include access and costs of POC A1c machines and standardization of testing in the primary care setting. Review of literature, however, suggests that POC A1c testing in primary care may lead to A1c reduction whereas being potentially cost-effective and strengths the patient-physician relationship.

SUMMARY

POC A1c testing in primary care, if widely available and integrated into workflow, has the potential to positively impact diabetes care. Real-time feedback may change patient and physician behaviors, allowing earlier therapeutic intensification.

Assessment of Patient Satisfaction with On-Site Point-of-Care Hemoglobin A1c Testing: An Observational Study

INTRODUCTION

Poor glycemic control is a serious challenge in successful diabetes management. Given the low adherence and compliance with HbA1c testing frequency and the corresponding delay in the appropriate medication adjustment, point-of-care testing (POCT) for HbA1c provides an opportunity for better control of diabetes and higher patient satisfaction. The data with this regard are limited in Saudi Arabia. Therefore, we aimed to assess the level of patient satisfaction associated with the POCT service implementation for HbA1c and evaluate the differences between the number of requested and conducted HbA1c tests before and after POCT implementation and its effect on glycemic control in Saudi clinical practice.

METHODS

We conducted a single-center ambispective descriptive cohort study in Riyadh, Saudi Arabia. This study had two phases: the retrospective phase (January 2017 to December 2017) and the prospective phase (January 2018 to December 2018). Patient satisfaction was assessed using the patient satisfaction questionnaire short form (PSQ-18) and on-site HbA1c point-of-care testing (HbA1c-POCT) satisfaction questionnaire.

RESULTS

This study included 75 patients with diabetes (37% type 1, 63% type 2) with a mean age of 44.35 (± 17.97) years. The adherence to physician recommendations for HbA1c testing frequency increased from 24% to 85% (before and after POCT implementation, respectively). High levels of satisfaction across seven dimensions of PSQ-18 (77-88%) were reported towards the provided healthcare service after POCT implementation. Furthermore, a high level of agreement on the statements of the on-site HbA1c-POCT satisfaction questionnaire was also observed. Finally, the mean HbA1c level has significantly improved after POCT implementation compared to the traditional HbA1c laboratory testing before POCT implementation [8.34 ± 0.67 and 8.06 ± 0.62, respectively, p < 0.001).

CONCLUSION

HbA1c testing at POCT improved adherence to recommendations for HbA1c testing frequency for better glycemic control and higher patient satisfaction. POCT reduces turnaround time, improves glycemic control, and facilitates the decision-making process. HbA1c measurement with POC devices is recommended to be implemented in diabetes treatment centers. All of the described benefits of POCT come together to make HbA1c testing the most common procedure for diabetes management at the point of care.

Advances in point-of-care testing for cardiovascular diseases

Point-of-care testing (POCT) is a specific format of diagnostic testing that is conducted without accompanying infrastructure or sophisticated instrumentation. Traditionally, such rapid sample-to-answer assays provide inferior analytical performances to their laboratory counterparts when measuring cardiac biomarkers. Hence, their potentially broad applicability is somewhat bound by their inability to detect clinically relevant concentrations of cardiac troponin (cTn) in the early stages of myocardial injury. However, the continuous refinement of biorecognition elements, the optimization of detection techniques, and the fabrication of tailored fluid handling systems to manage the sensing process has stimulated the production of commercial assays that can support accelerated diagnostic pathways. This review will present the latest commercial POC assays and examine their impact on clinical decision-making. The individual elements that constitute POC assays will be explored, with an emphasis on aspects that contribute to economically feasible and highly sensitive assays. Furthermore, the prospect of POCT imparting a greater influence on early interventions for medium to high-risk individuals and the potential to re-shape the paradigm of cardiovascular risk assessments will be discussed.

Health Economic Evidence of Point-of-Care Testing: A Systematic Review

OBJECTIVE

Point-of-care testing (POCT) has become an essential diagnostic technology for optimal patient care. Its implementation, however, still falls behind. This paper reviews the available evidence on the health economic impact of introducing POCT to assess if poor POCT uptake may be related to lacking evidence.

