Opinion: The use of point-of-care sonography in primary care: An ethical perspective

IntroductionC-reactive protein (CRP), a biomarker of infection, has been used widely in high-income settings to guide antibiotic treatment in patients presenting with respiratory illnesses in primary care. Recent trials in low- and middle-income countries showed that CRP testing could safely reduce antibiotic use in patients with non-severe acute respiratory infections (ARIs) and fever in primary care. The studies, however, were conducted in a research-oriented context, with research staff closely monitoring healthcare behaviour thus potentially influencing healthcare workers’ prescribing practices. For policy-makers to consider wide-scale roll-out, a pragmatic implementation study of the impact of CRP point of care (POC) testing in routine care is needed.Methods and analysisA pragmatic, cluster-randomised controlled trial, with two study arms, consisting of 24 commune health centres (CHC) in the intervention arm (provision of CRP tests with additional healthcare worker guidance) and 24 facilities acting as controls (routine care). Comparison between the treatment arms will be through logistic regression, with the treatment assignment as a fixed effect, and the CHC as a random effect. With 48 clusters, an average of 10 consultations per facility per week will result in approximately 520 over 1 year, and 24 960 in total (12 480 per arm). We will be able to detect a reduction of 12% to 23% or more in immediate antibiotic prescription as a result of the CRP POC intervention. The primary endpoint is the proportion of patient consultations for ARI resulting in immediate antibiotic prescription. Secondary endpoints include the proportion of all patients receiving an antibiotic prescription regardless of ARI diagnosis, frequency of re-consultation, subsequent antibiotic use when antibiotics are not prescribed, referral and hospitalisation.Ethics and disseminationThe study protocol was approved by the Oxford University Tropical Research Ethics Committee (OxTREC, Reference: 53–18), and the ethical committee of the National Hospital for Tropical Diseases in Vietnam (Reference:07/HDDD-NDTW/2019). Results from this study will be disseminated via meetings with stakeholders, conferences and publications in peer-reviewed journals. Authorship and reporting of this work will follow international guidelines.Trial registration detailsNCT03855215; Pre-results.

Download Full-text

Learning health systems in primary care: a systematic scoping review

BMC Family Practice ◽

10.1186/s12875-021-01483-z ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Danielle M. Nash ◽

Zohra Bhimani ◽

Jennifer Rayner ◽

Merrick Zwarenstein

Keyword(s):

Primary Care ◽

Quality Improvement ◽

Health Systems ◽

Scoping Review ◽

Early Stage ◽

Point Of Care ◽

The United States ◽

Stage Of Development ◽

Integrated Health ◽

Google Search

Abstract Background Learning health systems have been gaining traction over the past decade. The purpose of this study was to understand the spread of learning health systems in primary care, including where they have been implemented, how they are operating, and potential challenges and solutions. Methods We completed a scoping review by systematically searching OVID Medline®, Embase®, IEEE Xplore®, and reviewing specific journals from 2007 to 2020. We also completed a Google search to identify gray literature. Results We reviewed 1924 articles through our database search and 51 articles from other sources, from which we identified 21 unique learning health systems based on 62 data sources. Only one of these learning health systems was implemented exclusively in a primary care setting, where all others were integrated health systems or networks that also included other care settings. Eighteen of the 21 were in the United States. Examples of how these learning health systems were being used included real-time clinical surveillance, quality improvement initiatives, pragmatic trials at the point of care, and decision support. Many challenges and potential solutions were identified regarding data, sustainability, promoting a learning culture, prioritization processes, involvement of community, and balancing quality improvement versus research. Conclusions We identified 21 learning health systems, which all appear at an early stage of development, and only one was primary care only. We summarized and provided examples of integrated health systems and data networks that can be considered early models in the growing global movement to advance learning health systems in primary care.

Download Full-text

Cardio-Pulmonary Sequelae in Recovered COVID-19 Patients: Considerations for Primary Care

Journal of Primary Care & Community Health ◽

10.1177/21501327211023726 ◽

2021 ◽

Vol 12 ◽

pp. 215013272110237

Author(s):

Zouina Sarfraz ◽

Azza Sarfraz ◽

Alanna Barrios ◽

Radhika Garimella ◽

Asimina Dominari ◽

...

