This paper describes
three health programs - the 'Umoona
Kidney Project', the
national 'QAAMS' Program
for point-of-care HbA1c
testing and the 'Point-of-Care in Aboriginal Hands'
Program. The common
feature these models share
is the use of point-of-care
technology for the
early detection and/or
management of chronic
diseases (renal disease,
diabetes and cardiovascular
disease). The primary
focus of each program has
been the rural and remote
Aboriginal Community
Controlled Health Service
(ACCHS) sector, because
these three chronic
diseases account for a
huge burden of morbidity
and mortality in
Aboriginal Australians

Shephard, Mark Douglas

Flinders Academic Commons

The Clinical Biochemist Newsletter June 200426POCT in theIndigenous Rural CommunityMark ShephardDirector, Community Point-of-CareServices, Flinders University RuralClinical School, Adelaide.IntroductionThis paper describes three health programs that I've been fortunate to be involved in asProgram Manager over thepast 7 years - the 'UmoonaKidney Project', the national 'QAAMS' Programfor point-of-care HbA1ctesting and the 'Point-of-Care in Aboriginal Hands'Program. The common feature these models shareis the use of point-of-caretechnology for the early detection and/or management of chronicdiseases (renal disease,diabetes and cardiovascular disease). The primaryfocus of each program hasbeen the rural and remoteAboriginal CommunityControlled Health Service(ACCHS) sector, becausethese three chronic diseases account for ahuge burden of morbidityand mortality in Aboriginal Australians.  XMost laboratory people think of a point-of-care testing (POCT) model that ishospital-based, has direct connectivity with the laboratory and the laboratorybeing in full control of the service. The models described in this paper are different because they function outside the 'comfort zone' of the hospital base,with the Aboriginal community and their associated health service driving themodel. The point-of-care challenge in this context is to develop quality-assured, sustainable and clinically effective models for the communitysetting.POCT has several advantages specific to the Aboriginal health care setting.1Through appropriate training, Aboriginal Health Workers can perform POCTon-site, thereby empowering them to take greater responsibility for the healthof their own community members. Immediate availability of result means thatthe Aboriginal patient doesn't have to come back for a followup visit, something that may often be very difficult to organise in the Aboriginal community setting due to other social and cultural priorities taking precedentover health matters. By conducting the tests on-site, ownership and control ofhealth information remains with the community, a factor crucial to the acceptance and success of Indigenous health programs worldwide. Each of theworking models described is based on the four fundamental elements: continuing education, training, quality management and ongoing support forpoint-of-care technology.The Umoona Kidney Project The Umoona Kidney Project was a partnership between the UmoonaAboriginal community at Coober Pedy in South Australia's far north (850 kmfrom Adelaide) and the Renal Units at Flinders Medical Centre and Women'sand Children's Hospital, Adelaide, South Australia.2 The primary focus of theUmoona Kidney Project was a voluntary (or opportunistic) renal disease riskassessment and management program for the 400-plus adults and children inthe community. Above Left: Aboriginal health worker Richard Jones conducting a POC risk assessment on ElizabethTaylor at the Port Lincoln Aboriginal Health Service, West Coast, SA.  Above Right: Aboriginal healthworker Sandy Wilson and Mark Shephard discussing POC results with a patient from Hack's Point,near Meningie in the Coorong region of South Australia. Shephard, M.D.S., 2004. Point-of-care testing in the Indigenous rural community. Clinical Biochemist Newsletter, 153 (June), 26-31. Copyright 2004. Australasian Association of Clinical Biochemists.  Published version of the paper reproduced here with permission from the publisher.Archived at Flinders University: dspace.flinders.edu.au27The Bayer DCA 2000 was used formeasurement of urine albumin:creatinine ratio, or ACR, as the cornerstone of both the risk assessment and clinical management arms. Prior to thecommencement of the program, theAdelaide team spent six months of groundwork talking to the community, holding informationforums, demonstrating all aspectsof POCT and discussing the ACRtest.The overall risk factor profile of the158 adults assessed (which represented approximately 65% ofthe adults in the community)showed 42% of the people had high blood pressure, 24% had diabetes, 19% had persistent microalbuminuria and 9% macroalbuminuria. Thirty-five people were identified as being at risk for renal disease and offered the ACE inhibitorCoversyl (Servier Laboratories, Australia) which resulted in a sustained and statistically significant drop in blood pressure