STUDY DESIGN

The Scopus and PubMed databases were searched to identify publications describing a health economic evaluation of a point-of-care (POC) test. Data were extracted from the included publications, including general and methodological characteristics as well as the study results summarized in either cost, effects or an incremental cost-effectiveness ratio. Results were sorted into six groups according to the POC test's purpose (diagnosis, screening or monitoring) and care setting (primary care or secondary care). The reporting quality of the publications was determined using the CHEERS checklist.

RESULTS

The initial search resulted in 396 publications, of which 44 met the inclusion criteria. Most of the evaluations were performed in a primary care setting (n = 31; 70.5%) compared with a secondary care setting (n = 13; 29.5%). About two thirds of the evaluations were on POC tests implemented with a diagnostic purpose (n = 28; 63.6%). More than 75% of evaluations concluded that POCT is recommended for implementation, although in some cases only under specific circumstances and conditions. Compliance with the CHEERS checklist items ranged from 20.8% to 100%, with an average reporting quality of 72.0%.

CONCLUSION

There were very few evaluations in this review that advised against the implementation of POCT. However, the uptake of POCT in many countries remains low. Even though the evaluations included in this review did not always include the full long-term benefits of POCT, it is clear that health economic evidence across a few dimensions of value already indicate the benefits of POCT. This suggests that the lack of evidence on POCT is not the primary barrier to its implementation and that the low uptake of these tests in clinical practice is due to (a combination of) other barriers. In this context, aspects around organization of care, support of clinicians and quality management may be crucial in the widespread implementation of POCT.

The Impact of Point-of-Care Hemoglobin A1c Testing on Population Health-Based Onsite Testing Adherence: A Primary-Care Quality Improvement Study

BACKGROUND

The hemoglobin A1c (HbA1c) is a gold-standard test to diagnose and monitor diabetes mellitus and has been incorporated into population health performance metrics for quality care. However, patients and practices remain challenged in completing timely HbA1c tests. Point-of-care testing (POCT) for HbA1c provides a quick, easy, reliable method for monitoring diabetes in the primary care office setting. The objectives of this quality improvement study were to evaluate the impact of HbA1c POCT on onsite HbA1c testing frequency as a component of population health performance, as well as to measure the utility of HbA1c POCT in identifying clinically meaningful change in disease.

METHOD

Prospective quality improvement cohort study among sequentially scheduled adult patients with diabetes due for HbA1c testing across three primary care practices.

RESULTS

Practices with HbA1c POCT were 3.7 times less likely to miss HbA1c testing at the time of the visit compared with practices in which HbA1c POCT was not available (P < .001). Nearly one in four patients in each group were found to have clinically worsening diabetes (defined by an increase in HbA1c of ≥0.5% or 5.5 mmol/mol). Nearly half of those patients in the intervention group were identified by POCT.

CONCLUSIONS

HbA1c POCT can improve population health-driven HbA1c testing adherence at office visits in primary care and may enable more timely intervention of diabetes management for patients with worsening disease.

Current Status of Clinical Application of Point-of-Care Testing

CONTEXT.—

The clinical applications of point-of-care testing (POCT) are gradually increasing in many health care systems. Recently, POCT devices using molecular genetic method techniques have been developed. We need to examine clinical pathways to see where POCT can be applied to improve them.

OBJECTIVE.—

To introduce up-to-date POCT items and equipment and to provide the content that should be prepared for clinical application of POCT.

DATA SOURCES.—

Literature review based on PubMed searches containing the terms point-of-care testing, clinical chemistry, diagnostic hematology, and clinical microbiology.

CONCLUSIONS.—

If medical resources are limited, POCT can help clinicians make quick medical decisions. As POCT technology improves and menus expand, areas where POCT can be applied will also increase. We need to understand the limitations of POCT so that it can be optimally used to improve patient management.

