Determination of Actual Cost of POCT for Glucose or Hba1c & INR
Or Cholesterol Analytes
Laboratory test for patients have been in the past restricted to central laboratory but currently, but due to increased number of tests, the laboratory systems have been decentralized to Point-of-Care Testing (POCT). The potential of POCT is enormous and the medical fraternity can expect further streamlining of POCT facilities to curb the rising demand. As a result, various devices have been designed to offer POCT services, (1). However, appropriate measures must be put in place for its successful implementation; for instance, employing a personnel who is a team player, good communicator and a technologically driven staff. (2)This paper therefore focuses cost analysis of nominated POCT devices with respect to costing.
POCT Analytes Cost Analysis: Glucose vs. Cholesterol
Nominated Device Price (USD)
Hemoglobin Tester: 324.94
Accutrend Plus; 271.28
Accutrend Cholesterol; 78.68
Accutrend Plus; 271.28
HDL LDL GLU Monitor; 589
In POCT cholesterol testing the parameter used is total cholesterol while for glucose test the parameter is glucose. Amount of fee charged for the services are slightly different with glucose test being the most expensive when compared to cholesterol test. Benefit accruals from the use of these POCT analytes stand at either 75% or 85% of the fee charged for each test. Devices used for both tests differ with the only exception of Accutrend Plus System price which can be used for testing both glucose and cholesterol. It takes 5 - 15 seconds to conduct a glucose test while time limit for cholesterol test stands at between 60 - 180 seconds. (3) and (4).
Decision has to be made on which analyte to use in POCT and it depends on two factors: diagnosis requirements and target group. "However, the extremely rapid technological development in this sector, driven by the rapid growth in this market segment, provides an additional boost which should not be underestimated and carries the danger of undifferentiated and medically unjustified expansion of POCT." (5). Performance of coagulation tests is marred with great variation of cost margins depending on test principle and reagents in use. Also, variations may occur due to performed tests with either capillary blood or citrated plasma. This is because of availability of blood cells in POCT mechanism. There is bound to be variation in results even within a single institution in and this makes comparability of results difficult. The table below summarizes the POCT and laboratory costs that have been sanctified and applied in real medical situations.
The significance of comparing centralized and decentralized testing is to ascertain whether or not there are economic benefits and prompt services delivery in POCT. "Creation of initial prerequisites for carrying such comparisons in inpatients health care institutions has only started to take place relevant extent in the last few years. Such calculations require...and calculation of actual costs with regard to the respective individual service." (1). It is not possible to reduce decision making to economic issues alone in medical practice. To a patient, what matters is the speed with which tests are done, submitted, analyzed and treatment commenced. (6). All these services are crucial to POCT but their numerical costs cannot be expressed in monetary units.
However, economic aspects are the bases upon which competitiveness of services are either downplayed or chosen for adaptability. At times POCT may be quite expensive especially when transportation cost is high, for example the use of airplanes. (7) Institutions in general are always resource sensitive and most decision making mechanisms are pegged on economic grounds. POCT normally has an additional cost of purchasing equipment. A process must be put in place for cost generation and which is independent on laboratory cost generation. POCT costs when compared to centralized cost generation, the latter seem to have minimum reduction of Variable Costs, VC which are basically reagents and supplies costs. (8). In addition, minimum reduction of VC can be attained in labor costs; though to a very dismal margin. On the other hand, Fixed Cost, FC remains the same. FC includes calibration cost, capital cost, energy cost, service and maintenance cost, and quality check cost. POCT also generates FC regardless of the number of tests performed whereas VC depends on the number of tests performed. A comparison between POCT costs and laboratory costs reveals that POCT costs increase significantly at various points in the same hospital; but, they are not always properly documented.
FC arise from purchase of measuring devices which never last for more than 7 years and service and maintenance costs which may at times be high; for instance, peripheral blood analyzer. Installation costs like room lighting and fixing benches also form part of FC. In a situation where much equipment is used, FC increase during operation because of immediate response nature POCT services. These cost cases vastly affect energy consumption and automatic calibration costs which must be articulately considered. Some equipment like electrodes have short period of use regardless of number of time in which they are used for testing. As a comparison parameter, FC arising from POCT requirement should be weighed against actual laboratory FC in a bid to draft possible savings. The main goal of POCT is not only to ensure that it eliminate laboratory testing fixed costs but that it also renders laboratory workplace ineffectual.
Another associated cost of POCT is VC of materials needed in testing procedures. The greatest component of VC is reagents and supplies costs which are relatively high and include: lancets, capillaries for sample collection, reaction containers, chart papers among other devices. (9). Another constituent of VC is an estimated loss cost of reagents due to expiry because at times reagents which take long time to be used must be replaced. To correctly account for economy of POCT variable costs, savings made from centralized testing should be subtracted from these costs of materials. Also, savings accruing from sample containers, cannulas and test application forms should be considered provided they are not used in centralized testing. Finally, VC arises from the costs of personnel hire. In this scenario, time saved in carrying out POCT should be valued and compared to time saved in laboratory testing including standby time and the effective result noted.
When total FC and VC are computed and divided by tests carried out, cost of individual POCT are arrived at. The performance should be noted and comparison made with the corresponding laboratory testing. The eventual introduction of a common interfacing standard in all POCT devices will facilitate recordkeeping and many aspects of clinical governance." (10). When patients' benefits of POCT are valued, and with the growth of ICT in medication, services are bound to improve significantly making POCT services a frontier in future medicine. However, "Our understanding of the potential impact of these technologies on human or corporate behavior lags behind our ability to introduce them to clinical environment." (11). Overall benefit of POCT is cost effectiveness and as (12) notes "This has served as the premier reference for the field and remains highly regarded in the relevant expert literature of the day."
In summary, the inception of POCT services is bound to revolutionize the medical sector if and only if technology is given the priority it deserves. POCT services are relatively cheap compared to centralize testing because cost proportions and savings differ on use of testing devices of similar medical tests. POCT services are widely dependent on ICT, personnel management, accreditation credentials among other necessities. Therefore, implementers of POCT services should institute relevant mechanisms that would ensure the success of POCT.