to normal levels, as well as a stabilisation of renal function, with mean ACR of the group (monitored using theDCA 2000) falling from 17 to 12 mg/mmol (p=0.09, paired t-test). (Table 1). Across two years of continuous field testing (n=46) the DCA 2000 exhibiteda precision base (coefficient of variation, CV%) of 6.9 and 3.6% for urinealbumin (for Bayer QCs with concentrations of 36 and 208 mg/L respectively),3.2 and 4.1% for creatinine (9 and 36 mmol/L) and 6.7% and 5.3 % for urineACR (ratios of 4.1 and 5.8 mg/mmol). These are well within precision goalsof 10%, 6% and 12% for urine albumin, creatinine and ACR (which can bederived from biological variation and other international consensus data onperformance criteria).The Umoona Community evaluated the program through a survey conductedby community elders. By all criteria, the community expressed a high level ofsatisfaction with the program and the use of POCT (with a greater than 90%satisfaction rating being recorded for all questions). In December 2000, theprogram was handed over to the Umoona Community as a self-sustaining Table 1. Reduction in Renal and Cardiovascular Risk Two Years After Commencing Coversyl.Pre-Coversyl Post-CoversylMarker Measure/Matrix Baseline 2 Years P-Value*Units Mean (+/-SEM) Mean (+/-SEM)Blood PressureStanding Systolic mmHg 151 (±3) 137 (±3) <0.0001Diastolic mmHg 92 (±2) 84 (±2) <0.0001Lying Systolic mmHg 147 (±3) 131 (±3) <0.0001Diastolic mmHg 94 (±2) 84 (±2) <0.0001Albumin:Creatinine  Ratio (ACR) Urine mg/mmol 16.5 (±3.9) 12.0 (±2.8) nsPotassium Plasma mmol/L 4.0 ±0.1) 4.0 (±0.1) nsUrea Plasma mmol/L 4.9 (±0.3) 5.1 (±0.3) nsCreatinine Plasma mmol/L 0.081 (±0.003) 0.077 (±0.003) nsGlomerular Filtration Rate (GFR)** mLs/min 110 (±5) 118 (±8) 0.019* p < 0.05 is significant; ns = not significant.** Calculated GFR by Cockcroft DW and Gault MH. The Clinical Biochemist Newsletter June 200428activity fully integrated into thehealth service infrastructure. Boththe South Australian Government'sDepartment of Human ServicesRenal and Urology ServicesImplementation Plan 2000-2011and the Statewide Iga WartaAboriginal Renal Disease Summit,1999 endorsed the Umoona modelfor expansion to other Aboriginalcommunities in rural and remoteSouth Australia.One of the most pleasing aspectsof the Umoona Kidney Project wasthat POCT became a focal pointfor raising community awarenessabout renal disease. We were ableto build on the trust and respectgained from the renal program andconduct a number of other communityactivities around related healthissues and health promotion. Theseincluded developing a nutritiontraining program for Umoona'sAboriginal Health Workers, staging a poster competition forthe children at the Coober PedyArea School about healthy foodsand holding education days at theschool about kidney health and theimportance of good food (sponsored by the AustralianKidney Foundation).  A bush tucker trip was also conductedwith the Umoona CommunityElders for the school children,where the children were taughthow to dig for witchetty grubs, collect other bush foods and cookkangaroo.The National 'QAAMS' Program for Point-of-Care HbA1c testing The 'QAAMS' Program, or Quality Assurance for Aboriginal MedicalServices as it is known, arose from a recommendation of the NationalDiabetes Strategy in 1998, commenced as a pilot in June 1999 and, is nowfully integrated into mainstream Aboriginal health care in Australia.3 Since itsinception, the program has been a collaborative partnership between a numberof groups including the Office for Aboriginal and Torres Strait Islander Health(OATSIH), the Diagnostics and Technology Branch within the AustralianGovernment's Department of Health and Ageing, the National AboriginalCommunity Controlled Health Organisation (NACCHO), the RCPA QualityAssurance Programs Pty Ltd and the Community Point-of-Care Services Unit. The chronic disease focus of the QAAMS program is the management ofestablished diabetes. Over 2300 Aboriginal patients with diabetes are involvedin the program, which is being conducted at 50 Commonwealth andState/Territory funded Aboriginal Medical Services around Australia. Thesesites cover urban, rural and remote locations and encompass every state andTerritory in Australia (Figure 1). At each site Aboriginal Health Workersmeasure HbA1c using the Bayer DCA 2000. A Quality Assurance Program(called QAAMS) to constantly monitor the analytical performance of all theDCA 2000 instruments in the field was developed collaboratively by theCommunity Point-of-Care Services unit at Flinders University and the RCPAQuality Assurance Programs Pty Ltd. This is the first program of this type tobe developed for Indigenous people anywhere in the world.