Implementing Point-of-Care Troponin Testing in the Emergency Department: Impact on Time to Result

INTRODUCTION

In the emergency department, troponin assays are commonly used and essential in the evaluation of chest pain and diagnosis of acute coronary syndrome. This study was designed to assess the potential impact of implementing point-of-care troponin testing by comparing the time to point-of-care laboratory result and time to conventional laboratory result.

METHODS

The study enrolled 60 ED patients deemed to need a troponin test in the evaluation of low-risk chest pain (HEART score <4 based on history, electrocardiogram, age, risk factors). Point-of-care troponin testing was performed with the same blood sample obtained for a conventional troponin assay. If the provider determined that the patient required 2 troponin tests, the second laboratory draw was used in the data collection. This was to correlate the time of laboratory result to time of disposition.

RESULTS

Of the 60 subjects enrolled, 2 subjects were excluded because of user errors with the point-of-care testing equipment and 2 others for not meeting inclusion criteria on later review. The median times for the point-of-care troponin and conventional troponin assays were 11:00 minutes (interquartile range 10:00-15:30) and 40:00 minutes (interquartile range 31:30-52:30), respectively; P < 0.001. There were 3 extreme outliers from the conventional troponin assay that significantly skewed the distribution of the mean, making the median the more accurate assessment of the central tendency.

DISCUSSION

Point-of-care troponin testing provided results in a median time 29 minutes quicker than the conventional troponin assay. This result is statistically significant and has the potential to greatly improve time to disposition in all patients with chest pain requiring a troponin assay.

The Role of Diabetes Mellitus in Diseases of the Gallbladder and Biliary Tract

BACKGROUND

The increasing prevalence of diabetes mellitus worldwide continues to pose a heavy burden. Though its gastrointestinal impact is appropriately recognized, the lesser known associations may be overlooked.

OBJECTIVE

We aim to review the negative implications of diabetes on the gallbladder and the biliary tract.

METHODS

A MEDLINE® database search of literature was conducted with emphasis on the previous five years, combining keywords such as "diabetes," "gallbladder," and "biliary".

RESULTS

The association of diabetes to the formation of gallstones, gallbladder cancer, and cancer of the biliary tract are discussed along with diagnosis and treatment.

CONCLUSION

Though we uncover the role of diabetic neuropathy in gallbladder and biliary complications, the specific individual diabetic risk factors behind these developments is unclear. Also, in addition to diabetes control and surgical gallbladder management, the treatment approach also requires further focus.

XW-100: First FDA CLIA-Waived CBC Analyzer Designed for Physician Office Use

BACKGROUND

The XW-100 hematology analyzer (Sysmex America) is the first complete blood count (CBC) instrument waived by the US Food and Drug Administration. This analyzer also tests for a 3-part white blood cell count differential.

METHODS

The XW-100 analyzer was evaluated for preanalytical specimen variables including the need for mixing, specimen storage conditions, freeze-thaw cycles, the effect of under filling of tubes, precision, linearity, carryover, limits of the blank, detection, and quantification and interferences from common and CBC-specific substances. The clinical study examined 586 blood samples from 6 CLIA-waived clinical sites and 6 paired moderately complex sites. The point-of-care sites had different medical specialties and were using inexperienced operators. The results of 8 measurements and 4 calculated parameters were compared to a moderately complex point-of-care hematology analyzer (pocH-100i, Sysmex).

RESULTS

The precision was <6% for all analytics, and there was no carryover noted. Samples containing interfering substances were appropriately flagged or suppressed by the instrument. The correlation to the predicate analyzer was highly concordant, producing near unity slope and intercept and minimal bias. Delays from sample collection to testing resulted in decreased performance. The percentage of samples inside the allowable error was >98.8% for all parameters studied.

CONCLUSION

This CLIA-waived hematology analyzer produces acceptable results and can be used in offices and clinics.

