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Point-of-care Diagnostics: what are the real needs of general practioners?
Nicolas Senn, PMU, UNIL
Thursday, Oct. 26, 2017 · 10:19 a.m. · 28m 16s
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thank you very much for this person they shun and thank you much for the invitation i'm very happy
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and it's interesting to start by the end of the chain
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incense got the end users
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what you what developing or more stuff you are working on some very pleased to to give you some ideas about
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that so it's uh during this presentation what i'm going to talk about maybe just to briefly set the scene
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by a given you an over view of the characteristic of the
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g. p. settings what is done routinely by by g. p.
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uh in fact he says after a a brief overview and that would be with a few examples on
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how we do uh our work daily and making decision uh for
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patients with an example an inference after we've talked about
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oh what are really the outcomes of interests when we're are interested to make it past
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when we look at the science behind that's what's to prove that we need for this class
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and finally that would help us to design really briefly uh the needs for g. p.
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is when they wanted to adopt a a part or a point of that
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ah so the characteristics l. j. p. is fine make sure ah are taking care of a lot of different things
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like it see that's a study that we have done a few years ago uh and you see that
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can be very uh uh a different they can look at after your cattle infection
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oppression a particular set so it's very diverse so but i don't think you you learn a
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lot with that but that's a a ten or twenty years apart and it doesn't
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different on so still a a g. p. r. looking off a lot of different diseases
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uh but if we go more in depth into what the g. p. is doing and
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the the constraints he has a voice consultation that you get like a a small which queries
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about the answers so the average length of focusing the conservation biology p. into thin
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and maybe maybe you can have a gas into it and it's quite long
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i i it's twenty minutes so it can be very wrong in u. k. for example it's ten minutes
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in china it's two minutes so off you can i expect the time you have
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with your patients uh us and we have twenty minutes and after that
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the way so that's a major difference from the hospital when you're in hospital inpatient stay in hospital so we can go back to
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if anything if the patient is away so that to a major feature of a jeep directories
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they also take a usually overpopulation in switzerland is about one thousand one thousand five hundred uh
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different patients that the looking after an intense off number of consultation
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two four thousand and six thousand conservation for the g. p. working hundred purse
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re row that give you an idea of how many patients gassing printer so
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i'll link to that it's off uh it's very difficult to find this
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uh what the yeah concretely the number of different cases yes
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think we're here and you can see hater what numbers
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but it's very difficult to find new ones but i don't think it does change a lot so that this is in u. k.
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as i said uh i think much more present patient period and we're doing
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in switzerland so it's interesting to see that they're seeing a lot of
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different kind of conditions keen risk which really ah psychiatry and we which
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is quite interesting a lot of patient common is not specific fan
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thompson that's one of the characteristic object constipation we often go out of
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the office without actually diagnostic and we can leave without just fine
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you fall if we go more into the diagnostic themself uh that's uh the specific minor
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conditions that ah usually sing a a g. p. uh uh in in the office
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and you can see there is also a lot of diversity but the first one is quite interesting actually throat infection
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that mean you have all the french i think if you have the strip till infection so we know by
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that's only one ten uh a sore throat is is to uh uh stop toby
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factions so that mean in fact g. p. even is working hundred percent fee only one structure
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infection every malls so that's that's a lot and you have all the rest that
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so that's given idea what we call that we would come back and that's what we call low prevalence yeah
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and that is a major implication on the tests you you're going to use or not
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and how we're going to interpret that uh if we go to the major condition
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you can see that the the the most prevalent one is actually chest infection so you have
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two more yeah but most of them end up bacterial so that with the same
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a physician you get everyone is very frequent but if it should be seen probably less than one
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remote yeah true vector primordial problems so that's not a lot and if we go to more
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right conditions like actually up the menus you
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one two three four five for your soul very right so everything is
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quite rare but you know when you have a lot of diversity
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so that's the the the first very synthetic summary of the characteristic of
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so you have a large variety of this is but the or in fact quite rare so that mean you
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have a low prevalence of disease or in this setting you have a very short contact time and
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that's an additional thing i didn't mention other won't mention well but but uh it is implication
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with a private faxes that is just
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so the second apartments to talk about how we integrate
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a a point of care uh a test
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to the jenny clinical decision making you know tractors and that's exactly in contains a very good example of how you can use or
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not rap artist so that's a very practical example that's a a
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patient an operation uh she sixty one she is is you
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uh and she come suddenly because if you'd wake chest fever cough chills
