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

1. Minimizing Health Problems toOptimize 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

2. 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

3. 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)

4. Pharmacists Physicians Distribution by Region Beds Source:Bureau of Policy and Strategy, http://hrm.moph.go.th/resource/hr.report45rb, accessed 24 March 2004

5. Provinces versus People per Physician Source: Bureau of Policy and Strategy, http://hrm.moph.go.th/resource/hr.report45.rb, accessed 24 March 2004

6. Provinces versus People per Pharmacist Source: Bureau of Policy and Strategy, http://hrm.moph.go.th/resource/hr.report45.rb, accessed 24 March 2004

7. Provinces versusPeople per Bed Source: Bureau of Policy and Strategy, http://hrm.moph.go.th/resource/hr.report45.rb,accessed 24 March 2004

8. 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

9. 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

10. 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

11. Provinces versus People per PCU Source: Office of Health Care Reform Project, Public Health Development Bureau, Ministry of Public Health, 2002

12. DCU Priority Scores Summary

13. DCU Priority Score Distribution

15. Source: Bureau of Policy and Strategy website http://203.157.19.191/45%20table%202.3.2%20cause.xls., accessed 21January 2004.

16. Demographic Dividend Source: Bureau of Policy and Strategy website http://203.157.19.191index%20stat%2045.html,accessed 21 January 2004

17. 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.

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. 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.

20. Metrika A1cNow™ • Details • Disposable single-use glycosylated HbA1c monitoring • Home use with prescription • Results in 8 minutes • Cost: $21.99 USD

21. Design, Fabrication, and Assembly • Uses finger stick method to collect blood • Micro-optics and solid state chemistry detect glycosylated HbA1c

22. “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

23. Quantitative Cardiac Injury Markers • Details • Whole-blood POC measurement (Biosite) • cTnI, CK-MB, and myoglobin (AMI) • BNP (CHF)

25. “In Vitro”: i-Stat Portable Clinical Analyzer • Details • Microfluidic biosensor technology • Built-in quality control • Handheld

26. GEM Premier 3000 • Details (Instr. Labs) • Automated QC with “iQM” (Intelligent Quality Management) • Disposable multi-use cartridges • Web-based networking

27. 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)

28. 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 25pathogens

29. 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

30. 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

31. DISEASES, POCT, AND EVIDENCE

32. DISEASES, POCT, AND EVIDENCE

33. 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

34. 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 Telecommunications Critical Care and Triage Rapid Response, Acute Care, and Information Integration Esoteric Tests, Scarce Technology, and Specialty Therapy POCT/Care Spectrum

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

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