Point-of-care troponin testing in Dutch primary care: preferences and
referral decisions of general practitioners
Michelle M.A. Kip, MSc1, Maran Noltes, MSc1, Erik Koffijberg, PhD1, Ron Kusters, PhD1,2
1University of Twente, Department of Health Technology and Services Research, MIRA, Enschede, The Netherlands 2Jeroen Bosch Hospital, Laboratory for Clinical Chemistry and Haematology, ’s-Hertogenbosch, The Netherlands
Background
GPs express the desire to use a point-of-care troponin test, to enhance their ability to rule out acute coronary syndrome (ACS) in primary care.
• However: the majority of those tests are insufficiently sensitive, especially early after symptom onset.
Objective:
Investigate GPs’ preferences and requirements regarding point-of-care troponin testing for patients presenting with (a)typical chest pain in primary care, and to estimate the effect on referral decisions.
Online questionnaire in LimeSurvey:
• 34 questions
• distributed among 837 Dutch general practitioners in June 2015
Data were analyzed using R. Results are based on multiple imputation. 126 respondents were included in the final analysis.
POCT Costs > €30.000/QALY and/or results in QALY loss
POCT saves money and results in QALY gain POCT Costs ≤ €30.000
/QALY but results in QALY gain
Expected effect on referral decisions:
• Decrease in immediate referrals (figure 2) • However, possible increase in:
• Referrals to outpatient cardiology clinics • Consultations with cardiologists
• Other examinations (other laboratory tests, ECG)
Requirements:
• 78% - test result available within 10 minutes • 78% - funding of the test device
• 69% - perform test with finger prick blood sample
Methods
Results
Conclusion and Discussion
• According to GPs, the point-of-care troponin test can be of added value in excluding ACS.
• Actual test implementation will depend on test characteristics, including test duration, type of blood sample required, and funding of the analyzer.
Completecases Imputation Participating GPs, n (%) 115 (100.0) 126 (100.0)
Male, n (%) 74 (64.3) 80 (63.5)
Age in years, mean (SD) 49.0 (9.3) 48.4 (9.4)
Years of working experience as GP, mean (SD) 16.9 (9.7) 16.2 (9.7)
Independent GP (own practice), n (%) 98 (85.2) 107 (84.9)
0% 20% 40% 60% 80% 100%
No suspicion of ACS Doubt about ACS Strong suspicion of ACS
P er c ent age of G P s 0% 20% 40% 60% 80% 100%
No suspicion of ACS Doubt about ACS Strong suspicion of ACS
P er c ent age of G P s
Never (0/10) Occasionally (2/10) Regularly (4/10) Often (6/10) Very often (8/10) Always (10/10)
Figure 1a-b: Expected frequency of using regular troponin tests (a), and point-of-care troponin tests (b) in primary point-of-care, depending on the suspicion of ACS.
Use of regular troponin tests
Use of point-of-care troponin tests
Low risk case (prob. ACS: 11%)
Intermediate risk case (prob. ACS 32%) Non-elevated troponin Slightly elevated troponin Strongly elevated troponin No L: 98% I: 74% Yes L: 2% I: 26% No L: 67% I: 82% Yes L: 52% I: 56% No L: 48% I: 44% No L: 29% I: 41% Yes L: 71% I: 59% Yes L: 33% I: 18%
Figure 2: Estimated effect of point-of-care troponin test on immediate
referral rates in two hypothetical patient cases. L = low, I = intermediate)
Table 1: characteristics of respondents
Expected added value:
• Reasonable to very high added value: 67%
Effect on troponin test use:
• Expected increase in troponin test use due to availability of point-of-care test (figure 1)