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just today on the examination she mostly had a high fever with that eight point nine the rest
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is almost normal and respects rated high nineteen permit
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uh on the examination there's not much very
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specific if you pack was when you are here the lines but uh and around it is a
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few at dinner parties but nothing more so the questions here is you are in december
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that's the difference on technologies what is the probability or what is
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uh the probability of inference i would think about that but you have also all the other technology that you have to consider
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so one of the key questions when we make a decision it's
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two estimates the probability it's it's not an exact sciences it's
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just a goes but by the experience you know if it's unlikely that it's in france that if you want me to always
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the likelihood that the patient and size almost zero but if you
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are in for every time but here we are made
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uh uh uh december so that usually yep it it hasn't started mid december so
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you can go to the epidemiology of something that ah probably most of you have heard that
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so that's why we decide that we are in a pretty good knots usually and that was last year
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or an uh oh january or february don't it starts so now we are here for this patient
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so you have the the the magical data so only eight percent of the patients
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really have inference or not very much so it looks very helpful for
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these patients maybe with a specific clinical presentation like in this case maybe goes
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up to twenty percent we is high fever is uh the cheats
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that sudden onset sure you can guess that are brought twenty
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percent off chats or but like that the patient it
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so you need help so what can you do the the preference with this patient to convey and if you want to call him
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but it's an influence like it's so you can do a lot headcount
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usually or often the positions are doing that but it's not very
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useful because the sensitivities not good c. r. p. is or is it
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the same it's the same thing it's not very useful because
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is not good to coffee and a a diagnostic of the inference ah
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serology not useful because you had the results in a few days
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you get it at the beginning of the infections so you have now the new test data to block you have peace your
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for the time being it's not available usually in the brackets in house but that's a different topic but in the
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park to see it i mean you don't have p. c. r. so you have rapid diagnostic test foundation
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they have been developed for more than twenty years these many many brands that exist
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so but what's the situation uh in terms of science because the the the
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the g. p. is also scientists so we can go to the literature
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ah the problem we have with almost all the test is not the sensitivity is not good
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that's a very recent what just show last ones maybe a
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caesar interesting review the announcer family wealth internal medicine
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i mean the you see that's the pulled sensitivity for the rapid test is about fifty percent
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so not very high in another thing the maybe for those we've seen this uh uh interesting review uh another
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thing that i have seen that they have looked at ease the difference of sensitivity of the test
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if it was controls uh uh tryouts or if it was
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on sports out and use it quite the important difference
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it's not because they are a heavily biased or they're doing but sciences
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just because the settings where you're doing the studies completely different so i'm not blaming the manufactures but the
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the the objective of the two studies is completely different so that's why we probably one of us
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been points uh that we're going to talk also after is not really the the settings where you are
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doing the studies make often a big difference it can be in one sense or in the other
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oh so to come back to our patients within france ah finally when i have to
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make a decision i have to consider all the things before it would test
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uh i will do a test if the probabilities not great it's very low okay it's excluded i can
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uh uh if we just without looking at best and and sending back home of the patient
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ah but if i want to propose a curative treatment because you have you heard
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a lot about twenty flew a certain media uh uh so if we
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want to keep his jokes on me the patients positive so interested to do
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a test uh but if you want to rule that confronts not because
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monday or something else but i want to be sure it's not in france at so that can be all good reason why i wants to read it
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diagnostic test but the answer can be no because and that's usually the attitude of most physicians in switzerland
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oh what do you want to propose to oh for for this pottery you
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want to propose a symptomatic treatment anyway independently of the results or
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would you put it that that's what the american way off of of treating
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in france i do want to propose to directly treatment almost any time
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so in conclusion i despite the fact that we have a lot of protest that exist for
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inference of that they've been definite put twenty years the performance make them use this
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uh uh for the time being in switzerland but of course the future and that's the other part of the review that they're actually you
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also look at the the the preference of the p. c. r. and that's probably the future but for the time being you need
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you know that that that that me but one two hours to do that and what would be
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a infrastructure today that there's not really yet ready to the p. c. r. uh uh the
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patients uh in a small village detracts but that probably going agent but i i think i would learn about that later today
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ah the third part that's more related to scientific prop because before
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to to go to the insisted that i used to work
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development or the evaluation uh off the effectiveness of for this in a
