Near-patient testing in primary care

In the current climate of streamlined health care with an emphasis on community-based care and one stop clinics, the concept of near-patient testing is appealing. Near-patient testing (also known as point-of-care testing) is defined as an investigation taken at the time of the consultation with instant availability of results to make immediate and informed decisions about patient care, and has gained much attention over the last 15 years.

Near-patient testing offers a number of potential advantages in primary care, including earlier diagnosis, communication of diagnosis, and disease management, with potential for improved outcomes, improved patient satisfaction, and cost-effectiveness. Other potential advantages include reducing health inequalities by being accessible to certain hard to reach socioeconomic or ethnic groups. Use of simple urine testing strips and blood glucose measurements are routine in primary care, although more sophisticated near-patient tests have been limited to anticoagulant monitoring, diabetes management, and testing for C-reactive protein and Helicobacter pylori.

A study in this issue of the BJGP by Laurence et al evaluated patient satisfaction in relation to near-patient testing in a large randomised controlled trial (RCT) in Australia.1 Four key results are highlighted in this study: patients felt that near-patient testing allowed discussion of the management of their condition with their GP; patients felt they were more motivated to look after their condition; patients preferred near-patient testing using finger prick tests; and they were more satisfied, in particular, those who had anticoagulant monitoring.

There have been only a few RCTs of patient satisfaction with near-patient testing and these have reported mixed findings. For example, one RCT showed that people with diabetes accepted near-patients tests and confirmed that they may have potential benefits, such as saving time, reducing anxiety, and both patient management and job satisfaction.2^,3 However, satisfaction with diabetes care was already high in both intervention and control groups and the trial failed to show any improvements in outcomes for these patients; in addition, there were no cost savings.3 There is support among healthcare professionals for the principles of near-patient testing,3^,4 although at the same time healthcare practitioners have concerns about time pressures, maintenance, quality control, and cost implications.4

In the UK there has been recent interest in lipid monitors which have increased in availability over the years with the potential to assess cardiovascular risk.5 These machines have been validated for bias and imprecision and have been shown to have overall analytical goals for near-patient testing that are equivalent to those used in laboratories.5 One area where these monitors are being seriously considered in the UK is to help implementation of the ambitious NHS Health Check programme,6 in particular in the community pharmacy setting.

Previous studies have evaluated the feasibility of oral anticoagulant therapy monitoring using near-patient testing by community pharmacists, and have shown promising results.7 Furthermore, a recent evaluation of a cardiovascular risk screening programme by community pharmacists found that it was possible to provide near-patient cardiovascular disease risk assessment in deprived black and Asian communities, of whom 70% were referred for further tests to their GPs because of increased cardiovascular risk.8 Nevertheless, adequately powered rigorous evaluations are lacking.

If near-patient testing is to be implemented in primary care, then quality assurance of the programme will be a key recommendation. This will include quality control maintenance and external quality control. Guidelines also recommend quality assurance of near-patient testing to limit medical errors, and a mechanism for continued quality improvement.9 To help deliver the NHS Health Check programme, the recently published A Practical Guide to Point of Care Testing is therefore timely.10 The guidance gives advice on quality assurance, the process for accreditation of healthcare professionals, and a buyers' guide to near-patient testing equipment.10

A systematic review of near-patient testing in primary care, published in 1999, concluded that there was little research evidence to guide expansion of the use of near-patient testing, and further research was recommended.11 Ten years on, there has been little progress in terms of rigorous evaluations of near-patient testing initiatives in primary care. A recent guideline summarised some of the evidence base for near-patient testing, especially in emergency departments, but the evidence base for its impact in improving outcomes in primary care was lacking, except for monitoring of people on anticoagulants and for management of people with type 2 diabetes.9 Near-patient testing has a number of potential benefits beyond patient satisfaction, although the full potential of its integration and implementation has not been exploited. Rigorous evaluations of translating this technology into primary care are still required to determine improvements in harder outcomes and cost-effectiveness.

• © British Journal of General Practice, 2010.