Minimizing Health Problems to Optimize Demographic Dividend: Role of Point-of-Care Testing (POCT)

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Minimizing Health Problems toOptimize
Demographic DividendRole of Point-of-Care
Testing (POCT)

• Gerald J. Kost, M.D., Ph.D., M.S., F.A.C.B.
• Fulbright Scholar and Affiliate Faculty,
  Chulalongkorn University
• Point-of-Care Testing Center for Teaching and
  Research (POCT?CTR)
• School of Medicine, University of California,
  Davis, USA
• Narisara Peungposop, Civilize Kulrattanamaneeporn,
  
• Kua Wongboonsin, Ph.D., Navapun Charuruks M.D.,
• Suwanee Surasiengsunk, Ph.D., and Chatchalerm
  Surachaichan
• Chulalongkorn University, Bangkok, Thailand

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Challenges of the Demographic Dividend

• Largest proportion (67) of
• the labor force in 2009
• Burden of the elderly thereafter
• Dependency ratio increase
• starting 2010
• Optimal health care, minimal
• costs, and healthy aging

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Methods Needs Assessment Research

• Primary data from Thai MOPH database 2002
• -population, PCU, hospital beds, MD, PN, TN,
  P
• -classified by province (N 76)
• People per resource calculated from population
  divided by the number of PCUs or hospital beds
• People per personnel calculated from population
  divided by the number of MD, PN, TN, or P
• Statistical analyses included max, min, range,
  mean, SD, median, 25tile, 50tile, and 75tile
• Scoring based on attributes (0 to 6) in top
  quartiles
• Field research surveys (2)

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Distribution by Region
Pharmacists
Physicians
Beds
SourceBureau of Policy and Strategy,
http//hrm.moph.go.th/resource/hr.report45rb,
accessed 24 March 2004
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Provinces versus People per Physician
Source Bureau of Policy and Strategy,
http//hrm.moph.go.th/resource/hr.report45.rb,
accessed 24 March 2004
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Provinces versus People per Pharmacist
Source Bureau of Policy and Strategy,
http//hrm.moph.go.th/resource/hr.report45.rb,
accessed 24 March 2004
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Provinces versus People per Bed
Source Bureau of Policy and Strategy,
http//hrm.moph.go.th/resource/hr.report45.rb,
accessed 24 March 2004
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Distribution of Nurses
Technical Nurses
Professional Nurses
Source Bureau of Policy and Strategy
http//hrm.moph.go.th/resource/hr.report45rb,
accessed 24 March 2004
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Provinces versus People per Professional Nurse
Source Bureau of Policy and Strategy,
http//hrm.moph.go.th/resource/hr.report45.rb,
accessed 24 March 2004
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Provinces versus People per Technical Nurse
Source Bureau of Policy and Strategy,
http//hrm.moph.go.th/resource/hr.report45.rb,
accessed 24 March 2004
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Provinces versus People per PCU
Source Office of Health Care Reform Project,
Public Health Development Bureau, Ministry of
Public Health, 2002
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DCU Priority Scores Summary
Priority Score Province Population (1K) Population (1K) PCU (gt23,060) PCU (gt23,060) Bed (gt780) MD (gt8,291) PN (gt1,156) TN (gt2,943) P (gt13,705)
High (4) Amnatcharoen Sakaeo (MOPH bed only) Amnatcharoen Sakaeo (MOPH bed only) 369 537 11,191 9,943 879 1,116 879 1,116 12,734 9,257 1,122 1,475 3,730 2,871 19,437 13,767
Higher (5) Highest (6) Buriram Kalasin Mahasarakham Nakhonphanom Nongbualamphu Nongkhai Phetchabun Sakonnakhon Sisaket Surin Chaiyaphum Kamphaengphet Roiet Maximum Buriram Kalasin Mahasarakham Nakhonphanom Nongbualamphu Nongkhai Phetchabun Sakonnakhon Sisaket Surin Chaiyaphum Kamphaengphet Roiet Maximum 1,540 988 941 720 498 907 1,039 1,105 1,455 1,396 1,134 767 1,321 10,198 17,330 8,331 18,008 11,056 11,630 22,577 10,521 9,899 10,416 32,392 28,414 30,028 37,766 855 888 924 840 1,219 882 875 832 1,164 853 1,082 925 918 1,219 855 888 924 840 1,219 882 875 832 1,164 853 1,082 925 918 1,219 9,447 9,147 11,207 12,005 12,438 10,080 10,598 10,521 13,474 11,632 10,122 10,805 12,011 13,474 1,754 1,588 1,416 1,207 2,293 1,296 1,731 1,328 1,828 1,688 1,555 1,625 1,507 2,293 3,765 6,023 3,906 3,289 6,461 3,643 3,644 3,337 4,819 3,932 3,622 3,081 3,722 6,461 15,554 15,680 14,264 15,326 18,427 15,915 18,883 18,411 17,533 18,862 18,286 17,842 19,720 19,720