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different topic but it was also parameter that was my ire
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uh some other ah no it's uh uh uh uh uh uh put that infectious disease and
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for a while so about twelve years we have started to develop rapid test uh
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but at the beginning he was huge debate about that that they had been
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tested you d. l. condition and be upset that they would not perfect
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the sensitivity was ninety two ninety eight percent uh especially was not very great for one of the spaces
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blessed mother buybacks and uh uh so the question was really can we afford to take the test
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the fourth negative and we not cheat depiction but we need if it even more if it's
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a if it's if it's tried uh and that was really a a and for
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ten fifteen years we didn't there to rely only on the road tests to decide on the treatment now
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we have done this study and we're done the study in the place specifically with a with a
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lot of plasma them five acts up when he knew which is now suppose straight yeah
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and what we have done that it wasn't a frame of another uh a big trials malaria
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but what we have done we had about six thousand uh children with of rubber i've been up results
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and we made only rap tests to decide if they could receive or not treatment from our yeah
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to set of them for thousands when they get it from right so we sent them back home without any treatment
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and we observed what happened this cheated and what we observe it's
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about three persons came back within seven days you can
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expect that's that's a maximum of patients who came back with that mixed
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case because there was a false negative test at this stage
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but when we look more into details so uh to these patients we upset that in fact
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there was less than one percent of the children came back with a
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button she needs a infection with the r. t. and most import
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then went midi or died because of dismissed but
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delayed technologies so this says very different topic
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function packed is that's the kind of evidence that is interesting force it's behind that
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that despite the fact that there are that is not perfect it yeah
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and when we use that in the chair it works perfectly well
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so i'll and that's uh the the the final section of the presentation with
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or what we have said now how can we deal with all
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this elements to define the bit that needed a t. v. for now and for the future
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decides to get to a point of contest or so first we have seen that's uh we have a large variety of of
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so probably of course it's even if it's almost always low prevalence
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go on the most prevalent this is probably the most dangerous once when you want really to to
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decision i give a few examples like cardiovascular diseases so you want to
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be sure that the patient doesn't have them you cannot infraction
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and some frequent infections this is how i talk a lot about inference that uh stripped all in one yeah that
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interesting to have a performance yeah immediate test for this patient
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and maybe to have more general screening all all with tipper this is really a a four yeah
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important background infectious disease for example we should also focus on disease for which immediate action
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that's a very important we have seen we see the patient only twenty minutes so it's important that's at the
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end of the consideration or not in two hours i can make a decision for this patient this year
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very interesting in that sense because you can have a sympathetic tests uh
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in your face that will help you are directly tutsi okay could
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exclude these energies all have to go through the uh uh with
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looks uh with the examination so that's uh an important point
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so don't aspect low prevalence uh because we are low prevalence
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so this is not quite right so we we probably favour test which good negative predictive on so you want
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uh we ensure that you can send back to fiction all you have to more
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time if the test is a false positive to to do more examination
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i that's really probably uh also big humour is a perfect example because if it's
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below the trees all should be quite sure that the reasonable to mobile isn't
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if it's of what you have to do for the that's with the the way we uh i think uh in general practised
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uh that's mean for the future you mentioned that before uh out because you are sometimes very complex
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decision to maiden to integrate a lot of different uh information not there's some something like or
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uh an announcement without our written can be a a a a way to move forward
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with really read he's very complex decision we don't have time to integrate everything yourself
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and uh of course to have long expired it's if it's single test
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you have seen them was free can diseases like straight away
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see one someone's so if you have it this which is expert six months and you have to
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to buy a batch of twenty tests you have to swear we but the majority of them
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a short contact time with patients a mansion that's so there is a
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need a to that test that had to make a decision
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at the end of the consideration after after they have to be easy to a quick to perform and
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yeah you can get a get into another has half of the uh of the off
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like the the the medical assistance that can be a a a a good way to
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the more haitians are in doing the test ah i give you another few we classical examples that we have
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in engine practised proper name for you cannot infraction a blood cell counts
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maybe address and in the future now it's very heavy machines but
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developments you have like a a a just a smart phone and you
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can just uh the patient on your side and make a nitrous
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five or ten minutes not the same way that a radiologist will do it that
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can be useful just to exclude there is the uh from one yeah oh
