Barriers and facilitators to use of POCTs
Five major themes emerged from the data regarding barriers and facilitators to use of POCTs, namely:
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Impact of POCTs on clinical decision-making
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Concerns about perceived inaccuracy of POCTs
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Impact of POCTs on perceived patient experience and patient-provider relationship
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Impact of POCTs on staff and clinic workflow
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Influence of regulation, quality control and cost [on use of POCTs]
We present each of the above themes in detail (summarized in Table
2). To preserve participant confidentiality abbreviated quotes are protected using interview identification numbers, with letters to delineate type of respondent (e.g. Physicians, Resident physicians, Administrative/support staff, Laboratory) followed by clinic site number (e.g. S1, S2, S3). Full quotations supporting the themes are sequentially numbered within the narrative and are presented in more detail (see Additional file
2).
Table 2
Summary of the facilitators and barriers to use of point of care tests (POCT) in family medicine clinics
1. Impact on clinical decision-making | - Faster decision-making - Earlier triaging of possible serious illness - Improved confidence in treatment decisions (e.g. antibiotics) | - Immediate results not helpful in some situations (e.g., monitoring of chronic conditions) - Over-reliance undermining physician clinical skills - Increase in unnecessary testing |
2. Accuracy concerns | - Improved ‘rule out’ value when used with clinical features | - Less accurate than laboratory tests - Positive test results often misleading |
3. Impact of POCT on staff and clinic workflow | - Reduced clinic difficulties with patient follow-up for laboratory tests between office visits - More POCT may alleviate pressure on under-staffed laboratories | - Concerns increased testing volume may extend patient visits/overwhelm providers - Insufficient healthcare personnel within clinics to manage additional testing - Risk of error in reporting results for tests without EMR interface |
4. Impact on perceived patient experience and patient-physician relationship | - Improved patient-provider communication - Patient awareness of work involved in making a diagnosis, making providers feel more valued - Improved patient understanding and acceptance of provider treatment decisions (e.g., antibiotics) - Perceived greater acceptability of fingerstick blood testing by patients and clinic | |
5. Influence of cost, regulation and quality control | | - Perceived expense compared to laboratory tests - Uncertainty about reimbursement rates from insurers and loss of clinic revenue - Lack of laboratory trust in giving clinics responsibility for quality control processes - Lack of clinic autonomy to adopt new tests |
Impact of POCTs on clinical decision-making
Faster decision-making was frequently cited as an advantage to using POCTs amongst all participants, particularly providers. Having the test result available immediately enabled providers to make treatment decisions or changes in clinical management, avoiding the need to wait until test results were returned from an external laboratory. This characteristic was seen as potentially most valuable for acute triage for serious issues (e.g. possible sepsis) as providers could make quicker decisions about whether a higher level of care was needed, or, it would give them additional data to have “an idea of which way to go” (R, S1) to get the patient on the right track if they were concerned a patient was critically ill (Q1). Being able to make a determination quickly was perceived as enhancing patient safety and being more efficient (Q2). Participants added that the value of POCTs in guiding decision-making was limited if tests yielded intermediate results (i.e. neither positive nor negative), which they had experienced previously with point-of-care troponin and d-dimer tests. However, for monitoring other conditions, such as chronic illnesses, where time to consider treatment options can be helpful (Q3), it “might not be advantageous to know that result with the person sitting across from you” (P, S1).
Several providers expressed confidence (which some clinic support staff also recounted) in the use of clinical signs and symptoms to guide treatment decisions on whether to treat or not treat (both types of decisions were considered important) for commonly presenting illnesses such as respiratory infections, and identified scenarios where POCT may provide limited added value; for example, some felt they should be able to diagnose streptococcal tonsillitis based on clinical findings alone, and that a rapid antigen test for group A streptococcus would not alter their decision-making, regardless of the result “because you should be able to tell, and you’re going to treat it the same anyway” (A, S1). For these conditions, participants cautioned against over-reliance on testing which they believed could undermine providers’ clinical skills and usefulness (Q4). Nevertheless, POCTs were recognized as beneficial for situations where there was (continuing) uncertainty, for example discerning bacterial from viral infections in atypical presentations, or where there was perceived pressure from patients to prescribe (e.g. antibiotics) (Q5). For these types of scenarios POCTs were identified as useful for supporting prescribing decisions (Q6).
Concerns about perceived inaccuracy of POCTs
Another frequently occurring theme amongst participants across clinic roles, was the perception that POCTs were less accurate than routine laboratory tests. There was an assumption that even though they allowed providers to make on-the-spot clinical decisions, POCTs were not as accurate. These perceptions were partly the result of past experiences of inconsistencies between point-of-care and laboratory results (Q7; Q8). Concerns about inaccuracy were predominantly focused on getting false positive results from POCTs, which had occasionally misled participants in the past, resulting, for example, in a medication incorrectly being given. There was overall more inclination towards trusting negative results as rule-out tests, rather than positive results to rule in a condition (Q9). Consequently, participants reported that “almost all of the ones (POCTs) we do are followed up by a confirmatory (laboratory) test” (R, S3) especially if the test is positive, in order to be confident of the result (Q10). Providers believed POCTs could be used to rule in a condition provided they are used when clinically indicated, and in conjunction with clinical guidelines or findings, to increase the test’s specificity (Q11). Availability of false positive and false negative results with guidance on when the test should be used and how to interpret results, presented in summary format and pertaining to individual POCTs, would enable clinic staff to better understand the strengths and limitations of tests, which would offset imperfect diagnostic accuracy of POCTs.
