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HTA report: Near patient testing in primary care

Reviewed by Jonathan Kay

This review is one of the first products of the Health Technology Assessment Programme which aims "to ensure that high-quality research information on the costs, effectiveness and broader impact of health technologies is produced in the most efficient way for those who use, manage and work in the NHS". Throughout my entire career in clinical biochemistry this has been a subject which has generated vast amounts of heat and I came to this review looking for illumination. Even its title is controversial with "Near Patient Testing", "Extra Laboratory Testing" and "Point of Care Testing" competing in the marketplace of ideas. More importantly the brilliant and rapidly advancing technologies which can be used for this purpose usually depend on the consumption of expensive materials with very little interchangeability between those produced by different suppliers, and operated by staff with little background in analytical chemistry. The risks are obvious (see Bandolier 3 and 19 )

Where's the beef?

The method used in the review is that of a qualitative systematic review. The rigour of this can be seen in the allocation of space within the report. In a total of 231 pages, 137 are allocated to the systematic review summary tables with each paper analysed under pre-defined headings. Another 35 pages comprise an analysis of the top scoring papers. The style used follows the constraints of evidence based medicine. With the experts who wrote the assessment and the enormous amount of work that has gone into it, I read it avidly looking for the denouement, but the authors seem to avoid one, ending coolly with the first major conclusion that there is little evidence to support the general introduction of NPT into general practice.

I was looking for more than this: with the enormous commercial pressures to introduce near patient testing I was looking for more detailed questions which would enable someone considering this option to make a rational decision. Clearly the decision would differ between different possible analyses and, more importantly, different clinical situations. Being told that further evaluation is needed falls short of this.

One of the widely quoted advantages of near patient testing is the rapid availability of reports. Although some of the relevant factors in this area are mentioned, including patient satisfaction, immediate availability of results and the value of traditional laboratory procedures in playing for time, the general issues involved in assessing the required turnaround time of laboratory results are not discussed in detail. These would need to include the assessment of value of information at times after the patient has left the consultation and the ease of communication after the consultation.

The review intelligently includes the study of computerised decision support systems and electronic data interchange for the transmission of reports where analyses are not carried out in the primary care setting. Again the unwillingness to go beyond what is in the published literature creates a weakness here. Electronic data interchange has the unique property of laboratory reports automatically appearing in a computerised patient record without re-keying, a property which is quite independent of its comparison with other methods of communication in terms of speed of transmission. Similarly, the fragmentation of lots of longitudinal population based records for laboratory reports which would follow wide-scale devolution of laboratory investigations away from central laboratories and towards primary care is not discussed. The risk of this is obvious without any publications on the subject.

Making rational decisions

The review does not remark on the inadequacy of our current natural language for making rational decisions in this area. The worst example of this is the ambiguity of the word "test" between the meanings of "investigation carried out" and "the procedure used to gather information about a patient or decide what action to take next". Only when there is a useful test in the second sense is it appropriate to ask where and how the chemical analysis should be carried out. Unfortunately the potentially unholy alliance of pressure from manufacturers and patients inevitably leads to too many tests (in the former sense) being carried out.

This review is an outstanding achievement, but I think it should have gone further in providing guidance to those currently making decisions concerning the use of this technology. It will have three great uses for managers and practitioners in this field: as a source of the highest quality of information; as a criticism of the historically poor way in which evaluations have been carried out, both within the NHS and by workers in the field; and in assisting in constructing a set of questions, based on those used in the systematic review, which will improve the quality of future publications.

FDR Hobbs et al. A review of near patient testing in primary care. Health Technology Assessment 1997 1: No 5.
Dr Jonathan Kay is a Consultant Chemical Pathologist at the Oxford Radcliffe Hospital. He was a member of the ACB Working Group on Near Patient Testing and with Dr John McVittie was responsible for the introduction of clinical electronic data interchange between Primary and Secondary Care ( ).

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