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so there's a lot of developments in that sense or
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it should be also integrate it to the uh to clinical decision making that mean uh when
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we decide to make a test or to buy the test to make it afterwards
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we should be clear that there is management strategies that exists for people
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disease or this is that these guidelines but i'm going to do
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positive or if it's negative uh of course and that's what the background of
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the g. p. s. but we should know the epitome largely approximately
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uh we were talking about oh yeah i don't think there's any g. p. who has a rapid destinies office
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maybe once a case every year or every second uh an
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what already mentioned before uh the point after this
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and also in france a demon get decision maybe to decide if you are going to
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be for the patient to the hospital after you're done a chest x. ray
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off one of the best i've mentioned before easy these no immediate function you you
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can imagine uh a long lasting disease and you want to make a test
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you can leave with i think the results one two weeks and see the patient again it only to have the results right now
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and that's what for the research of it was well researchers some interesting also in that
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it's really to assess uh uh this device for example outside the lab vertices
00:19:34
when we live to test them out with the raw how do they work what we call
00:19:38
effectiveness that you get a tract is that really highly control uh efficacy tree up for
00:19:45
uh and to choose the outcomes also features it's not because the device is able
00:19:49
to get x. x. percent of parasites that's the device would save life
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best product and does the patient up the the outcome will be different at the end
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is the patient we is going better as you change something in the press
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then doing out what's the cost uh that it does it has
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an impact on the relationship between the doctor and the patient
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or the that has that well this questions uh are the the key questions if we want to be really sure
00:20:17
this device would bring something to to to the patients and that and maybe have b. is sometimes the
00:20:24
some confusion about what is it you're gonna stick test but it's really a vehicle intervention of course
00:20:30
making the diagnostic doesn't change the the lack sufficient of them you
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have to do something afterwards but it can still be seen
00:20:37
as an intervention that you had to to to test is such a and maybe to combine that with management structure
00:20:45
still to to have in mind that's object is a is a medical intervention needs to be assessed probably
00:20:53
so in conclusion uh really and that's not an exhaustive list but i think
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there is already a lot of uh of things that we have mentioned
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uh uh if we want to have part of campus which are suitable
00:21:06
for general praxis we should i think at least consider this point
00:21:10
first they should be focused on this is for which the schema national traditions
00:21:15
a second they should focus on diseases for which there is an urgent decision uh it needed
00:21:21
and they should have probably very good predictive value very often you see sensitivity spaces just test
00:21:28
i'm more rarely also in the study is you see the predictive values because it depends on the prevalence of disease
00:21:34
and waited interested it's very important to see if you're this would
00:21:38
be the facts which good performances or not you're setting
00:21:42
uh and also well maybe sometimes to have studies that they've
00:21:47
been run independently uh ineffectiveness trend in real life
00:21:52
they should have and we mentioned that on it for dates uh
00:21:58
the uh the uh the easy to perform and finally uh we should be members
00:22:04
one thing about that to this afternoon about the reinforcement very important if you're not reimbursed probably to be when i never
00:22:10
use this test so they would send the patient somewhere else so that was really re for for a few off
00:22:17
i can see from the g. p. perspective of this test so i'm happy to take a few questions if we have time thank you very much for your attention
00:22:31
um professors in many senses load is a very interesting inside
00:22:36
the tractors as a general practitioner i see yeah
00:22:42
we have some time of course for question of of of us want science the
00:22:47
if you talk from the perspective of the solution yeah in a developed country
00:22:52
records most patients are not to know what countries and germany positions
00:22:58
how would you modify your your description real prescriptions things that need to
00:23:02
be done if you move outside of the services domingo group
00:23:06
some place where there are barely trained healthcare providers and no we'll clinical some
00:23:10
solutions ah yeah the with the the setting is different of course
00:23:15
to uh make other has ah while going performed that mall strict guidelines you have uh the the
00:23:23
we worked much more with algorithm like uh but it's not necessary electronic coverage
00:23:28
can be when you have a patient come with that and you have a decision tree that helps you to be guided to the test
00:23:35
because you have little money you have to be very cautious which just use and if we have done this work with
00:23:40
my glasses because we want we need to be sure that we bring something for the money we going to invest
00:23:46
so that's really the way to the to develop would be to the end of
00:23:49
the chain to see in we'll conditions in this kind of has specifically outward
00:23:57
yes it it well even without the cell phone can be just or in in in uh they have
00:24:03
something to get me with this not for there is a lot of developments in that sense
00:24:07
we we already is it or they have stuff was so scared to go out of
00:24:11
fitting everyone organism microscopy like we have done four hundred years a soft uh it
00:24:18
change the way of wreck things also and to uh to to to go with this change is very important
00:24:28
so uh are there any other questions from the audience uh
00:24:36
uh_huh
00:24:39
it's only use the microphone
00:24:46
when you move to turn him diagnostics that question for your wasn't
00:24:50
exactly the to raise the issue also um in the the
00:24:52
decision nodes disease as it is in the proper clinical setting it's
00:24:57
like you say that the loop rather than sitting it's
00:25:00
extremely difficult to find patients for this kind of study it's also the case uh in the output than sitting for example the
00:25:06
d. t. s. install product markets is always a real challenge
00:25:11
because the intended use of the essays are meant for
00:25:15
it's couple social but we know that is you will do that the
00:25:17
robot uses kind of different it's so it's indices for pen
00:25:24
it's g. p. sitting doing discuss it is false in the
00:25:28
the disease casing the completion what sucks but oh the conclude population
00:25:33
can do this with the surrogates for the typical conditions
00:25:38
easy to emergencies punishments impassioned out patients but does you've you want that
00:25:45
right it's a very important point i think they've used to aspect they wheeze first the way we conduct a study
00:25:51
how are we really in real life so i think that's we don't we don't inference
00:25:56
to match the decision of the physicians or have stuff with doing
00:26:01
the too good yes that that's uh the first point maybe what we
00:26:04
call pragmatic uh uh setting a it can emergency setting but
00:26:10
the prevalence it's usually much higher it can be uh uh uh uh uh
00:26:14
other settings but i think the the methodology to be pragmatic say okay
00:26:18
well we don't say you anything you just have to test if you want if you
00:26:22
want to use it and you are free to do the decision you want afterwards
00:26:26
and at the back up you have the the study stuff with really recording everything
00:26:30
to see it yeah and we could bring something so that's the methodological
00:26:34
and for the g. p. settings and we are starting to do some something else g.
