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

Bangkok 34% South 10%

Distribution by Region

Physicians

Central 24% South 14%

Pharmacists

Bangkok 20% North 19% Northeast 17% Central 24% North 15% Northeast 23%

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 12 10 8 6 4 3 2 0 <1,891 6 5 2,691 3,490 7 9 6 6 3 3 4 4 2 3 2 4,291 5,090 5,891 6,690 7,491 8,290 Number of People per Physician 9,091 9,890 10,691 11,490 12,291 13,090 1

Provinces versus People per Pharmacist

14 12 11 10 8 6 4 3 2 0 <6,700 6 7,700 8,699 13 9 6 6 3 4 4 2 9,700 10,699 11,700 12,699 13,700 14,699 15,700 16,699 Number of People per Pharmacist 2 3 17,700 18,699 3 1 >19,699 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 16 14 12 10 8 6 4 2 0 7 11 12 17 10 4 8 4 3 <300 300-399 400-499 500-599 600-699 700-799 800-899 900-999 Number of People per bed >999 Source: Bureau of Policy and Strategy, http://hrm.moph.go.th/resource/hr.report45.rb, accessed 24 March 2004 7

Distribution of Nurses

North 18%

Professional Nurses

South 13% Northeast 20%

Technical Nurses

Bangkok 24% Central 25% North 18% South 17% Northeast 24% Bangkok 14% Central 27%

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 20 18 15 12 11 10 8 7 6 5 4 4 2 2 2 0 <410 410 559 560 709 710 859 860 1,009 1,010 1,159 1,160 1,309 1,310 1,459 Number of People per Professional Nurse 1,460 1,609 1,610 1,759 >1,759 Source: Bureau of Policy and Strategy, http://hrm.moph.go.th/resource/hr.report45.rb, accessed 24 March 2004 9

Provinces versus People per Technical Nurse

6 4 2 0 20 18 16 14 12 10 8 1 12 18 15 11 5 10 4 <1,000 1,000 1,499 1,500 1,999 2000 2,499 2,500 2,999 3,000 3,499 Number of People per Technical Nurse 3,500 3,999 >3,900

Provinces versus People per PCU

14 12 10 8 6 6 4 2 0 <8,060 12 12 10,560 13,059 7 10 4 5 5 2 15,560 18,059 20,560 23,059 25,560 28,009 Number of People Per PCU 4 4 30,460 32,959 3 1 >35,459 Source: Office of Health Care Reform Project, Public Health Development Bureau, Ministry of Public 11 Health, 2002

DCU Priority Scores Summary

Priority Score High (4) Province

Amnatcharoen Sakaeo (MOPH bed only)

Population (1K) PCU (>23,060) Bed (>780)

369 537 11,191 9,943 879 1,116

MD (>8,291)

12,734 9,257

Higher (5)

Buriram Kalasin Mahasarakham Nakhonphanom Nongbualamphu Nongkhai Phetchabun Sakonnakhon Sisaket Surin

Highest (6)

Chaiyaphum Kamphaengphet Roiet Maximum 1,540 988 941 720 498 907 1,039 1,105 1,455 1,396 1,134 767 1,321 10,198 17,330 8,331 18,008 11,056 11,630 22,577 10,521 9,899 10,416 32,392 28,414 30,028 37,766 855 888 924 840

1,219

882 875 832 1,164 853 1,082 925 918 1,219 9,447 9,147 11,207 12,005 12,438 10,080 10,598 10,521

13,474

11,632 10,122 10,805 12,011 13,474

PN (>1,156)

1,122 1,475

TN (>2,943)

3,730 2,871

P (>13,705)

19,437 13,767 1,754 1,588 1,416 1,207

2,293

1,296 1,731 1,328 1,828 1,688 1,555 1,625 1,507 2,293 3,765 6,023 3,906 3,289

6,461

3,643 3,644 3,337 4,819 3,932 3,622 3,081 3,722 6,461 15,554 15,680 14,264 15,326 18,427 15,915 18,883 18,411 17,533 18,862 18,286 17,842

19,720

DCU Priority Score Distribution

20 15 10 5 0 40 35 30 25 35 0 15 10 1 9 3 1 2 3 Number of Criteria 4 5 3 6 13

80 70 60 50 40 30 20 10 0 19 92 '9 3 '9 4 '9 5 '9 6 '9 7 '9 8 '9 9 '0 0 '0 1 20 02 Cancer Heart disease AIDS (reported) AIDS (estimated) Pneumonia and other lung diseases Nephritis and nephritic syndrome Liver and pancreas disease Tuberculosis Hypertension and cerebrovascular disease Septicemia Diabetes Mellitus 14

35 30 25 20

Male Female

15 10 5 0 H IV S e pt ice m ia L ive r ca n ce r C er e b ro va scu la r d ise a se P n eu m e o m ni a ic he a rt d ise a se L ive r d ise a se Isch L u n g ca C n ce hr r o n T ic u lo b w er cu er r lo e si sp s ir a to ry d ise a se D ia b e te s m H e yp lli e tu rt s e n si ve d ise a se M a la ri a P ro st a te ca n ce r B re a st ca nce C r er vi ca l ca n ce r

Source:

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

15

30 15 10 25 20

Demographic Dividend

Cancer Transport Accident Tuberculosis Pneumonia Heart and Cerebrovascular Disease AIDS (reported) Diabetes mellitus 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 16

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.

17

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 20 30 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

Diabetes Hematology ●Coagulation ●Anemia Infectious Diseases Cardiovascular Disease Drugs of Abuse

Analytes

Glucose, HbA1c, Ketones, Fructosamine Prothrombin time (PT) Hemoglobin or hematocrit Strep A/B, HBV, HIV 1/2, Influenza A/B, Malaria, Syphilis, Chlamydia, H. pylori, HCV, SARS virus, CMV, EBV, Cholera, Listeria, CRP Cholesterol, HDL, LDL, Lipids, Triglycerides, CRP Amphetamines, Barbiturates, Benzodiazepines, Cocaine, Methadone, Methamphetamines, Opiates, Phencyclidine, Tricyclic antidepressants, Ethanol, Ecstasy (MDMA), PCP 31

DISEASES, POCT, AND EVIDENCE

Disease/condition

Women’s Health ●Pregnancy ●Fertility ●Fertility ●Osteoporosis ●Parentage

Analytes

hCG LH FSH Cross-linked N-telopeptides DNA Cancer ●Prostate ●Liver, testicular, ovarian, pancreatic, & stomach ●Colon ●Colorectal, breast, thyroid, lung, ovarian,& stomach Prostate-specific antigen (PSA) Alphafetoprotein (AFP) Fecal occult blood Carcino-embryonic antigen (CEA) Function Monitoring ●Blood Pressure ●Urinalysis 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

Home, Village, and Community

PCU PCU

Anamai (Health Center) Community Regional Hospital Community Hospital

PCU PCU PCU

Regional Hospital Home Testing, Self-Monitoring, and Telecommunications Primary Counseling and Treatment Rapid Response, Acute Care, and Information Integration

POCT/Care Spectrum PCU

Province Referral Hospital Towns and Cities

PCU

Specialty, University, and National Centers

PCU PCU

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 POCT Demographic Dividend New Skills HEALTH Productivity Small-World Networks Economic Growth

43