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DCU Priority Score Distribution
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Source Bureau of Policy and Strategy website
http//203.157.19.191/4520table202.3.220cause.x
ls., accessed 21 January 2004.
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Demographic Dividend
Source Bureau of Policy and Strategy website
http//203.157.19.191index20stat2045.html,
accessed 21 January 2004
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Point-of-Care Testing (POCT)

• Definition
• Diagnostic testing at or near the site of
  patient
• care. (Does not depend on the type
  of instrument!)
• Goals
• To improve medical and economic outcomes, and
• to decrease therapeutic turnaround time
  (TTAT).
• (TTAT time from test order to patient
  treatment.)
• Practice
• Principles and Practice of Point-of-Care
  Testing.
• G. Kost, Editor. Lippincott, Williams, and
  Wilkins (www.LWW.com), 2002.

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Poor diet with too much sugar and cholesterol

• Example One soda has seven teaspoons of sugar.
• 5.4 of Thais have impaired fasting glucose (1.4
  million).
• 9.6 of Thais are diagnosed as diabetics (2.4
  million 1.3 f 1.1 m).
• An additional 50 of all cases are not diagnosed
  and all have higher risk of cardiovascular
  disease, such as hypertension.
• Low-cost preventative therapies, such as lowering
  glucose and blood pressure, will produce
  substantial health benefits in Thailand.
• Source
• Diabetes Care 2003262758-2763.

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Poor diet with too much sugar and cholesterol

• Example One soda has seven teaspoons of sugar.
• 5.4 of Thais have impaired fasting glucose (1.4
  million).
• 9.6 of Thais are diagnosed as diabetics (2.4
  million 1.3 f 1.1 m).
• An additional 50 of all cases are not diagnosed
  and all have higher risk of cardiovascular
  disease, such as hypertension.
• Low-cost preventative therapies, such as lowering
  glucose and blood pressure, will produce
  substantial health benefits in Thailand.
• Source
• Diabetes Care 2003262758-2763.

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Metrika A1cNow

• Details
• Disposable single-use glycosylated HbA1c
  monitoring
• Home use with prescription
• Results in 8 minutes
• Cost 21.99 USD

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Design, Fabrication, and Assembly

• Uses finger stick method to collect blood
• Micro-optics and solid state chemistry detect
  glycosylated HbA1c

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In Vitro Disposable Cardiac STATus

• Use Just One Time
• Assays for cardiac troponin I, myoglobin, and
  CK-MB (Spectral Diagnostics)
• Qualitative results
• Requires 15 minutes or less

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Quantitative Cardiac Injury Markers

• Details
• Whole-blood POC measurement (Biosite)
• cTnI, CK-MB, and myoglobin (AMI)
• BNP (CHF)

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In Vitro i-Stat Portable Clinical Analyzer

• Details
• Microfluidic biosensor technology
• Built-in quality control
• Handheld

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GEM Premier 3000

• Details (Instr. Labs)
• Automated QC with iQM (Intelligent Quality
  Management)
• Disposable multi-use cartridges
• Web-based networking

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New Neonatal Bilirubin Assay OMNI S

• Details
• Whole-blood neonatal bilirubin (Roche
  Diagnostics)
• Validation results published in 2004 in
  multicenter and multinational study
• 17 other tests (BG, lytes, mets, Co-Ox)

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Faster Diagnosis LightCycler 2.0

• Details
• Rapid response testing (Roche Diagnostics)
• High speed thermocycling
• Complete PCR cycle in 20-30 minutes
• Detect nucleic acid in blood
• Sepsis panel of 25 pathogens

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Nucleic Aid Detection Method

• Multi-channel PCR-based system
• Fluorescent probes facilitate detection of target
  DNA
• Kits for EBV, HSV, Anthrax, Parvovirus, Hepatitis
  A, Pseudomonas, Candida, Enterococcus, VRE,
  Staphylococcus, and MRSA

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Health Care Delivery Needs Assessment

• Critical care including emergencies, trauma,
  and surgery
• Diabetes and other conditions that benefit from
  treatment monitoring
• Infectious diseases and sepsis
• Cardiovascular diseases (acute myocardial
  infarction, sudden death,
• and CHF)
• Women health including birthing
• Cancer