The value proposition for point-of-care testing in healthcare: HbA1c for monitoring in diabetes management as an exemplar

Point-of-care testing (POCT) is a key enabling technology for disruptive and transformative innovation in healthcare, allowing tests to be performed quickly and close to the patient. This results in faster clinical decision making and new, more efficient models of care, with clinical, process and economic benefits potentially accruing to all stakeholders. Recognised barriers to the adoption of new technology such as POCT include poor understanding of current practice and thus the unmet need, the challenges of process change, and reluctance to disinvest in redundant resources resulting from improved pathway efficiency. Major contributors to this problem include a background of funding, organisation and management of healthcare that fails to recognise the complexity of a multiple stakeholder health economy seeking to become more outcomes-based and value driven. We examine the concept of a structured value proposition as a generic tool to achieve better adoption of POCT using as an example, the evidence that is available for the rapid measurement of glycated haemoglobin (HbA1c) in the management of diabetes. We highlight the key components of the value proposition, identifying the impact of the test result on all stakeholders and the metrics which are required to define current practice (e.g. a laboratory-based HbA1c testing service), in order to develop the business case and the implementation plan required to demonstrate effective adoption of a POCT-based service. We conclude that the value proposition helps to identify the potential benefits to be gained from using POCT, and the stakeholders to whom they accrue.

Implementation of point-of-care testing in a pediatric healthcare setting

Point-of-care testing (POCT) refers to testing performed outside the clinical laboratory near the patient or at the site of patient care. This could be in critical care settings like the intensive care unit (ICU) and emergency department (ED) or primary care settings like physician offices where testing is performed by nonlaboratory personnel. POCT circumvents several steps in central laboratory testing including specimen transportation and processing resulting in faster turnaround times. Provider access to rapid test results at the site of patient care allows for prompt medical decision making which can lead to improved patient outcomes, operational efficiencies, patient satisfaction, and even cost savings in some cases. In addition to providing results rapidly, POCT devices have small specimen volume requirements compared to central laboratory tests making POCT particularly attractive for pediatric healthcare settings. The availability of published reports on the impact of POCT implementation in pediatric care are helpful resources when evaluating the clinical necessity of POCT prior to implementation. Even though several studies have shown advantages to implementing POCT in different pediatric settings, it is important to note that limitations exist that might limit the utilization of certain POCTs in some pediatric populations. So, it is important that these limitations and the analytical performance of a test are considered while keeping the target patient population in mind. Since POCTs are performed by non-laboratory staff who are not trained laboratory personnel, one challenge with POCT is maintaining regulatory compliance and quality assurance. It is therefore important that regulatory and quality assurance programs be put in place prior to implementing POCT in the pediatric hospital. With advances in POCT technology, most POCT devices have the capability to interface to the laboratory information system (LIS) and electronic medical record (EMR). POCT device interfacing allows for improved compliance to regulatory and quality assurance standards. Maintaining a cost efficient POCT program is becoming increasingly important as hospitals and healthcare systems are undergoing consolidation and harmonization. This includes assessing the clinical and operational benefit of POCT before implementation and inventory management to ensure minimal reagent wastage. This review discusses these different considerations when implementing POCT with a focus on the pediatric healthcare setting.

Implementation of HbA1c Point of Care Testing in 3 German Medical Practices: Impact on Workflow and Physician, Staff, and Patient Satisfaction

BACKGROUND

Medical practices face challenges of time and cost pressures with scarce resources. Point-of-care testing (POCT) has the potential to accelerate processes compared to central laboratory testing and can increase satisfaction of physicians, staff members, and patients. The objective of this study was to evaluate the effects of introducing HbA1c POCT in practices specialized in diabetes.

METHOD

Three German practices that manage 400, 550, and 950 diabetes patients per year participated in this evaluation. The workflow and required time before and after POCT implementation (device: Alere Afinion AS100 Analyzer) was evaluated in each practice. Physician (n = 5), staff (n = 9), and patient (n = 298) satisfaction was assessed with questionnaires and interviews.