Impact of POCTs on staff and clinic workflow
A perceived benefit of POCTs, which was linked to immediate knowledge of the test result, was the potential for streamlining patient care. Many participants expressed difficulties contacting patients to communicate results between visits, or arranging follow-up laboratory testing (Q12). Following-up hard-to-reach populations (e.g. individuals who are homeless, minority populations) was highlighted as a major problem due to lack of fixed address, incorrect or no telephone numbers, and language barriers (Q13). This also applied to patients living in more remote geographic settings or with busy work schedules, who were described as often unable to take further time off work to travel lengthy distances for additional office visits, or to be reached by follow-up telephone calls.
There was, however, apprehension about the impact increased use of POCTs might have on providers’ and clinic administrative/support staff workload during patient visits. For patients presenting with multiple problems, providers felt they may be placed under pressure to test and manage each complaint there and then, extending patient visits and overwhelming staff (Q14). Similarly, lack of health care personnel to run POCTs was identified by clinic administrative/support staff as impeding workflow, as POCTs were “another thing that has to be done by someone” (A, S2). Some clinics did not have high levels of staffing for their clinic laboratories, or sometimes no dedicated laboratory technician, meaning medical assistants (MAs) performed some laboratory duties within two of the practices, in addition to their primary role. There were mixed opinions about the feasibility of having MAs (or other support staff) undertake more testing. Providers were sensitive towards additional workload and time pressures more POCTs might impose on support staff as it would potentially “pull her [the MA] out of the rotation for 10 minutes, when they could be rooming the next patient” (P, S2). This seemed to be less of a concern for support staff themselves, who were motivated by their role in using POCTs to be “that one step ahead” (A, S3) for their provider (Q15). From the laboratory staff perspective the fact that POCTs could be performed by other staff, was considered an advantage, as it could ease their workload (Q16; Q17).
Without an interface automating integration of results into electronic medical records (EMR), there were concerns expanding POCT use within clinics may compound pressures on clinic administrative/support staff, and that manual data entry had already led to results being erroneously entered and reported in the past (Q18; Q19). For one site, lack of health care personnel and absence of seamless data entry features were primary reasons for not adopting certain POCTs (Q20).
Impact of POCTs on perceived patient experience and patient-provider relationship
Providers felt POCTs helped improve communication with patients and were an opportunity for health education (Q21). Providers believed patients did not always understand test results when they received them in a letter, so being able to have that discussion with them in real time was viewed as giving patients the opportunity to seek clarification, which might help improve understanding of their clinical management or provide reassurance (Q22). Additionally, one participant stated that giving patients results directly “from the horse’s mouth” (meaning the provider) might make patients appreciate that “we really are trying to help ‘em out” (P, S3), making providers feel their efforts to alleviate patient concerns/symptoms is better understood. Moreover, providers believed an immediate test result might improve patient acceptance of a provider’s treatment decisions. Providers described pressure for antibiotics and particular situations where providing patients with a tangible result could substantiate providers’ decision-making, without negatively affecting patient satisfaction (Q23).
Participants, irrespective of job role, perceived certain characteristics of POCTs as more acceptable to patients. Notably, the ease of blood sampling with finger stick POCTs was viewed as more convenient to participants and believed to improve patient compliance. Participants reflected on experiences where patients had explicitly favored finger stick testing and were felt to cause less anxiety than a venous draw due to the needle being hidden from view. Consequently, participants identified broader utility of this type of test (e.g. drug users with collapsed veins), which would facilitate clinical practice (Q24; Q25).
Influence of cost, regulation and quality control on use of POCTs
A major barrier to POCTs was perceived cost to the clinic. For certain POCTs (e.g. HbA1c) the cost per test was thought to be greater than send-out laboratory tests, though most providers did not know exact comparative costs, and acknowledged that costs varied depending on the test (Q26). Perceived higher costs was thought to be due to the up-front cost of purchasing analyzers and test strips/reagents and the labor involved in their set-up and daily running (e.g. staff training, quality checks, data entry procedures). In addition, lack of standardized reimbursement rates across insurers left participants unclear about the overall cost-effectiveness at the clinic-level of POCT (Q27).
Laboratory staff had reservations about quality control and calibration procedures for POCTs, such as who does them (in-house, or externally) and how frequently (Q28). There was skepticism by the laboratory technicians regarding how realistic it would be for quality control procedures to be conducted in-house by clinic staff, and whether laboratories would be comfortable relinquishing control of centralized testing. Usability of POCTs and consistency in how they are conducted by various clinic staff was felt to contribute to quality control concerns (Q29).
In terms of implementing POCTs, two clinics noted a lack of autonomy regarding decisions to adopt new tests, one of which described a perceived resistance by the clinic’s overarching healthcare system and its central laboratories to clinic-based testing, describing lengthy previous attempts (between 6 months and 2 years) getting new POCTs approved for clinic use (Q30).