Point-of-care testing to improve cost-effectiveness of health check programmes in primary care

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In our feature article series, we take a look at publications of particular relevance to point-of-care testing (POCT), providing summaries and expert commentary on the key aspects of the paper and within the wider context of POCT systems.

In our feature article series, we take a look at publications of particular relevance to point-of-care testing (POCT), providing summaries and expert commentary on the key aspects of the paper and within the wider context of POCT systems.

In this article, we cover the below publication by Dr El Osta and co-authors:

Does use of point-of-care testing improve cost-effectiveness of the NHS Health Check programme in the primary care setting? A cost minimisation analysis

Cardiovascular disease is a driver of premature mortality

Cardiovascular disease (CVD) is a major cause of disability and premature mortality worldwide, accounting for around one-third of all deaths annually in England alone. To help overcome the burden of CVD, a national CVD primary prevention programme in England was launched by the Department of Health in April 2009, namely the National Health Service (NHS) Health Check programme. The programme aims to prevent heart disease, stroke, diabetes and kidney disease, while reducing health inequalities.

The programme aims to prevent 1600 heart attacks and strokes, 650 premature deaths and over 4000 new cases of diabetes each year. It is currently delivered in general practice using both laboratory and point-of-care testing (POCT) equipment to assess blood sugar (glucose or HbA1c) and total cholesterol levels. In this way, the use of POCT can facilitate communication of a patient’s CVD risk score in a single visit. The authors of this publication highlight that although the use of POCT leads to better coverage and higher rates of statin prescribing, it is not uniformly used.

Point-of-care testing can form part of health check screenings

The primary aim of this analysis was to investigate a range of NHS Health Check screening scenarios to determine if routine use of POCT is less costly than laboratory testing to the NHS. Data were collected on the number and breakdown of various tests requested from general practitioners (GPs), internal and external costs of tests, transport/courier costs (2013–2014), cost of consumables (2013–2014) and other infrastructure costs (2013–2014).

A total of nine GPs (n=7 using POCT; n=2 not using POCT) between September 2013 and August 2014 delivering the NHS Health Check were recruited from four Clinical Commissioning Group localities in Northwest London (with a combined list size of 71,500 patients). The lineage, nature and time required for each procedure undertaken to enable a Health Check leading up to CVD risk score presentation, was recorded. Healthcare staff were also asked to describe how patients are identified and invited, and what processes were involved in administering the NHS Health Check in each respective practice. Lastly, a micro-costing analysis was undertaken from the NHS perspective based on healthcare assistant (HCA) or nurse salary costs.

Point-of-care testing is quicker and less costly than laboratory testing

The time required to conduct an NHS Health Check up to the point of CVD risk score calculation varied from practice to practice (range=20–40 min) irrespective of whether they were using POCT. The average time required to acquire a blood sample was 2.5 minutes longer with the cannulated syringe method used in the laboratory pathway than via the finger pin prick sampling method used in the POCT pathway.

All seven GPs using POCT (100%) demonstrated that: (1) their staff were suitably trained to use POCT devices; (2) an appropriate internal quality control process was in place, as evidenced by daily control sample and monthly calibration of the POCT device; and (3) each POCT location was registered in an accredited External Quality Assessment Programme.

Without taking into account ‘did not respond’ (DNR) and ‘did not attend’ (DNA) rates, it was found that one entire Health Check in the laboratory pathway would cost £22.32, while one entire Health Check in the POCT pathway would cost £17.04. Therefore, without taking into account DNR and DNA, one completed Health Check using POCT would cost £5.28 less than one completed using laboratory pathway. According to the results of the mathematical model, the cost savings to the NHS associated with POCT were estimated at £29 per 100 patients.

Policy change could overcome barriers to adoption of point-of-care testing

The study also reported that barriers such as prevailing attitudes of healthcare practitioners or a preference to use laboratory services over POCT, can be overcome with relatively minor changes to work patterns. However, structural barriers including the lack of a suitable funding and reimbursement model will require policy change if widespread NHS adoption is to be achieved. It was highlighted that evidence of cost savings to the NHS from using POCT may provide a rationale for a change in the current reimbursement model and incentives to GPs in favour of wider adoption and use of POCT for specified purposes.

This is the first study using a cost-minimisation analysis to investigate the potential cost-saving use of POCT in delivering NHS Health Checks in the primary care setting. The total expected cost was lower than the laboratory-led pathway. In addition, a traditional laboratory-led pathway offers up to three times more opportunities for a patient to miss an NHS Health Check appointment or to exit the care pathway compared with POCT pathway, further incentivising POCT. Healthcare professionals should be aware that general practices using POCT can act as a 'one stop shop' to patients wishing to undertake their NHS Health Check in a single sitting.

Reference:

El-Osta, et al. BMJ Open 2017;7(8):e015494

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