RESULTS

After POCT implementation the number of required visits scheduled was reduced by 80% (88% vs 17.6%, P < .0001), the number of venous blood collections by 75% (91% vs 23%, P < .0001). Of patients, 82% (vs 13% prior to POCT implementation) were able to discuss their HbA1c values with treating physicians immediately during their first visit ( P < .0001). In two of the practices the POCT process resulted in significant time savings of approximately 20 and 22 working days per 1000 patients per year (95% CI 2-46; 95% CI 10-44). All physicians indicated that POCT HbA1c implementation improved the practice workflow and all experienced a relief of burden for the office and the patients. All staff members indicated that they found the POCT measurement easy to perform and experienced a relief of burden. The majority (61.3%) of patients found the capillary blood collection more pleasant and 83% saw an advantage in the immediate availability of HbA1c results.

CONCLUSIONS

The implementation of HbA1c POCT leads to an improved practice workflow and increases satisfaction of physicians, staff members and patients.

Which Point-of-Care Tests Would Be Most Beneficial to Add to Clinical Practice?: Findings From a Survey of 3 Family Medicine Clinics in the United States

BACKGROUND

Point-of-care tests (POCTs) are increasingly used in family medicine to facilitate screening, diagnosis, monitoring, treatment, and referral decisions for a variety of conditions. Point-of-care tests that clinicians believe might be beneficial to add to clinical practice and the conditions for which they would be most useful in family medicine remain poorly understood in the United States.

METHODS

Forty-two clinicians at 3 family medicine residency clinics completed a brief survey asking which POCTs they believed would be beneficial to add to their clinical practice and the conditions POCTs would be most useful for. We calculated frequencies of reported POCTs and conditions using descriptive statistics.

RESULTS

Clinicians identified 34 POCTs that would be beneficial to add to family medicine, of which hemoglobin A1c, chemistry panels, and human immunodeficiency virus and gonococcal and/or chlamydia were most frequently reported and anticipated would be used weekly. Clinicians reported 30 conditions for which they considered POCTs would be useful. Diabetes mellitus, sexually transmitted infections, and respiratory tract infections were the most often reported and were identified as benefiting diagnosis, monitoring, and treatment decisions.

CONCLUSIONS

Clinicians identified a number of POCTs they viewed as being beneficial to add to their routine clinical practice, mostly to inform diagnosis and treatment planning. Some POCTs identified are available in the United States; thus, understanding barriers to implementation of these POCTs in primary care settings is necessary to optimize adoption.

Multidisciplinary Point-of-Care Testing in South African Primary Health Care Clinics Accelerates HIV ART Initiation but Does Not Alter Retention in Care

BACKGROUND

Lack of accessible laboratory infrastructure limits HIV antiretroviral therapy (ART) initiation, monitoring, and retention in many resource-limited settings. Point-of-care testing (POCT) is advocated as a mechanism to overcome these limitations. We executed a pragmatic, prospective, randomized, controlled trial comparing the impact of POCT vs. standard of care (SOC) on treatment initiation and retention in care.

METHODS

Selected POC technologies were embedded at 3 primary health clinics in South Africa. Confirmed HIV-positive participants were randomized to either SOC or POC: SOC participants were venesected and specimens referred to the laboratory with patient follow-up as per algorithm (∼3 visits); POC participants had phlebotomy and POCT immediately on-site using Pima CD4 to assess ART eligibility followed by hematology, chemistry, and tuberculosis screening with the goal of receiving same-day adherence counseling and treatment initiation. Participant outcomes measured at recruitment 6 and 12 months after initiation.

