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Patient self-testing: its here, but is it the way forward?

Mark Jones
MSc BSc(Hons)Nurs RN RHV
RCN Primary Care Policy and Practice Adviser
RCN, London

Many diagnostic tests ordered by nurses and doctors in general practice still involve the acquisition of a sample - blood, cell scrape, tissue, and so on - that is dispatched to a remote laboratory for analysis. The facility to which the sample goes may well be the only place with sufficient equipment to produce an accurate and informative result, but inevitably there is a delay in that result coming back to the practice and then being passed on to the worried patient.
Mindful of these issues, the medical and diagnostics community have worked to condense the testing equipment hitherto only available in a large regional laboratory to a size where it sits comfortably on the worktop of the treatment room and can be used by practice nurse and GP alike. Such equipment may still not be commonplace in British general practice, but the technology has been with us for a decade,(1) and the term "point-of-care" (POC) testing is accepted as a descriptor of diagnostic testing at or near the site of patient care rather than in the traditional laboratory.(2)

Self-testing
While we might still be grappling with the concept of POC, the technology moves on. The presence of an ever more-informed patient population, keen to take more control over their own health, has led many companies to utilise the time-proven chemistry of antibody:antigen reactions, together with newer developments such as DNA tagging, to bring test kits into the home - a market which, in the USA, is worth in excess of 1.2 billion dollars per year.(3)
Although potential profit margins may drive the move toward home testing, there are real advantages to patient health. A cursory surf through the internet reveals test kits for a wide range of conditions, from simple urinalysis through to HIV, many of with unproven efficacy. More well-established areas for home testing would include cholesterol and blood glucose, while newer tests for Chlamydia trachomatis, influenza, Helicobacter pylori, mononucleosis and streptococcus A hold promise. If, for example, we consider the exponential rise in the ­incidence of chlamydia over the last decade - diagnosis up by 76%, and estimated 10% infection in the under-20 population(4,5) - and the millions spent in the UK on treatment of CHD (coronary heart disease)-associated illness with relatively low investment in prevention, then any test that improves early recognition and awareness among patients must surely be welcome?
Similarly, if we are to encourage people to take control over their lives and manage the ever-stretched time resources of general practice, home testing might well have its place. The winter waiting room full of people claiming to have flu could be diminished somewhat if self-administered flu virus detection kits that are able to give a 10-minute accurate result from a simple nasal swab were widely available.(6) Combined with other simple kits to detect respiratory syncytial virus and group A streptococci, we could see better targeting of antibiotic prescribing and, more significantly, patients willing to accept that they do not require a prescription medicine based on the evidence of a test that they administered themselves rather than having to take the word of a doctor or nurse. Add in other home tests for conditions such as osteoporosis, which are already available, and the possibilities for preventive care are tremendous.
The potential downside is that, as with many interventions, the informed anxious patient will go ahead and purchase a test whereas the recurrent user of services who either does not appreciate the technique of the test or have the wherewithal to obtain it will not. Nevertheless, having the "worried well" check themselves out can still prevent inappropriate attendance at the practice. This does pose new challenges for healthcare professionals, though, specifically the nurse. If we move into an era where home testing is commonplace, it is essential that information is available about the tests, how they should be used, and the significance of the results. Although not one test is approved for use either in the USA or UK, an internet search reveals many companies offering home HIV testing, most with a callback or postback results service. They may contain comprehensive information leaflets, but the impact of being given a positive result over the telephone could be dramatic - a point not lost on Nursing magazine, as they advise readers to inform patients of the need to undertake such radical tests having obtained some pretest counselling.(7) At the end of the day, of course, the information held in one's own antibodies, antigens and DNA is self-knowledge and should no more be withheld from an individual than the reading they can obtain from a home thermometer.
The key is that nurses must now move to position themselves as information brokers. As with the diabetic patient, who is well able to titrate insulin against a test they perform for blood glucose levels, patients need to be assisted in understanding the results of any test they might self-administer, and to play a part in developing any care plan that might be necessary, as well as receiving guidance as to which tests are suitable in the first place and how they should be used correctly. A study by the University of Minnesota showed that 95% of 47,000 people inaccurately home-tested positive for fecal occult blood using the same home test, with something as innocuous as eating a steak or broccoli leading to a false-positive. Much as tests will provide people with another means of taking responsibility for their health, a stream of patients seeking appointments for suspect results will not help anyone, and nurses can do a great deal to ensure this doesn't happen.

Ethical issues
Finally, there are the ethical consequences of home testing to be considered. Most professionals would argue that there is little point in offering a test if there is no useful means of addressing the problem that might be identified. Others might disagree - such as insurance companies. Many practice nurses undertake assessments for insurance purposes, but are we willing to provide a DNA screen from a mouth swab identifying a wide range of possible outcomes for our patients' health in 40 years' time? Home testing is with us, and patients will seek out alternative means to information about themselves whether we as health professionals like it or not. The paternalism of "we know best", ­easily enforced by the GP practice acting as the gatekeeper to tests that could hitherto only be performed in a well-equipped laboratory, is no more. The responsibility now is to help patients acquire the information properly, and once they have it, to understand what it means for them and how we can work with them to provide the best solution to any problem they might find.

Practice ­pointers

  • Be familiar with the range of tests ­available to patients through your ­practice and commercially
  • Have time to discuss with patients why they feel they should have a test and how they might deal with the results
  • Be prepared to talk through the results of any test a patient may have performed


References

  1. Kost GJ. The hybrid laboratory: shifting the focus to the point of care. Med Lab Observer 1992;24:17-28.
  2. Kost GJ. The laboratory - clinical interface (point of care medical ­testing). Chest 1999;115:1140-54.
  3. Tippit S. Home medical tests. Better Homes and Gardens January 1997.
  4. Thompson C, MacDonald M, Sutherland S. A family cluster of Chlamydia trachomatis infection. BMJ 2001;322:1473-4.
  5. Public Health Laboratory Service. Data on STIs in the United Kingdom.New cases of acute sexually transmitted­ ­infections seen in genitourinary medicine clinics: United Kingdom 1999-2000. Colindale: PHLS; 2000.
  6. Have I got Flu.com 2001.QuickVue Influenza Test. Available from: www.haveigotflu.com/products
  7. Anon. Steer clear of internet test kits. Nursing 1999;October:1.

Resources
Human Genome Project
(Information on educational, research, ethical, legal and social issues associated with mapping the human genome)
W:www.ornl.gov/hgmis

Ethics and human genetics
W:www.georgetown.
edu/research/nrcbl/nirehg.htm

Issues in genetic testing and ­screening
W:www.georgetown.edu/research/nrcbl/scopenotes/sn22.htm

Further reading
Borriello SP. Near patient
microbiological tests. BMJ 1999;319:298-301

Marshall KG. Prevention - how much harm, how much benefit? Can Med J 1996;155:377-83