Transcript Slide 1

Minimizing Health Problems to
Optimize Demographic Dividend:
Role 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
1
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
2
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, 25%tile, 50%tile, and 75%tile
• Scoring based on attributes (0 to 6) in top quartiles
• Field research surveys (2)
3
Distribution by Region
Pharmacists
Physicians
South
14%
Central
24%
Bangkok
34%
Bangkok
20%
North
19%
Northeast
17%
South
10%
Central
24%
Northeast
23%
North
15%
Beds
South
13%
Bangkok
20%
North
18%
Northeast
21%
Central
28%
Source:Bureau of Policy and Strategy, http://hrm.moph.go.th/resource/hr.report45rb, accessed 24 March 2004
4
Provinces versus People per Physician
14
12
Number of Provinces
12
10
9
8
7
6
6
6
6
5
4
4
3
3
4
3
3
2
2
2
1
0
<1,891
2,6913,490
4,2915,090
5,8916,690
7,4918,290
9,0919,890
10,69111,490
12,29113,090
Number of People per Physician
Source: Bureau of Policy and Strategy, http://hrm.moph.go.th/resource/hr.report45.rb, accessed 24 March52004
Provinces versus People per Pharmacist
14
13
Number of Provinces
12
11
10
9
8
6
6
6
6
4
4
3
4
3
3
2
3
2
2
1
0
<6,700
7,7008,699
9,70010,699
11,70012,699
13,70014,699
15,70016,699
17,70018,699
>19,699
Number of People per Pharmacist
Source: Bureau of Policy and Strategy, http://hrm.moph.go.th/resource/hr.report45.rb, accessed 24 March 2004
6
Provinces versus People per Bed
18
17
Number of Provinces
16
14
12
12
11
10
10
8
8
7
6
4
4
4
3
2
0
<300
300-399 400-499 500-599 600-699 700-799 800-899 900-999
>999
Number of 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
South
13%
South
17%
Bangkok
24%
Bangkok
14%
North
18%
North
18%
Northeast
20%
Central
25%
Central
27%
Northeast
24%
Source: Bureau of Policy and Strategy http://hrm.moph.go.th/resource/hr.report45rb, accessed 24 March 2004
8
Provinces versus People per Professional Nurse
25
Number of Provinces
20
18
15
11
12
10
8
6
7
4
5
2
2
4
2
0
<410
410559
560709
710859
860- 1,010- 1,160- 1,310- 1,460- 1,610- >1,759
1,009 1,159 1,309 1,459 1,609 1,759
Number of 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
20
18
Number of Provinces
18
15
16
14
12
11
12
10
10
8
5
6
4
4
2
1
0
<1,000
1,0001,499
1,5001,999
20002,499
2,5002,999
3,0003,499
3,5003,999
>3,900
Number of People per Technical Nurse
Source: Bureau of Policy and Strategy, http://hrm.moph.go.th/resource/hr.report45.rb, accessed 24 March
102004
Provinces versus People per PCU
14
12
12
Number of Provinces
12
10
10
8
7
6
6
5
5
4
4
4
4
3
2
2
1
0
<8,060
10,56013,059
15,56018,059
20,56023,059
25,56028,009
30,46032,959
>35,459
Number of 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
High
(4)
Higher
(5)
Highest
(6)
Province
Amnatcharoen
Population
(1K)
PCU
(>23,060)
Bed
(>780)
MD
(>8,291)
PN
(>1,156)
TN
(>2,943)
P
(>13,705)
369
537
11,191
9,943
879
1,116
12,734
9,257
1,122
1,475
3,730
2,871
19,437
13,767
Buriram
Kalasin
Mahasarakham
Nakhonphanom
Nongbualamphu
Nongkhai
Phetchabun
Sakonnakhon
Sisaket
Surin
1,540
988
941
720
498
907
1,039
1,105
1,455
1,396
10,198
855
888
924
840
1,754
1,588
1,416
1,207
3,765
17,330
8,331
18,008
9,447
9,147
11,207
12,005
11,056
11,630
22,577
10,521
9,899
10,416
1,219
882
875
832
1,164
853
12,438
10,080
10,598
10,521
13,474
11,632
2,293
1,296
1,731
1,328
1,828
1,688
6,023
3,906
3,289
6,461
3,643
3,644
3,337
4,819
3,932
15,554
15,680
14,264
Chaiyaphum
Kamphaengphet
Roiet
1,134
767
1,321
32,392
28,414
30,028
1,082
925
918
10,122
10,805
12,011
1,555
1,625
1,507
3,622
3,081
3,722
18,286
17,842
19,720
37,766
1,219
13,474
2,293
6,461
12
19,720
Sakaeo (MOPH
bed only)
Maximum
15,326
18,427
15,915
18,883
18,411
17,533
18,862
DCU Priority Score Distribution
40
35
35
Number of Provinces
30
25
20
15
15
10
9
10
5
3
3
1
0
0
1
2
3
Number of Criteria
4
5
6
13
80
Cancer
70
Heart disease
AIDS (reported)
AIDS (estimated)
50
Pneumonia and other lung
diseases
Nephritis and nephritic
syndrome
40
Liver and pancreas disease
30
Tuberculosis
20
Hypertension and
cerebrovascular disease
Septicemia
10
Diabetes Mellitus
20
02
'0
1
'0
0
'9
9
'9
8
'9
7
'9
6
'9
5
'9
4
'9
3
0
19
92
Death Rate Per 100,000
60
14
Ch
r on
accessed 21 January 2004.
