Clinical and operational benefits of international normalized ratio point-of-care testing in remote indigenous communities in Australia's Northern Territory

Among Indigenous people of Australia's Northern Territory, the prevalence of rheumatic heart disease is one of the highest in the world. Warfarin is a common anticoagulant used to treat this condition and to minimize risk of a cardiac event. International normalized ratio (INR) testing is used routinely to monitor the efficacy of warfarin therapy and to ensure a patient's INR remains within a tight therapeutic range. Since 2008, the i-STAT point-of-care testing (POCT) device has been used tomeasure INR for patients on warfarin therapy in 32 remote health centers participating in the Northern Territory POCT Program. A training and quality program to support i-STAT INR POCT is delivered by Flinders University International Centre for POCT and offers flexible options for training including on-site workshops, interactive teleconference training, and training via e-learning. Since 2008, more than 13,000 INR POCTs have been performed on more than 900 patients. Two hundred ninety-eight patients have had 5 or more INR POCTs performed, and 212 of these have had more than 10 serial INR tests. The volume of patient INR testing has increased every year of the program, from 853 in 2008 to 3332 in 2014 (representing a 291% increase in testing since the program's inception). The number of remote health staff trained as POCT device operators is now greater than 700. The between-site imprecision (CV%) from monthly INR quality control testing has averaged 6.3%over the past 6 years (range, 4.6%-7.6%). A clinical audit of patient cases has identified improved clinical outcomes and operational benefits through POCT.