“One of the most pleasing aspects of theUmoona Kidney Project was that POCT became a focal point for raising community awarenessabout renal disease. Wewere able to build on thetrust and respect gainedfrom the renal program andconduct a number of othercommunity activities aroundrelated health issues andhealth promotion.”Figure 1. Map showing general location of QAAMS Participants in 2003.Above: Mark Shephard conducting training for participants in the QAAMS ACR Program.29Each QAAMS participant is provided with an annual kit of quality assurancesamples for testing (with 2 samples to be tested per month), a single-pageresult sheet, and a monthly summary report with a graphical result formatsimilar to, but more simplified than, that provided for laboratories. Each sitehas its own Community Number to ensure confidentiality of results. Eight six-monthly testing cycles have been completed over the four years from July1999 to July 2003.  Participation rate has averaged 87% (range 81-93%)across all eight testing cycles with over 3500 quality assurance resultsreturned during this time. The percentage of results considered acceptable hasaveraged 83% (range 81 to 86%), using limits for acceptable performance thatare the same as those for the laboratory-based Glycohaemoglobin Programrun by the RCPA Quality Assurance Programs Pty Ltd (±5%). Across the pastfive testing cycles in particular, the median precision base (CV%) achieved byAboriginal medical services in the QAAMS program has been equivalent tothat achieved by 75 laboratory-based DCA 2000 users registered in theGlycohaemoglobin program (Table 2). As the table also shows, the precisionachieved by Aboriginal medical services has been very consistent over timeand approaches the 3% mark, which is the desired performance for monitoring of people with diabetes. In March 2001, NACCHO conducted an independent evaluation of the first18 months of the QAAMS program. The Executive Summary of this reportstated that the use of the DCA point-of-care technology represented a majoropportunity to better care for and manage Aboriginal clients with diabeteswithin the community setting, while the ability of POCT to generate rapidresults served as a catalyst to enhance patient self-management. The summary concluded the DCA 2000's simplicity of use led to high levels ofacceptance by Aboriginal health workers nationally, with nearly two-thirds ofservices expressing the view that it had raised the self esteem of their healthworkers.  Importantly, the sense of community control was enhanced as aresult of diabetes management becoming more focused within Aboriginalmedical services.Table 2. Comparative Precision Base Over Last Five Testing Cycles: Aboriginal Community Controlled HealthServices (ACCHS) versus Laboratories using the Bayer DCA 2000.Cycle PeriodProgram Type of Service Jan to June July to Dec Jan to June July to Dec Jan to July 2001 2001 2002 2002 2003QAAMS ACCHS 3.7 4.1 3.9 3.4 3.8Glycohaemoglobin Laboratories 3.4 4.1 3.7 3.5 3.6* Coefficient of variation (CV%) is calculated by dividing the standard deviation by the mid-point of the service’srange of concentrations, expressed as a percentage. The standard deviation is the error of the estimate Sy.x andrepresents the average standard deviation across the range of concentrations analysed.To further enhance the sustainabilityof the QAAMS HbA1c program, aMedicare rebate is now availablefor participating sites and an annualworkshop has been held since 2001.These workshops have now becomea key feature of the QAAMS calendar. The meetings are veryinteractive, with significant opportunities for retraining and networking. All participants nowundergo competency assessmentand certification (in both practicaland theoretical elements of the program) at the Workshop. A newQAAMS program for ACR testing on the DCA 2000 commenced in 2003 and involves30 ACCHS. “Over 2300 Aboriginalpatients with diabetes areinvolved in the HbA1c program, which is beingconducted at 50Commonwealth andState/Territory fundedAboriginal Medical Services around Australia.”Beryl Mazzachi, medical scientist from theCommunity Point-of-Care Services unit,training Aboriginal health workers BarbaraWhite (left) and Erica Cox at the BroomeAboriginal Medical Service, Kimberley, WA. The Clinical Biochemist Newsletter June 200430The Point-of-Care in AboriginalHands Program The Point-of-Care in AboriginalHands program, which commenced in mid 2001, is a partnership between theCommunity Point-of-CareServices unit and four rural andremote Aboriginal health servicesat Port Lincoln, the Riverland andMeningie in South Australia and atKalgoorlie in Western Australia.4Education, training and qualitymanagement of POCT againunderpin the program and the localAboriginal Health Worker(s) isresponsible for the day-to-dayoperation of the point-of-care technology. However the Point-of-Care inAboriginal Hands program differsfrom the other models described inseveral fundamental ways. Firstlyit has a greater local communityfocus with local medical officersand/or Medical Directors undertakingall clinical management at eachhealth service.  