RESULTS

Four hundred thirty-two of 717 treatment eligible participants enrolled between May 2012 and September 2013: 198 (56.7%) SOC; 234 (63.6%) POC. Mean age was 37.4 years; 60.5% were female. Significantly more participants were initiated using POC [adjusted prevalence ratio (aPR) 0.83; 95% confidence interval (CI): 0.74 to 0.93; P < 0.0001], the median time to initiation was 1 day for POC and 26.5 days for SOC. The proportion of patients in care and on ART was similar for both arms at 6 months (47 vs. 50%) (aPR 0.96; 95% CI: 0.79 to 1.16) and 12 months (32 vs. 32%) (aPR 1.05; 95% CI: 0.80 to 1.38), with similar mortality rates. Loss to follow-up at 12 months was higher for POC (36% vs. 51%) (aPR 0.82; 95% CI: 0.65 to 1.04).

CONCLUSIONS

Adoption of POCT accelerated ART initiation but once on treatment, there was unexpectedly higher loss to follow-up on POC and no improvement in outcomes at 12 months over SOC.

Ensuring the Quality of Point-of-Care Testing in a Large and Decentralized Ambulatory Care Setting

OBJECTIVES

In this project, we assessed the breadth, quality, trends, and outcomes of point-of-care (POC) testing and regulatory compliance in 200 University of California, Los Angeles (UCLA) Health system outpatient clinics.

METHODS

We retrospectively extracted clinic POC test orders, results, and e-prescription data from the UCLA electronic health record over a 1-year period.

RESULTS

Over 100,000 total tests were performed, encompassing 10 POC tests. Initially, 40% of clinics did not have complete licensure, but after implementation of the POC team, this metric improved to 100% licensure within 6 months. Most clinics used two or fewer POC tests, resulted fewer than 200 tests per year, and performed little to no external quality control measures. Our data analytics approach showed that peak POC testing occurred in January 2015, driven by influenza and urinalysis testing, and that both the testing and resulting clinical decision making do not routinely follow society guidelines.

CONCLUSIONS

This decentralization of laboratory testing presents challenges to ensuring quality POC testing. Optimization and analysis of informatics data allow for the identification of POC test utilization trends, areas of improvement for clinical workflows, and increased education on national guidelines.

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.

How can point-of-care HbA1c testing be integrated into UK primary care consultations? - A feasibility study

AIMS

Point-of-care (POC) HbA1c testing gives a rapid result, allowing testing and treatment decisions to take place in a single appointment. Trials of POC testing have not been shown to improve HbA1c, possibly because of how testing was implemented. This study aimed to identify key components of POC HbA1c testing and determine strategies to optimise implementation in UK primary care.

METHODS

This cohort feasibility study recruited thirty patients with type 2 diabetes and HbA1c>7.5% (58mmol/mol) into three primary care clinics. Patients' clinical care included two POC HbA1c tests over six months. Data were collected on appointment duration, clinical decisions, technical performance and patient behaviour.

RESULTS

Fifty-three POC HbA1c consultations took place during the study; clinical decisions were made in 30 consultations. Five POC consultations with a family doctor lasted on average 11min and 48 consultations with nurses took on average 24min. Five POC study visits did not take place in one clinic. POC results were uploaded to hospital records from two clinics. In total, sixty-three POC tests were performed, and there were 11 cartridge failures. No changes in HbA1c or patient behaviour were observed.

CONCLUSIONS

HbA1c measurement with POC devices can be effectively implemented in primary care. This work has identified when these technologies might work best, as well as potential challenges. The findings can be used to inform the design of a pragmatic trial to implement POC HbA1c testing.

Impact of HbA1c Testing at Point of Care on Diabetes Management

Diabetes is a highly prevalent disease also implicated in the development of several other serious complications like cardiovascular or renal disease. HbA1c testing is a vital step for effective diabetes management, however, given the low compliance to testing frequency and, commonly, a subsequent delay in the corresponding treatment modification, HbA1c at the point of care (POC) offers an opportunity for improvement of diabetes care. In this review, based on data from 1999 to 2016, we summarize the evidence supporting a further implementation of HbA1c testing at POC, discuss its limitations and propose recommendations for further development.

