Clinical and Operational Benefits of International Normalized Ratio Point-of-Care Testing in Remote Indigenous Communities in Australia’s Northern Territory

Abstract

Among Indigenous people of Australia's Northern Territory, the prevalence of rheumatic heart disease is one of the highest in the world. Warfarin is a common anticoagulant used to treat this condition and to minimize risk of a cardiac event. International normalized ratio (INR) testing is used routinely to monitor the efficacy of warfarin therapy and to ensure a patient's INR remains within a tight therapeutic range. Since 2008, the i-STAT point-of-care testing (POCT) device has been used to measure INR for patients on warfarin therapy in 32 remote health centers participating in the Northern Territory POCT Program. A training and quality program to support i-STAT INR POCT is delivered by Flinders University International Centre for POCT and offers flexible options for training including on-site workshops, interactive teleconference training, and training via e-learning. Since 2008, more than 13,000 INR POCTs have been performed on more than 900 patients. Two hundred ninety-eight patients have had 5 or more INR POCTs performed, and 212 of these have had more than 10 serial INR tests. The volume of patient INR testing has increased every year of the program, from 853 in 2008 to 3332 in 2014 (representing a 291% increase in testing since the program's inception). The number of remote health staff trained as POCT device operators is now greater than 700. The between-site imprecision (CV%) from monthly INR quality control testing has averaged 6.3% over the past 6 years (range, 4.6%-7.6%). A clinical audit of patient cases has identified improved clinical outcomes and operational benefits through POCT.

Ending rheumatic heart disease in Australia: the evidence for a new approach

“…234 National standards of care for centres providing cardiac surgery for people with RHD should be developed, and tertiary centres should share and adapt successful models of enhanced discharge planning and clinical handover. [235][236][237] Increasing access to and participation in culturally safe cardiac rehabilitation programs could prevent subsequent RHD-related complications and readmissions. Increased resourcing for cardiac rehabilitation in rural and remote areas is likely to improve long term outcomes.…”

“…Improving access to safe anticoagulation and monitoring on return to communities must also be a priority. Community care providers should be resourced and supported to provide culturally appropriate education on the importance of anticoagulation, and increase the capacity for self‐management of anticoagulation using point‐of‐care international normalised ratio testing machines 235‐237. Finally, the safety and effectiveness of novel anticoagulants for use in RHD should be explored.…”

Sustained Quality and Service Delivery in an Expanding Point-of-Care Testing Network in Remote Australian Primary Health Care

“…Detailed overviews of the NT POCT Program from 2008 to 2015 have been published elsewhere. [7][8][9] Methods specific to the NT POCT Program from 2016 to 2019 are documented below. Top End regions and Primary Health Care Centres in the Ngaanyatjarra Lands.…”

“…7 By 2015, the NT POCT Program had effectively doubled to include all 72 remote health services within the Northern Territory. 9 In 2016, 8 remote health services from the Ngaanyatjarra Lands in the Western Desert region of Australia were also enrolled into the NT POCT Program (Figure 1).…”

The Benefits and Challenges of Point-of-Care Testing in Rural and Remote Primary Care Settings in Australia

“…With these core elements in place, many clinical benefits of using POC testing in rural and remote primary care settings, both nationally and internationally, have been documented (Table 1). 11,13,[19][20][21][22] There is now also a large source of evidence from ICPOCT networks for the operational, cultural, and economic benefits of POC testing for the patient (convenience and accessibility), the POC test operator (empowerment), the medical practitioner (timely clinical decision-making) and the community (building workforce capacity for POC testing); these benefits are listed in Table 2. 18,22,24,[26][27][28][29] In the opinion of the authors, infectious disease POC testing has the greatest potential for growth during the next decade.…”