Secondly, the program has a broader chronic disease focus that looks at the earlydetection, risk assessment andmanagement of diabetes, renal disease and cardiovascular diseasecollectively rather than having asingle disease focus for examplerenal for the Umoona project ordiabetes for the QAAMS HbA1cprogram. Finally, there is wider useof POCT with  Aboriginal HealthWorkers trained to use the BayerDCA 2000 for both HbA1c andurine ACR testing and theCholestech LDX lipid analyser.While most of the point-of-carerisk assessments are conducted inthe clinic setting, the opportunity istaken whenever possible to conduct field-testing outside the clinic. For example, testing has been carried out atsuch diverse locations as a local eco-tourism centre, a TAFE (adult education)College, and in a tin shed at the Pt Lincoln Aboriginal Women's Centre (anevent which was also linked with a nutrition health promotion activity). In theRiverland, a bus has been purchased and renovated to provide a mobile POCTservice throughout the Riverland region (with risk assessment also linked toan eye check for people with diabetes through a separate program). These examples really show the flexibility and versatility of POCT in thecommunity setting.Across all four participating sites over 600 chronic disease risk assessmentshave been performed by POCT. Diabetes is extremely prevalent, there is alarge incipient pool of renal disease, with rates of microalbuminuria rangingfrom 19 to 26% in the general community and elevated lipids are very common. An example of the risk assessment profile found at one communityis shown in Figure 2. For clinical management flow charts for POCT havebeen developed in collaboration with each community, based on best practice evidence and input of the local clinicians. The frequency of follow-up testingis determined by diabetes, blood pressure, microalbumin and lipid status. AtPort Lincoln a subset of 29 patients with diabetes have shown a mean decreasein HbA1c of 0.4% after a year on POCT and managed care planning.All sites are now enrolled in both national QAAMS programs - for HbA1c andurine ACR - and they conduct on-site internal quality control testing, theresults of which are immediately faxed to and managed by the Flinders'Community Point-of-Care Services unit. There is also monthly communicationbetween the unit and each participating site around a quality managementchecklist. Quarterly on-site field visits are also conducted by the Flinders'team. Table 3 details the analytical performance achieved by each site forQAAMS testing in the most recent cycle. These results again clearly demonstratethat point-of-care testing can be carried out to a high level of analytical competency by Aboriginal Health Workers, provided they are supported by aquality management framework comprising on-going education, training andparticipation in structured quality management programs. Figure 2. Chronic Disease Risk Assessment Profile at one community.Left : Conducting POC chronic disease risk assessments in a tin shed at the PortLincoln Aboriginal Women's Centre. 31Table 3. Median Precision Achieved for QAAMS HbA1c and Urine ACRTesting by the Four Sites Participating in the Point-of-Care in AboriginalHands ProgramHbA1c Urine ACRSite Median Precision Median PrecisionPrecision Goal Precision Goal(CV%) (CV%) (CV%) (CV%)1 3.2% 3% 4.3% 12%2 3.1% 5.1%3 3.1% N/A*4 2.9% 5.0%* Data is not available for the Urine ACR Program for Site 3. References1. Shephard M. Point-of-care testing in the Aboriginal community.Australian Journal of Medical Science 2003; 24: 10-16.2. Shephard MDS, Allen GG, Barratt LJ, Paizis K, Brown M, BarbaraJAJ, McLeod G, Vanajek A. Albuminuria in a remote SouthAustralian Aboriginal community: results of a community-based screening program for renal disease. Rural and Remote Health 2003;3 (online) 8 February 2003. Available from http://rrh.deakin.edu.au. 3. Shephard MDS and Gill JP. Results of an innovative education,training and quality assurance program for point-of-care HbA1c test-ing using the Bayer DCA 2000 in Australian Aboriginal CommunityControlled Health Services. The Clinical Biochemist Reviews 2003;24(4): 124-31.4. Jones R, Mazzachi B and Shephard M. Point-of-Care in AboriginalHands. Aboriginal and Islander Health Worker Journal 2002; 26 (6):13-16.Acknowledgement: The author wishes to acknowledge the continued sponsorship of the work of the Community Point-of-CareServices unit by Servier Laboratories (Australia) Pty Ltd and theongoing support of Bayer Australia and Point of Care DiagnosticsAustralia. The QAAMS programs are funded by the AustralianGovernment’s Department of Health and Ageing (Diagnostics andTechnology Branch). The Pfizer Foundation and Pfizer Australiasponsored the POC in Aboriginal Hands Program in 2002.Mark Shephard training Maxine Gosam (Innisfail, North Queensland) and JacquelineFreeburn (Grafton, NSW) in how to conduct quality assurance testing on theBayer DC 2000 point-of-care analyser.

Point-of-care testing in the Indigenous rural community

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Point-of-care testing in the Indigenous rural community

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