00:26:39
p. facilities so of course we focusing more on on problem disease but i think
00:26:44
of now we're can be had with what we got
00:26:47
big gap i mean the interconnection uh uh of
00:26:51
the the the the gathering of information to uh electronic medical record
00:26:56
can help to bring together a lot of different physicians well very it was very difficult when you had
00:27:03
the papers before now you can feel everything uh electronically make the
00:27:08
life much easier on you have you can have much more
00:27:11
fact this is together so it i think it's still important to think about
00:27:16
doing the study low prevalence settings in g. p. break this is but
00:27:20
with the new to switch are coming in terms of collecting
00:27:23
information we had us lots to to to do
00:27:27
this or so that thing up but that's another way to do that i think we can knots ah
00:27:32
maybe for some or read this and not in every possible uh uh to do that jeep wreck
00:27:38
but as much as possible we should try to do that and we should develop the the
00:27:42
infrastructure to collect information about what we need to do that and we do we know
00:27:51
it's it's a it's a it's here yes yes and after every night and oh yeah
Conference Program
Welcome Note
Gaëtan Cherix, Director - School of Engineering
Oct. 26, 2017 · 10:08 a.m.
210 views
Welcome Note
Marc E. Pfeifer, Symposium Chair
Oct. 26, 2017 · 10:15 a.m.
564 views
Point-of-care Diagnostics: what are the real needs of general practioners?
Nicolas Senn, PMU, UNIL
Oct. 26, 2017 · 10:19 a.m.
157 views
Recent developments in microtechnologies for point-of-care testing
Philippe Renaud, EPFL
Oct. 26, 2017 · 10:47 a.m.
217 views
GenePOC, a breakthrough solution in molecular point-of-care testing
Patrice Allibert, GenePOC
Oct. 26, 2017 · 11:19 a.m.
273 views
mHealth in the therapy follow-up of chronic inflammatory diseases – a smartphone based self-monitoring tool
Jakob Weber, BÜHLMANN Laboratories
Oct. 26, 2017 · 11:47 a.m.
104 views
Reglementary aspects ruling the reimbursement of laboratory analyses in the context of the compulsory health insurance
Michèle A. Fleury-Siegenthaler, Federal Office of Public Health
Oct. 26, 2017 · 2:12 p.m.
166 views
The applied research programme "Diagnostic Biochips": novel technologies for point-of-care diagnostics
Jean-Manuel Segura, HES-SO Valais
Oct. 26, 2017 · 2:42 p.m.
198 views
From brain proteomics discovery to the use of a POCT: The translation to mild traumatic brain injury (mTBI)
Jean-Charles Sanchez, CMU, UNIGE
Oct. 26, 2017 · 3:25 p.m.
466 views
Recent advances in non-invasive diagnostics
Samantha Paoletti, CSEM
Oct. 26, 2017 · 3:53 p.m.
199 views
How nanofluidics bring diagnostics closer to the patient
Fabien Rebeaud, Abionic
Oct. 26, 2017 · 4:17 p.m.
224 views
Keynote Session introduction
Marc E. Pfeifer, Symposium Chair
Oct. 26, 2017 · 5:07 p.m.
Keynote session: Accessible Bioanalysis for the Developing World and the Point of Care
George M. Whitesides, Harvard University, Cambridge - USA
Oct. 26, 2017 · 5:09 p.m.
230 views