Keyword(s):

Primary Care ◽

Primary Infection ◽

Clinical Laboratory ◽

Point Of Care ◽

Case Reports ◽

Case Series ◽

Infectious Complications ◽

Care Physician ◽

Cross Sectional ◽

Infection Period

Background: Current literature lacks characterization of the post-recovery sequelae among COVID-19 patients. This review characterizes the course of clinical, laboratory, radiological findings during the primary infection period, and the complications post-recovery. Primary care findings are presented for long-COVID care. Methods: Adhering to PRISMA guidelines, 4 databases were searched (PubMed, Embase, CINAHL Plus, Scopus) through December 5, 2020, using the keywords “COVID-19 and/or recovered and/or cardiovascular and/or long-term and/or sequelae and/or sub-acute and/or complication.” We included published peer-reviewed case reports, case series, and cross-sectional studies providing the clinical course of COVID-19 infection, and cardiopulmonary complications of patients who recovered from COVID-19, while making healthcare considerations for primary care workers. Results: We identified 29 studies across 9 countries including 37.9% Chinese and 24.1% U.S. studies, comprising 655 patients (Mean Age = 45) with various ethnical backgrounds including Asian and European. Based on the WHO COVID-19 severity classification scale, initial disease severity was mild for 377 patients and severe for 52 patients. Treatments during primary infection included corticosteroids, oxygen support, and antivirals. The mean value (in days) for complication onset after acute recovery was 28 days. Complete blood counts and RT-PCR tests were the most common laboratory results described. In 22 of the studies, patients showed signs of clinical improvement and were prescribed medications such as anticoagulants or corticosteroids. Conclusion: Post-recovery infectious complications are common in long-COVID-19 patients ranging from mild infections to life-threatening conditions. International thoracic and cardiovascular societies need to develop guidelines for patients recovering from COVID-19 pneumonia, while focused patient care by the primary care physician is crucial to curb preventable adverse events. Recommendations for real-time and lab-quality diagnostic tests are warranted to establish point-of-care testing, detect early complications, and provide timely treatment.

Download Full-text

»Point-of-Care« D-Dimer Testing

Journal of Medical Biochemistry ◽

10.2478/v10011-010-0032-9 ◽

2010 ◽

Vol 29 (4) ◽

pp. 282-287 ◽

Cited By ~ 3

Author(s):

Jovan Antović

Keyword(s):

Primary Care ◽

Venous Thromboembolism ◽

Emergency Departments ◽

Laboratory Testing ◽

Point Of Care ◽

Turnaround Time ◽

The Other ◽

Clinical Conditions ◽

D Dimer ◽

Laboratory Assay

»Point-of-Care« D-Dimer TestingD-dimer testing is efficient in the exclusion of venous thromboembolism (VTE). D-dimer laboratory assays are predominantly performed in centralised laboratories in intra-hospital settings although most patients with suspected VTE are presented in primary care. On the other hand decreasing turnaround time for laboratory testing may significantly improve efficacy in emergency departments. Therefore an introduction of a rapid, easy to perform point of care (POC) assay for the identification of D-dimer may offer improvement in diagnostics flow of VTE both in primary care and emergency departments while it could also improve our diagnostic possibilities in some other severe clinical conditions (e.g. disseminated intra-vascular coagulation (DIC) and aortic aneurism (AA)) associated with increased D-dimer. Several POC D-dimer assays have been evaluated and majority of them have met the criteria for rapid and safe exclusion of VTE. In our hands three assays (Stratus, Pathfast and Cardiac) have the laboratory performance profile comparable with our routine D-dimer laboratory assay (Tinaqaunt).

Download Full-text

Point-of-Care Virtual Radiology Consultations in Primary Care: A Feasibility Study of a New Model for Patient-Centered Care in Radiology

Journal of the American College of Radiology ◽

10.1016/j.jacr.2021.07.007 ◽

2021 ◽

Author(s):

Dania Daye ◽

Evita Joseph ◽

Efren Flores ◽

Avinash Kambadakone ◽

Garrett Chinn ◽

...

Keyword(s):

Primary Care ◽

Feasibility Study ◽

Point Of Care ◽

Patient Centered Care ◽

Patient Centered ◽

New Model ◽

Centered Care

Download Full-text

Improving early exclusion of acute coronary syndrome in primary care: the added value of point-of-care troponin as stated by general practitioners

Primary Health Care Research & Development ◽

10.1017/s1463423617000135 ◽

2017 ◽

Vol 18 (04) ◽

pp. 386-397 ◽

Cited By ~ 5

Author(s):

Michelle M.A. Kip ◽

Amber M. Noltes ◽

Hendrik Koffijberg ◽

Maarten J. IJzerman ◽

Ron Kusters

Keyword(s):