[Introduction of capillary glycosylated haemoglobin determination in a Primary Care Health Area: Multicentre study of the evolution of patients with type 2 diabetes mellitus]

PURPOSE

The aim of this study was to evaluate the efficiency of a joint intervention that included educational components, self-assessment, and information to optimise diabetes control through the introduction of instant capillary glycosylated haemoglobin (HbA1c) determination in Primary Care.

MATERIALS AND METHODS

A multicentre prospective descriptive study was carried out over 3years in 10Primary Care Centres of the Area VII Murcia East. At the end of the study there were 804 patients with type 2 diabetes (DM2). Patients were divided into 4 groups based on initial values of HbA1c, and if changes in their treatment were needed. HbA1c, body mass index, and blood pressure were monitored. A financial assessment was also performed on the impact of the implementation of a protocol to measure instant capillary RESULTS: A significant reduction was observed in HbA1c values. The initial HbA1c mean value was 7.4±1.4%, which decreased to a final value of 6.9±1.0% (P<.001). At the end of the study, 71.4% of patients included reached diabetic control objectives. In addition, the financial assessment demonstrated that the implementation of this diabetes control system led to a decrease of the 24.7% in spending on glucose strips after the first year of study in Area VII Murcia Health Service.

CONCLUSIONS

The introduction of capillary HbA1c determination in Primary Care has demonstrated to improve diabetes control and the efficiency of the health personnel. Furthermore, a reduction in the health costs of patients with DM2 was also shown.

Collaborative Paradigm of Preventive, Personalized, and Precision Medicine With Point-of-Care Technologies

Recent advances in biosensors, medical instrumentation, and information processing and communication technologies (ICT) have enabled significant improvements in healthcare. However, these technologies have been mainly applied in clinical environments, such as hospitals and healthcare facilities, under managed care by well-trained and specialized individuals. The global challenge of providing quality healthcare at affordable cost leads to the proposed paradigm of P reventive, Personalized, and Precision Medicine that requires a seamless use of technology and infrastructure support for patients and healthcare providers at point-of-care (POC) locations including homes, semi or pre-clinical facilities, and hospitals. The complexity of the global healthcare challenge necessitates strong collaborative interdisciplinary synergies involving all stakeholder groups including academia, federal research institutions, industry, regulatory agencies, and clinical communities. It is critical to evolve with collaborative efforts on the translation of research to technology development toward clinical validation and potential healthcare applications. This special issue is focused on technology innovation and translational research for POC applications with potential impact in improving global healthcare in the respective areas. Some of these papers were presented at the NIH-IEEE Strategic Conference on Healthcare Innovations and POC Technologies for Precision Medicine (HI-POCT) held at the NIH on November 9-10, 2015. The papers included in the Special Issue provide a spectrum of critical issues and collaborative resources on translational research of advanced POC devices and ICT into global healthcare environment.

Exploring the barriers and facilitators to use of point of care tests in family medicine clinics in the United States

Background

Point-of-care tests (POCTs) are increasingly used in family medicine clinics in the United States. While the diagnostics industry predicts significant growth in the number and scope of POCTs deployed, little is known about clinic-level attitudes towards implementation of these tests. We aimed to explore attitudes of primary care providers, laboratory and clinic administrative/support staff to identify barriers and facilitators to use of POCTs in family medicine.

Methods

Seven focus groups and four semi-structured interviews were conducted with a total of 52 clinic staff from three family medicine clinics in two US states. Qualitative data from this exploratory study was analyzed using the constant comparison method.

Results

Five themes were identified which included the impact of POCTs on clinical decision-making; perceived inaccuracy of POCTs; impact of POCTs on staff and workflow; perceived patient experience and patient-provider relationship, and issues related to cost, regulation and quality control. Overall, there were mixed attitudes towards use of POCTs. Participants believed the added data provided by POCT may facilitate prompt clinical management, diagnostic certainty and patient-provider communication.

Perceived barriers included inaccuracy of POCT, shortage of clinic staff to support more testing, and uncertainty about their cost-effectiveness.

