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EDITORIALS: ET Murray and M Greaves INRs and point of care testing BMJ 2003; 327: 5-6 [Full text]

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Letīs follow the example of diabetes care

Iņigo Romon-Alonso   (4 July 2003)

Community-based solutions for community-based problems

Preeti Choudhary, Vi Nguyen and Nicholas Collins   (22 July 2003)

Letīs follow the example of diabetes care 4 July 2003
Iņigo Romon-Alonso, Quality Manager Banco de Sangre y Tejidos de Cantabria, Santander, 39008, SPAIN Send response to journal: Re: Letīs follow the example of diabetes care	Everyday more and more patients are treated with oral anticoagulants. This implies a huge effort for hematology and pathology services caring for them in centralised, hospital-based systems. This control means that samples have to be taken, carried to the central laboratory, analysed and results sent back to the patient. Most often, thanks to computerized programs, the hematologist will adjust the patientīs dose, which will take some hours of his time everyday. This is only the beginning, since results get lost , some patients show surprising results and cannot be interviewed, etc...Besides, the GP losses his patient, can only prescribe what the hematologist orders, has to face complications heīs not familiar with while managing the original cause of anticoagulation... Point of care devices can change this situation. While it will mean some extra work for GPs, this will not be more than the actual work they get by prescribing and resolving problems with controls. The laboratories will get rid of an increasing load and will have the opportunity to relocate resources, possibly improving attention to other primary care problems. Diabetics take care of themselves in a more dangerous context, using more dangerous medication. Even when point of care devices need to improve, they set free patients and bring them back to their family doctor. Competing interests:   None declared
Community-based solutions for community-based problems 22 July 2003
Preeti Choudhary, Year 4 Medical Student Macarthur Health Service, P O Box 149, Campbelltown NSW 2560, Vi Nguyen and Nicholas Collins Send response to journal: Re: Community-based solutions for community-based problems	As Murray and Greaves1 have highlighted, point-of-care (POC) INR testing has become an issue of increasing relevance as there are a growing number of indications for long-term warfarin therapy (including atrial fibrillation, venous thrombosis and artificial valve replacement)2. With regular INR testing at a central location, patients must take time to travel to the hospital, have the test done, then wait for the results before any necessary action regarding the dosages can be taken. This has an impact on patient compliance, empowerment and quality of life that might be improved by POC testing3. The main concern surrounding POC testing systems are the accuracy of the machines and the reliability of the techniques,3,4. However, several studies have provided evidence that no significant difference exists between the INR readings generated by a central laboratory and POC testing devices4. Thus, provided that the devices are calibrated according to the WHO ISI standards5, POC INR testing should be considered as reliable. The rapid availability of results reduces the time to make decisions, thereby allowing for more rapid triage, treatment, or discharge planning6. Such advantages might be particularly beneficial in the remote and rural setting. In the longer term, use of these tests to improve patient management and therefore reduce the disease burden will also benefit the healthcare system6. Thus, POC INR testing exemplifies a community-centred approach to a community-based issue and provides a safe and effective management strategy with recorded higher levels of patient satisfaction3 and adherence. Overburdened hospital clinics and laboratories would be better able to direct their economic resources toward other areas, which truly cannot be managed within the community rather than directing funds and staff towards a service which is less efficacious in the hospital setting, less accessible and less likely to induce patient compliance. It is time hospitals learnt to relinquish some of their traditional tasks, in order for them to be carried out by health professionals within the community at equal if not better standards. References: 1. Murray ET, Greaves M. INRs and point of care testing. BMJ 2003; 327: 5-6. 2. Laposata M. Point-of-care coagulation testing: stepping gently forward.[comment]. [Comment. Editorial] Clinical Chemistry 47(5):801-2, 2001 May. 3. Shiach CR. Campbell B. Poller L. Keown M. Chauhan N. Reliability of point-of-care prothrombin time testing in a community clinic: a randomized crossover comparison with hospital laboratory testing. [Clinical Trial. Journal Article. Randomized Controlled Trial] British Journal of Haematology 119(2):370-5, 2002 Nov. 4. Poller L, Keown M, Chauhan N, AMHP van den Besselaar, Tripodi A, Shiach C, et al. Reliability of international normalised ratios from two point of care test systems: comparisons with conventional methods. BMJ 2003:327: 30 -2. 5. Tripodi A. Chantarangkul V. Bressi C. Mannucci PM. International sensitivity index calibration of the near-patient testing prothrombin time monitor, ProTime. [Journal Article] American Journal of Clinical Pathology 119(2):241-5, 2003 Feb. 6. Price C.P. Point of Care testing. [Clinical review] BMJ 2001;322:1285- 1288, May. Preeti Choudhary, Med IV student, Macarthur Health Service. Vi Nguyen, Med IV student, Macarthur Health Service. Dr Nicholas Collins, Staff Specialist, Macarthur Health Service, Campbelltown, NSW 2560. Competing interests:   None declared