Primary Care ◽

Acute Coronary Syndrome ◽

Blood Sample ◽

General Practitioners ◽

Point Of Care ◽

Added Value ◽

Lower Sensitivity ◽

Test Duration ◽

Referral Rates ◽

Coronary Syndrome

AimTo investigate general practitioners’ (GPs’) desire and perceived added value of point-of-care (POC) troponin, its effect on referral decisions, and test requirements.BackgroundExcluding acute coronary syndrome (ACS) in primary care remains a diagnostic challenges for GPs. Consequently, referral rates of chest pain patients are high, while the incidence of a cardiovascular problem is only 8–15%. Previous studies have shown that GPs are interested in a POC troponin test. This test could enhance rapid exclusion of ACS, thereby preventing unnecessary patient distress, without compromising safety and while reducing costs. However, using this test is not recommended in current guidelines due to uncertainty in the test’s potential added value, and the lower sensitivity early after symptom onset as compared with troponin tests in a regular laboratory.MethodsAn online survey containing 34 questions was distributed among 837 Dutch GPs in June 2015.FindingsA total of 126 GPs (15.1%) completed at least 75% of the questions. 67.1% of GPs believe that POC troponin tests have moderate to very high added value. Although the availability of a POC test is expected to increase the frequency at which troponin tests are used, it likely decreases (immediate) referral rates. Of the responding GPs, 78.3% only accept 10 min as the maximum test duration, 78.1% think reimbursement of the POC device is required for implementation, and 68.9% consider it necessary that it can be performed with a finger prick blood sample. In conclusion, according to GPs, the POC troponin test can be of added value to exclude ACS early on. Actual test implementation will depend on test characteristics, including test duration, type of blood sample required, and reimbursement of the analyzer.

Download Full-text

The Integrating Pharmacogenetics in Clinical Care (I-PICC) Study: Protocol for a point-of-care randomized controlled trial of statin pharmacogenetics in primary care

Contemporary Clinical Trials ◽

10.1016/j.cct.2018.10.010 ◽

2018 ◽

Vol 75 ◽

pp. 40-50 ◽

Cited By ~ 1

Author(s):

Jason L. Vassy ◽

Charles A. Brunette ◽

Nilla Majahalme ◽

Sanjay Advani ◽

Lauren MacMullen ◽

...

Keyword(s):

Primary Care ◽

Randomized Controlled Trial ◽

Study Protocol ◽

Point Of Care ◽

Controlled Trial ◽

Clinical Care ◽

Randomized Controlled

Download Full-text

Cost-Effectiveness Analysis of the Use of Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing in Primary Care

Antibiotics ◽

10.3390/antibiotics7040106 ◽

2018 ◽

Vol 7 (4) ◽

pp. 106 ◽

Cited By ~ 6

Author(s):

Emily Holmes ◽

Sharman Harris ◽

Alison Hughes ◽

Noel Craine ◽

Dyfrig Hughes

Keyword(s):

Primary Care ◽

Cost Effectiveness ◽

Respiratory Tract ◽

Clinical Guidelines ◽

Antibiotic Prescription ◽

Point Of Care ◽

Cost Effective ◽

Routine Practice ◽

C Reactive Protein ◽

Reactive Protein

More appropriate and measured use of antibiotics may be achieved using point-of-care (POC) C-reactive protein (CRP) testing, but there is limited evidence of cost-effectiveness in routine practice. A decision analytic model was developed to estimate the cost-effectiveness of testing, compared with standard care, in adults presenting in primary care with symptoms of acute respiratory tract infection (ARTI). Analyses considered (1) pragmatic use of testing, reflective of routine clinical practice, and (2) testing according to clinical guidelines. Threshold and scenario analysis were performed to identify cost-effective scenarios. In patients with symptoms of ARTI and based on routine practice, the incremental cost-effectiveness ratios of CRP testing were £19,705 per quality-adjusted-life-year (QALY) gained and £16.07 per antibiotic prescription avoided. Following clinical guideline, CRP testing in patients with lower respiratory tract infections (LRTIs) cost £4390 per QALY gained and £9.31 per antibiotic prescription avoided. At a threshold of £20,000 per QALY, the probabilities of POC CRP testing being cost-effective were 0.49 (ARTI) and 0.84 (LRTI). POC CRP testing as implemented in routine practice is appreciably less cost-effective than when adhering to clinical guidelines. The implications for antibiotic resistance and Clostridium difficile infection warrant further investigation.

Download Full-text