Conclusions

The potential benefits of using POCTs in family medicine clinics are countered by several barriers. Clinical utility of many POCTs will depend on the extent to which these barriers are addressed. Engagement between clinical researchers, industry, health insurers and the primary care community is important to ensure that POCTs align with clinic and patient needs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0549-1) contains supplementary material, which is available to authorized users.

National Institute of Biomedical Imaging and Bioengineering Point-of-Care Technology Research Network: Advancing Precision Medicine

To advance the development of point-of-care technology (POCT), the National Institute of Biomedical Imaging and Bioengineering established the POCT Research Network (POCTRN), comprised of Centers that emphasize multidisciplinary partnerships and close facilitation to move technologies from an early stage of development into clinical testing and patient use. This paper describes the POCTRN and the three currently funded Centers as examples of academic-based organizations that support collaborations across disciplines, institutions, and geographic regions to successfully drive innovative solutions from concept to patient care.

Challenges of development and implementation of point of care pharmacogenetic testing

INTRODUCTION

Just as technology was the underlying driver of the sequencing of the human genome and subsequent generation of volumes of genome sequence data from healthy and affected individuals, animal, plant, and microbial species alike, so too will technology revolutionize diagnostic testing. One area of intense interest is the use of genetic data to inform decisions regarding drug selection and drug dosing, known as pharmacogenetic (PGx) testing, to improve likelihood of successful treatment outcomes with minimal risks.

AREAS COVERED

This commentary will provide an overview of implementation research of PGx testing, the benefits of point-of-care (POC) testing and overview of POC testing platforms, available PGx tests, and barriers and facilitators to the development and integration of POC-PGx testing into clinical settings. Sources include the published literature, and databases from the Centers for Medicaid and Medicare Services, Food and Drug Administration. Expert commentary: The utilization of POC PGx testing may enable more routine test use, but the development and implementation of such tests will face some barriers before personalized medicine is available to every patient. In particular, provider training, availability of clinical decision supports, and connectivity will be key areas to facilitate routine use.

Opportunistic Screening for CVD Risk Factors: The Dubai Shopping for Cardiovascular Risk Study (DISCOVERY)

BACKGROUND

Comprehensive cardiovascular disease risk factor (CVDRF) screening programs are limited in the developing world. Simplifying screening can increase its utility.

OBJECTIVES

The present study aims to estimate the burden of CVDRF in volunteers and the yield of newly discovered CVDRF comparing different sites and nationalities using this screening method.

METHODS

Voluntary point-of-care CVDRF screening was conducted in 4 shopping malls, 9 health care facilities, and 3 labor camps in 5 cities in the United Arab Emirates. Follow-up for newly diagnosed diabetes mellitus, hypertension, and dyslipidemia was made 1 month after screening to inquire about physician consultation, confirmation of diagnosis, and lifestyle changes.

RESULTS

A total of 4,128 subjects were screened (43% at malls, 36% at health care facilities, and 22% at labor camps). Subjects were relatively young (38 ± 11 years), predominantly male (75%), and of diverse nationalities (United Arab Emirates: 7%, other Arabs: 10%, South Asians: 74%, other Asians: 5%, and other nationalities: 5%). CVDRF were frequent (diabetes mellitus: 32%, hypertension: 31%, dyslipidemia: 69%, current smokers: 21%, obesity: 20%, and central obesity: 24%). Most subjects (85%) had ≥1 CVDRF, and many (17%) had ≥3 CVDRF. A new diagnosis of diabetes mellitus, hypertension, or dyslipidemia was uncovered in 61.5%, with the highest yield (74.0%) in labor camps. At follow-up of those with new CVDRF, positive lifestyle changes were reported in 60%, but only 33% had consulted a doctor; of these, diagnosis was confirmed in 63% for diabetes mellitus, 93% for hypertension, and 87% for dyslipidemia.

CONCLUSIONS

In this relatively young and ethnically diverse cohort, CVDRF burden and yield of screening was high. Screening in these settings is pertinent and can be simplified.