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DISEASES, POCT, AND EVIDENCE
Disease/condition Analytes
Diabetes Glucose, HbA1c, Ketones, Fructosamine
Hematology ?Coagulation ?Anemia Prothrombin time (PT) Hemoglobin or hematocrit
Infectious Diseases Strep A/B, HBV, HIV 1/2, Influenza A/B, Malaria, Syphilis, Chlamydia, H. pylori, HCV, SARS virus, CMV, EBV, Cholera, Listeria, CRP
Cardiovascular Disease Cholesterol, HDL, LDL, Lipids, Triglycerides, CRP
Drugs of Abuse Amphetamines, Barbiturates, Benzodiazepines, Cocaine, Methadone, Methamphetamines, Opiates, Phencyclidine, Tricyclic antidepressants, Ethanol, Ecstasy (MDMA), PCP
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DISEASES, POCT, AND EVIDENCE
Disease/condition Analytes
Womens Health ?Pregnancy ?Fertility ?Fertility ?Osteoporosis ?Parentage hCG LH FSH Cross-linked N-telopeptides DNA
Cancer ?Prostate ?Liver, testicular, ovarian, pancreatic, stomach ?Colon ?Colorectal, breast, thyroid, lung, ovarian, stomach Prostate-specific antigen (PSA) Alphafetoprotein (AFP) Fecal occult blood Carcino-embryonic antigen (CEA)
Function Monitoring ?Blood Pressure ?Urinalysis
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Home and PCU Care Locally

• Self-monitor key variables (e.g., glucose in
  diabetes, SMBG)
• Control other conditions that decrease the
  efficiency of highly productive workers
• Manage public health problems (e.g., HIV) that
  compromise the worker and family
• The VisionEmpower patients and the care team to
  optimize efficiency, care paths, and resources

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PCU
PCU
Community Regional Hospital
PCU
PCU
Home, Village, and Community
PCU
Specialty, University, and National Centers
Province Referral Hospital
Anamai (Health Center)
PCU
PCU
Regional Hospital
Community Hospital
PCU
Towns and Cities
PCU
PCU
PCU
Primary Counseling and Treatment
Home Testing, Self-Monitoring, and Telecommunicati
ons
Critical Care and Triage
Rapid Response, Acute Care, and Information
Integration
Esoteric Tests, Scarce Technology, and Specialty
Therapy
POCT/Care Spectrum
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Acute Care Nationally

• Support anesthesia, surgery, and birthing e.g.,
  C-sections place two lives at risk
• Diagnose age-related conditions quickly (e.g.,
  neonatal kernicterus and myocardial infarction)
• Focus infectious and parasitic disease treatment
• Reduce high mortality problems (e.g., sepsis)
• The VisionEmpower physicians to reduce risk and
  treat medical problems quickly on site

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EVIDENCE-BASED POLICY RECOMMENDATIONS

• Policy recommendations in four categories
• Critical care and point-of-care testing
  (POCT)
• Integrated laboratory and medical practice
• Demographic dividend and economic
  development
• Public health and the standard of care

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I. Critical Care and Point-of-Care Testing

• Provide critical tests necessary for the ER,
  OR, LR, and ICU
• Enable rapid quantitative diagnosis of
  myocardial infarction
• Improve PCU and community hospital test menus
• Assign point-of-care coordinators for oversight
  and QC
• Re-design nursing POCT and infections disease
  testing

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II. Integrated Laboratory and Medical Practice

• Supply POCT and diagnostic instruments to high
  score provinces
• Increase medical and laboratory personnel in
  these provinces
• Develop care paths for acute myocardial
  infarction and sepsis
• Target HIV and diabetes with enhanced
  diagnostic algorithms
• Set up emergency notification systems for
  critical test results

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III. Demographic Dividend Economic Development

• Adopt efficient care paths and Centers of
  Excellence
• Train health science engineers and
  multidisciplinary experts
• Employ the demographic dividend and
  reciprocally support needs
• Foster age-related diagnosis, monitoring, and
  treatment
• Synergize the economics of technical, social,
  and medical growth

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IV. Public Health and the Standard of Care

• Increase beds, MDs, nurses, pharmacists, and
  anesthesiologists
• in deficient NE provinces where workload is
  excessive
• Use resource quartiles, medical audits, and
  workload analysis
• Balance PCU distribution to avoid over
  utilization of hospitals
• Move to evidence-based practice and a uniform
  standard of care
• Institute rigorous peer-based accreditation and
  inspection

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National Care Equitably

• Improve access to diagnostic data and knowledge
  with small-world networks
• Enhance regional decision making
• Coordinate public and private health centers
• Distribute medical resources by workload audit
• The visionEmpower Thailand (and other countries)
  to deliver equitable health care

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10-Year Plan to Increase Thai Doctors Public
hospitals will offer higher salaries and bonuses
Rural specialists will receive compensation
for extra time Siriraj Hospital will
increase students 63 (to 250) next year Top
students will study and work in home provinces
New doctors returning to provinces will receive
40-50K baht/month Government will assist
financially troubled hospitals within 2 years
Students should be trained in POCT and quality
management!

• Source Public Health Minister, Bangkok Post, 22
  November, 2003

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Demographic Dividend
Centers of Excellence
New Skills
Small-World Networks
HEALTH
POCT
Productivity
Economic Growth