ic l
o
ise
ce
r
r
25
ca
n
an
ce
er
nc
30
Ce
r vi
ca
l
as
tc
ca
ria
e
as
Ma
la
sta
te
Bre
Pro
se
me
llitu
s
ea
dis
is
er
nc
los
ca
ed
siv
tes
e
as
ea
se
be
r cu
ng
se
on
ia
ea
ise
di s
tor
y
be
Hy
pe
r te
n
Dia
ira
Tu
Lu
mi
a
nc
er
eu
m
rt d
Liv
er
ic h
ea
sp
em
Pn
ca
dis
er
ptic
e
cul
ar
as
rov
we
r re
Isc
h
Ce
r eb
Liv
Se
HIV
Death Rate Per 100,000
35
Male
Female
20
15
10
5
0
Source: Bureau of Policy and Strategy website http://203.157.19.191/45%20table%202.3.2%20cause.xls.,
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Demographic Dividend
30
Cancer
Transport Accident
Tuberculosis
25
Pneumonia
Percentage Deaths in Age Bracket
Heart and Cerebrovascular Disease
AIDS (reported)
20
Diabetes mellitus
15
10
5
0
0-4
5-9
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
Age Group
Source: Bureau of Policy and Strategy website http://203.157.19.191index%20stat%2045.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 2003;26:2758-2763.
18
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 2003;26:2758-2763.
19
Metrika A1cNow™
• Details
– Disposable single-use
glycosylated HbA1c
monitoring
– Home use with
prescription
– Results in 8 minutes
– Cost: $21.99 USD
20
Design, Fabrication, and Assembly
• Uses finger stick
method to collect blood
• Micro-optics and solid
state chemistry detect
glycosylated HbA1c
21
“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
22
Quantitative Cardiac Injury Markers
• Details
– Whole-blood POC
measurement
(Biosite)
– cTnI, CK-MB, and
myoglobin (AMI)
– BNP (CHF)
23
24
“In Vitro”: i-Stat Portable Clinical Analyzer
• Details
– Microfluidic biosensor
technology
– Built-in quality control
– Handheld
25
GEM Premier 3000
• Details (Instr. Labs)
– Automated QC with
“iQM” (Intelligent
Quality Management)
– Disposable multi-use
cartridges
– Web-based
networking
26
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)
27
Faster Diagnosis: LightCycler® 2.0
• Details:
– Rapid response testing
(Roche Diagnostics)
– High speed thermocycling
– Complete PCR cycle in 2030 minutes
– Detect nucleic acid in blood
– Sepsis panel of 25
pathogens
28
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
29
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
30
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
Women’s Health
●Pregnancy
●Fertility
●Fertility
●Osteoporosis
●Parentage
hCG
LH
FSH
Cross-linked N-telopeptides
Cancer
●Prostate
●Liver, testicular, ovarian, pancreatic,
& stomach
●Colon
●Colorectal, breast, thyroid, lung,
ovarian,& stomach
Function Monitoring
●Blood Pressure
●Urinalysis
DNA
Prostate-specific antigen (PSA)
Alphafetoprotein (AFP)
Fecal occult blood
Carcino-embryonic antigen (CEA)
32
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 Vision—Empower patients and the care team
to optimize efficiency, care paths, and resources
33
PCU
PCU
Community
PCU
Regional
PCU
Home,
Village,
and
Community
Hospital
PCU
Specialty,
University, and
National Centers
Province
Referral
Hospital
Anamai
(Health
Center)
PCU
PCU
Regional
Hospital
Community
Hospital
PCU
PCU
Home Testing,
Self-Monitoring,
and
Telecommunications
Primary
Counseling
and
Treatment
PCU
Rapid Response,
Acute Care, and
Information Integration
POCT/Care Spectrum
PCU
Towns
and
Cities
Critical Care
and
Triage
Esoteric Tests,
Scarce Technology, and
Specialty Therapy
34
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 Vision—Empower physicians to reduce risk
and treat medical problems quickly on site
35
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
36
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
37
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
38
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
39
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
40
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 vision—Empower Thailand (and other
countries) to deliver equitable health care
41
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
42
Centers of
Excellence
Demographic
Dividend
New
Skills
Small-World
Networks
HEALTH
POCT
Productivity
Economic
Growth
43