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Kit Watch Near-Patient Testing

The Health Services Research Unit at the University of Warwick has produced a report on near-patient testing (NPT) in general practice. The objectives were:-
  • To investigate the ways in which GPs make use of the tests marketed for NPT when they are made available in the surgery.
  • To investigate the impact on patient care of two selected tests.
  • To investigate the economic aspects of NPT in primary care.
The research involved a four month baseline which involved observation of current laboratory use for all tests. This was followed by a 12 months period during which practices were given access to bacteriological and biochemical NPT for six months each, when both laboratory and NPT use were monitored. Finally practices retained the NPT equipment for nine months, during which time a detailed study was made of the impact on patient care of one biochemistry and one bacteriology test.

The NPT tests examined were:-

Bacteriology

  • MSU for UTI
  • Chlamydia

Biochemistry

  • Cholesterol
  • Haemoglobin
  • Gamma GT
  • Sodium & Potassium
The biochemistry tests involved the manipulation of samples and instruments to obtain the results, as did some of the bacteriology tests.

A total of 25,300 tests was analysed, with test costs estimated in practice and laboratory settings. Patient questionnaires were also used to measure extra associated costs.

Attitudes

Most GPs were very keen about the potential of NPT at the start of the study. At the end of the study, this positive attitude had largely evaporated. Concern about time, both their own and practice nurses was a major factor. Time involved in maintenance, quality assessment and time needed to perform the test were the major negative factors.

Practice nurses were more cautious initially, with a significant minority concerned about the time and work involved running the equipment. At the end of the study, one test (MSU for UTI) received widespread enthusiastic responses from practice nurses. Time pressure was felt as a major negative factor on performing NPTs by over half the nurses.

Quality assessment

Considerable quality assessment was involved in the study, including internal quality control, parallel testing by local laboratories and external QA in local and national schemes. Some of the equipment needed checks carried out each day, and there was no doubt that this all contributed significantly to the negative impact of NPT.

Performance of the NPT testing in QA schemes was generally acceptable to good.

However, during the study only one case (out of 25,300) came to light where a possible erroneous result may have led to incorrect diagnosis or treatment.

Uptake of NPT

The practices observed averaged only 9 NPT tests per week.

There was much greater uptake where there was enthusiasm from a practice nurse, who was in control of equipment and testing.

Some tests increased markedly, especially cholesterol testing, while there was little impact on testing rates for other analytes.

Cost implications

Because the average uptake of NPT was low, the cost per NPT test was high, and generally higher than laboratory costs. The cost per test could approach laboratory costs if there was a higher uptake.

Costs in this study included equipment costs, costs for the reagents or consumables required for the tests and controls, and patient costs. The major contribution was the consumable/disposable cost.

For cholesterol, the analysis showed that NPT could increase the average practice investigation costs by about £2,400, even with no increase in testing.

For MSU investigations, by contrast, the cost impact on the average practice would be negligible.

Patient management

There was a positive impact only for NPT urine testing. For patients who received only an NPT test with no immediate laboratory follow up, there was a significantly higher level of antibiotic prescribing. There were also significantly fewer referrals and investigations of the urinary tract in NPT tested patients in the six month follow up period.

These positive benefits were seen only for NPT testing of MSU for UTI. There was no gain for patients for NPT cholesterol testing.

Cost effectiveness

For MSU the observed reduction in referrals and investigations of the urinary tract for patients who first received a NPT test leads to sizeable potential annual savings of between £1,150 and £2,450.

Potential national costs for widespread national introduction of NPT for cholesterol and MSU for UTI were calculated. For cholesterol, a large health care cost increase of £16.5 - £24.5 million per year was estimated. For MSU for UTI, the savings predicted were £1.1 - £3.1 million.

Survey conclusion

Widespread introduction of NPT into general practice is likely to have far reaching and complex effects. The paper from Warwick looks at these in detail, together with the policy implications that stem from the study. They particularly point out that careful attention should be given to which tests are required, for what purpose, and what specification, if NPT is going to be of future value in primary care.

Bandolier's comments

One of the problems with the introduction of near patient testing is that manufacturers are making small versions of laboratory equipment for introduction into primary care. These units need much the same attention and sample handling as does true laboratory equipment, and the result is predictable - too much time demanded of busy practice staff, and with high unit test costs making NPT largely uneconomic.

For NPT to be successful, a different approach needs to be followed. Near patient tests that confer substantial benefit to GP and patient need to involve the minimum of sample handling, have a minimum of no reagent or disposable cost, and have results which are available virtually instantaneously.

Only when these criteria are met is it likely that the benefits so long trumpeted for NPT will be fulfilled.

Details of useful publications:-

Near Patient Testing in General Practice costs £4 and is available from The Secretary, Health Services Research Unit, Warwick Business School, University of Warwick, Coventry CV4 7AL.

The Association of Clinical Biochemists also produces a helpful booklet entitled "Guidelines for Implementation of Near Patient Testing". It is available from ACB, Royal Society of Chemistry, Burlington House, Piccadilly, London W1V 0BN.

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