While the decision whether to test and counsel patients with results during the visit or batch for lower cost and more convenient workflow is a practice decision, our customers deserve and expect guidance from their suppliers.
Point-of-care testing has always been my passion. I know many seasoned distribution account managers feel the same way.
As we consult with customers to describe the benefits to their practice and patients resulting from point-of-care testing, some customers adopt point-of-care testing readily, while others are more reluctant. I’ve spent many years trying to figure out why.
One reason came down to workflow: whether to provide a test result now during the patient visit or to batch tests later using lower cost per test systems. As the technology to perform point-of-care testing evolved to include liquid chemistry profiling systems and immunoassay instruments for thyroids and therapeutic drug testing, the dichotomy of cost versus convenience in point-of-care testing first became apparent.
Should the clinician test while the patient was in the office using simpler fixed menu meter-based systems, or do batch testing later in the day on more sophisticated systems with broader menus and lower the cost per test? As I sold in-office testing in those days, I was often asked “What’s the value of testing in the physician office if I don’t discuss the results with the patient during the visit?” That was a tough question to which I had no real clear answer. Economics were usually part of the answer then, but for clinicians looking to optimize patient treatment and communication, it simply was not enough. As a result, my story of in-office testing missed the mark for those clinicians driven to improve patient care irrespective of economics.
As reimbursement has declined under PAMA and patient outcomes have become more important under MACRA, this challenge has come front and center once again. Over the years, I eventually learned to provide a more sophisticated answer: “You should test at the point-of-care if the test result will help you initiate or modify a patient treatment program.” That helped, but the questions then switched to: “That makes sense, but who do I test now? And who can I wait to test later in the day with more economical testing systems?”
While ultimately the decision whether to test and counsel the patient with results during the visit or batch for lower cost and more convenient workflow is a practice decision, our customers deserve and expect some level of credible and logical guidance from us and our manufacturer partners. In this article, I will try to explore this question and give you some ideas on how to help your customers think about their choices and make a sensible determination.
Patient treatment program
As I have considered the question of cost versus convenience, it has led me to think of why the patient is in the office in the first place. Typically, there are three reasons:
- A patient presents with acute symptoms (respiratory, physical injury or pain)
- A patient is there for an annual physical for routine general health
- The patient falls into a “risk-based screening” population based on age, personal or family history, gender or some combination
Once I realized this, the situation became clearer and I was able to refine my testing recommendations. I offer this reasoning and logic to you.
Implementing or modifying a patient treatment program still underpins whether to test at the point-of-care. But the rationale determining whether to test now or batch is based on both available technology and why the patient presents in the first place. Any time the technology can present an actionable answer during the patient visit, there is some credible reason to perform it then and discuss directly with the patient during the visit.
Hematology tests are a perfect example. They are quick, accurate, actionable, easy to perform tests and provide information valuable no matter why a patient present in the office. Rapid respiratory tests no matter whether they are lateral flow, meter based or molecular are a first line of defense when respiratory symptoms present. Stand-alone glucose and hemoglobin A1C tests are also pretty logical choices to perform during the visit for a patient with history or symptoms indicating diabetes, no matter the economics of testing now or later. The rapid rise of type 2 diabetes makes it very important to implement screening and patient counseling broadly for older, more sedentary and overweight patients in particular.
Once these easy tests and patient scenarios are out of the way, the line between cost, care and convenience becomes somewhat blurrier.
Additional considerations to form the decision to test and counsel now include whether there is a risk that the patient will not return or follow up on healthcare recommendations if test results and treatment plan follow-up are provided after the visit. Community-based clinics, in particular, face this challenge.
Institutional/clinical support for risk-based screening is very broad and includes CDC, U.S. Preventive Services Task force, various medical societies. Some of these recommendations include:
- Medicare preventative services (See link for more information on tests and other procedures) www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html
- CDC HIV/HCV/HPV screening recommendations
- HCV screening is recommended by CDC for baby boomers (See link for more detail) www.cdc.gov/hepatitis/hcv/guidelinesc.htm
- CDC recommends HIV screening for adults between 13 and 64 (See link for detail) https://www.cdc.gov/hiv/testing/
- CDC recommends HPV screening in combination with PAP tests www.cdc.gov/cancer/cervical/pdf/guidelines.pdf
In summary, as we think about how to credibly present the benefits of point-of-care testing, we need to be aware of not just the basic premise that tests should be provided at the point-of-care if their result will be used to initiate or modify a patient treatment program. We also need to consider the patient mix of the practice and use that information to provide more concrete, credible and thoughtful guidance regarding who to test, why to test and when to test. Using this thought process will provide you with the logic and rationale needed to confidently present point-of-care testing. Your customers will thank you as a result.
How technology and the patient situation influences immediate patient testing
| Technology | Why test? | Recommend testing during patient visit? |
| Hematology (CBC) | • Upon symptoms • General screening • Risk-based screening | Yes |
| Rapid respiratory tests | • Upon symptoms | Yes |
| Glucose, A1C | • Upon symptoms • Risk-based screening | Yes |
| Lipids | • Risk-based screening | Yes |
| PT/INR | • Anticoagulant therapy | Yes |
| Lead testing | • Risk-based screening | Yes |
| HIV/HCV/HPV | • Risk-based screening | Opinions vary |