Point-of-care testing (POCT) for diabetes management has been implemented successfully in indigenous communities through two programs: 1) The QAAMS program in Australia which uses POCT for HbA1c and urine testing in 175 indigenous medical services. It has shown improvements in glycemic control and high satisfaction rates among operators and patients. 2) The international ACE program which provides POCT for HbA1c and urine testing in over 30 indigenous services. Studies have shown improved glycemic control and engagement among patients. Operators also report more effective diabetes management. Both programs demonstrate strong cultural effectiveness through indigenous leadership and appropriate practices. They also maintain high analytical quality and have been shown to

1. Increasing Global Capacity to Improve Diabetes Care for Indigenous Peoples through Point-of-Care Testing
Lara Motta BMedSc(Hons)
Flinders University International Centre for Point-of-Care Testing
Flinders University Adelaide, Australia 27 October 2014
Muster 2014, Uluru

2. Faculty/Presenter Disclosure
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Faculty: Flinders University International Centre for Point-of-Care Testing, Lara Motta
•Relationships with commercial interests:
–Research Support: Siemens Ltd

3. What is a Point-of-Care Test?
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A pathology test
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Performed on a small device
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In a clinical setting outside the laboratory setting
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At the time of patient consultation
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Results immediately available for care and management
… fastest growing sector of pathology

4. QAAMS Program (Quality Assurance for Aboriginal & TSI Medical Services)
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Diabetes management
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Siemens DCA Vantage
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POCT for HbA1c and urine ACR
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Funded for 15 years by the Australian Government (1999-present)
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175 ATSI Medical Services
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Primarily AHW trained as POCT operators
.
Largest national POCT network in Australia
www.qaams.org.au

5. QAAMS Wins International Award - ‘Projects That Work’ 2013
“The Foundation for Advancement of International Medical Education and Research (FAIMER) is pleased to announce the selection of five winners of its first annual Projects That Work awards. They will be presented the 2013 annual meeting of The Network: Towards Unity for Health (TUFH), to be held November 16-20, 2013, in Ayutthaya, Thailand. There they will showcase projects that have been successfully addressing the theme of “Rural and Community-based Healthcare: Opportunities and Challenges for the 21st Century” for three years or longer. An open worldwide call resulted in 120 submissions from which five were selected by an international panel of 11 reviewers.”
QAAMS was one of the 5 award winners
along with other projects from
Philippines, South Africa, India and Colombia

6. ACE Program (Analytical and Clinical Excellence)
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Diabetes management & screening
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Siemens DCA Vantage
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POCT for HbA1c and urine ACR
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Over 30 services servicing Indigenous peoples in rural/remote & urban
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Primarily local health workers or nurses trained as POCT operators
Canada (Saskatchewan & Ontario), South Africa, Thailand, East Timor, Papua New Guinea, Solomon Islands, Western Samoa

7. •
Essential for sustainable and high-quality POCT service
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Principles & Practice of quality-assured POCT
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Written and Practical Competency Assessment
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>1000 health professionals (AHWs, eye care workers, nurses, nurse practitioners, doctors)
Training & Competency Assessment

8. Flexible Training Options
a)
Face-to-face training (On-site, regional or annual workshops)
b) Videoconference or Skype

9. Flexible Training Options
c) Self-directed e-learning via website
www.qaams.org.au www.flinders.edu.au/point-of-care

10. •
Competency refreshed every 2 years
Competency Certificate

11. Program
Baseline HbA1c (Mean ± SD)
After POC Testing (Mean ± SD)
Time After POC Testing
No. of Patients
QAAMS Study 1 (2006)
9.3% ± 2.0
78 mmol/mol
8.6% ± 2.0*
70 mmol/mol
12 months
74
QAAMS Study 2 (2010)
8.8% ± 2.2
73 mmol/mol
8.2% ± 2.2*
66 mmol/mol
29 months
272
QAAMS Study 3 (2012)
9.2% ± 2.1
77 mmol/mol
8.8% ± 2.2*
73 mmol/mol
15 months
181
ACE Study (2014)
8.9% ± 2.7
74 mmol/mol
8.1% ± 2.3*
65 mmol/mol
22 months
119
Change in glycaemic control in diabetes patients who had ≥2 HbA1c POC tests during the study periods
*Statistically significant (p <0.05, paired t-test)
Clinical Effectiveness QAAMS & ACE: Improvements in Glycaemic Control

12. Parameter
24 months before POCT,
when lab was used
24 months after POCT introduced to service
Mean change in HbA1c; first to most recent
9.5% to 9.8%
80 to 84 mmol/mol
10.6% to 7.9%
92 to 63 mmol/mol
Mean TAT for HbA1c result
42 hours
6 minutes
Mean TAT for patient follow-up
24 days
Less than 10 minutes
Mean number of HbA1c tests per patient
2.7 tests
4.2 tests
Clinical Effectiveness QAAMS: Clinical and Operational Efficiency

13. HbA1c not available in lab …
Clinical Effectiveness ACE: Glycaemic profile from first two years

14. Clinical Effectiveness ACE: Albuminuria profile from first two years

15. “The ACE program is a great adjunct to our Diabetes program. Without the program our clients would have to wait at least 2 weeks before we would have a HbA1c result. As a result of the program we are able to manage our diabetics and change medications in one visit instead of having to follow up when results come in. The clients enjoy having the fast results and seeing how their efforts have paid off for them.” Saskatchewan, Canada
“Now I am able to give the patients hard facts and evidence about their diabetic control … I found patients understand better and are more engaged… I feel our management is more effective with all this information now made available to the patients and also to us in an instant.”
Western Samoa
Cultural Effectiveness ACE: POCT Operator Survey

16. Shephard M & Gill J. Clinical Biochemist Reviews 2006; 27: 161-170
Indigenous Stakeholder
Satisfaction
% Unsatisfied
% Unsure
% Satisfied
Number of responses
Operators
Before POCT
30
28
42
57
After POCT
4
7
90
Patients
Before POCT
11
28
61
159
After POCT
3
6
91
Cultural Effectiveness QAAMS: Stakeholder Survey
Shephard, MDS 2006, 'Cultural and clinical effectiveness of the ‘QAAMS’ point-of-care testing model for diabetes management in Australian Aboriginal medical services', Clinical Biochemist Reviews, vol. 27, pp. 161-70.

17. “All sources of evidence suggest that QAAMS is meeting best practice standards in the areas of Indigenous healthcare, chronic disease management and Point of Care testing.”
“QAAMS is one of the few programs to successfully navigate the cultural complexities and potential pitfalls of chronic disease management in Indigenous communities.”
Final Report to Australian Government, 2008
Cultural Effectiveness QAAMS: Independent Review Campbell Research and Consulting, 2008

18. Cultural Effectiveness QAAMS: Indigenous Leaders Team ACE: Cultural Advisory Group
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Demonstrate outstanding leadership and commitment to POCT
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Ensure QAAMS and ACE are culturally appropriate

19. Analytical Quality QAAMS: HbA1c Imprecision, QA Testing

20. Conclusion
Both QAAMS and ACE:

are clinically effective
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culturally effective
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and analytically sound.
Indigenous communities have been engaged and empowered with the skills and resources needed to manage and sustain POCT to help close the gap in health equity for diabetes care.