Diagnosis at the point of care

Point-of-care testing (POCT) in pathology is an exciting and emerging field of community medicine.

It involves using portable diagnostic and medical devices that deliver the same tests as hospital laboratories in remote community health care settings on a finger-prick blood sample or drop of urine, with the result generally available in less than 10 minutes.

This potentially means an immediate health outcome for the patient that would otherwise be impossible.

Dr Mark Shephard is director of the Community Point-of-Care Services (CPS) Unit at Flinders University Rural Clinical School, and will discuss his experiences with community-based point-of-care testing in rural and remote Australia for the management of chronic diseases at the South Pacific Congress in Auckland this week.

Only a decade after its inception, the CPS Unit at Flinders is recognised nationally and internationally for its innovative POCT services in rural and remote settings, particularly in Aboriginal communities.

The unit's overarching goal is to develop POCT models for the prevention and management of chronic disease that are analytically sound and clinically and culturally effective in the community setting.

It has achieved considerable success in these aims, and at the conference Shephard will focus on the evidence base for the clinical and cultural effectiveness of POCT in indigenous medical services, based one of the unit's major programs.

Armed with nothing more than a good idea...

Point-of-care (POC) programs for remote communities did not exist in Australia before 1997. This changed when, armed with nothing more than an idea, scientific experience and a vision for improving the health of some of the world's poorest people, Shephard left his position at the Flinders Medical Centre diagnostic laboratory to launch a POCT initiative in the Umoona Aboriginal community near Coober Pedy in South Australia's far north.

This move had two triggers: Shephard's long-standing interest in Australian deserts and a colleague's request for help.

For many years, Shephard had spent most of his non-work time travelling extensively across the desert regions, visiting many Aboriginal communities, and has written several books on various aspects of Australian deserts.

During these trips, he witnessed first hand the extensive poverty, ill-health and chronic disease endemic in many communities.

"I began to wonder whether I could translate my laboratory experience to a niche within Aboriginal health," he says. "About that time, I met a woman called Waluwe Simpson-Lyttle, who was part of the new Flinders Aboriginal Research Initiative, with which I was also involved.

"Simpson-Lyttle was just about to start as director of the Umoona Community Health Service, and being aware of my interest in POCT, asked if we could try and address the renal disease problem in the Umoona community."

Shephard had access to a Bayer DCA 2000 device, which measures two things - blood haemoglobin A1c (HbA1c) for monitoring diabetes control, and the urine ACR or albumin/creatinine ratio, which is specifically a test for early renal disease.

"So, we took this device up to the community to both screen for the presence of renal disease and develop a management plan for those identified in the screening program as having renal disease," he says.

The venture attracted funding from some pharmaceutical companies and a small grant from the State Government.

"So, that was how our entire POCT endeavour got its start," Shephard says. Umona pioneered on-site testing for renal disease risk assessment in small remote communities, with a demonstrated success and benefit to that community.

Out of the 400-strong Umoona community, 35 adults showed either a significant risk of developing renal disease or established renal disease (previously undiagnosed), and affected individuals voluntarily entered a management program.

The project was well accepted by the health service and community members, and in 2000 was handed over to the Umoona community as a fully integrated, self-sustaining venture.

Building from there

Shephard says his vision grew from there. "Just at the closing stages of the Umoona project set-up, the Federal Government's 1998 National Diabetes Strategy recommended a trial of the DCA2000 machine be carried out in Aboriginal communities to help with diabetes management."

Diabetes is a significant cause of morbidity and mortality among indigenous Australians, and in fact most indigenous populations across westernised countries. Good control of blood glucose is critical to diabetic management and the prevention of complications, particularly chronic renal disease.

"So, the government was looking for someone to run that project and I had experience with the DCA at Umoona. Then, about that time, I happened to sit next to a Commonwealth representative at a renal disease conference at Uluru and we got talking... and that is how I became the program manager of a national program called QAAMS (Quality Assurance for Aboriginal Medical Services).

"We started in 1999 and have been continuously funded by the Federal Government since then, through the Department of Health and Ageing."

The program is ongoing through Shephard's CPS Unit at Flinders and now involves about 90 Aboriginal medical services around the country testing their diabetes clients for HbA1c (diabetes control) and ACR - renal disease being the main complication of diabetes."

Delivering POCT

Shephard says that with the QAAMS program in hand, the collaboration has developed a framework to deliver POCT for diabetes management to indigenous health services. It is based on sound laboratory principles for delivering POCT in a community health care setting.

"The program developed a common structure for education and training that was culturally appropriate, and a management framework that included both quality control (QC) and QA testing," he says.

The QAAMS program was the first of its type to be developed for chronic disease management in indigenous communities anywhere in the world, particularly with respect to the quality management framework.

"The work was truly pioneering in delivering these services," he says. QAAMS places Aboriginal medical services in Australia at the leading edge internationally in using POCT to support disease management or provide services otherwise unavailable to remote communities. Shephard's unit is now co-ordinating several POCT-based programs for health management in both indigenous and non-indigenous communities.

A pivotal part of the CPS unit's activity in POCT has also been the training of Aboriginal health workers to do the testing in their own medical service.

"We have shown through the results of our quality management programs that these trained health workers can do the testing just as effectively as laboratory scientists. This was very important to demonstrate, that the work can be carried out locally to a satisfactory analytical standard so as to enable proper patient care and management."

The CPS unit at Flinders is continually looking to expand on its POC activity to remain at the cutting edge.

"We want to develop our framework worldwide by translating the QAAMS model into other indigenous populations that suffer high rates of diabetes, which is a significant and growing problem worldwide mainly due to lifestyle factors and associated health problems such as high blood pressure, obesity, low birth weight and poor nutrition. New Zealand and Canada could potentially benefit from the program," he says.

Local hero

Mark Shephard commenced his scientific career in clinical biochemistry at Flinders Medical Centre in Adelaide in 1977. Twenty years later, he moved to the renal unit at FMC and in 2003 was appointed director of the Community Point-of-Care Services (CPS) Unit and senior research fellow in the Flinders University Rural Clinical School. He recently completed the first Australian PhD in the field of point-of-care testing.

Shephard still takes regular trips to the Australian deserts with his family, this year travelling to the Gibson Desert and Rawlinson Ranges. These regions are certainly "in his blood", from the flora and fauna, to the early pioneers, to conservation and Aboriginal rights.

He was publicly recognised for his work and passion with an Australian of the Year Award in the category of Local Hero in 2004, and a Medal of the Order of Australia (OAM) in June 2006.

The OAM award recognised Shephard's broad service to public health, the environment, and to aviculture, while the 2004 award acknowledged Shephard's dedication and hard work in establishing and managing POCT services for the prevention and management of diabetes and renal disease in rural and remote communities.