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There was a time when only a doctor would do to deliver a diagnosis. Nowadays, patients can use diagnostic kits, available for sale OTC or via the internet, to identify and monitor a myriad of conditions – often with minimum involvement from healthcare professionals.
While these kits may empower patients and relieve some of the pressure on health services – early screening can improve outcomes through disease prevention – there are risks in removing responsibility for testing from healthcare specialists.
Self-testing might appear to be a quick and easy answer for patients who want to take charge of their health in the privacy of their own home, but the use of these kits raises ethical questions and moral dilemmas regarding confidentiality, privacy and information sharing. For example, who should have access to test results (other than the patient) and how should this be managed?
Who patients should share their test results with will depend on what patients are being tested for, and the type, complexity and severity of the results they get.
Jay Badenhorst, superintendent pharmacist and managing director for Whitworth Chemists, says that with the increase in point-of-care testing for HIV, for example, “it is really crucial that, when there is a positive result, the person receives support, not just from a healthcare professional, but also from someone who can help with the psychological impact of that test”. People buying such tests from the internet may not always have that psychological support available to them, he says.
People who have positive self-test results for an STI, such as chlamydia, will also need to inform their partner or partners, says Jay, because it is not normally a confined disease.
“If people have multiple partners, then they could all potentially spread the disease – so they will all need to be contacted and potentially have treatment. With a self-test, people may be scared or unwilling to tell their partners, so it is important for pharmacists to advise patients to do so, and to also contact their GP and/or local sexual health service for further support.”
Of course, not every self-test will need psychological input – people who test their blood pressure can speak to a member of the pharmacy team about making changes to their lifestyle and diet.
If doctors initially detect high blood pressure in patients, it is now increasingly common to recommend they monitor their blood pressure at home. “This can help exclude ‘white coat hypertension’ and by monitoring at home you can get a better understanding of blood pressure,” says Charles Fox, general manager, Omron Healthcare UK, which has been providing home blood pressure monitoring devices for almost 50 years.
Devices such as the Omron M7 Intelli IT as well as Omron Evolv, which are recommended to be used in combination with a clinician, allow people to track their blood pressure by sending their results to their smart phone via Bluetooth. These results can then be extracted as a file and shared with whoever the patient wants to share them with, says Fox.
Whatever condition patients are self-testing for or monitoring, healthcare professionals need to be mindful of how best to discuss the results, by taking into account an individual’s literacy levels and cultural practices, and maybe having to share details with a family member or friend.
“It can be cultural practice for patients to bring someone with them to the pharmacy who can understand the results better than they can, perhaps because of language issues. So you may find yourself having to explain them to someone other than the person that has been tested, with that person’s consent,” says Dr Mahendra Patel, a senior lecturer and academic, and member of the RPS English Pharmacy Board.
Explaining test results and the implications clearly, and checking those details are understood – and not lost in translation – is a crucial part of the interpretation process for pharmacy and should be done in a private area, such as a consultation room, to ensure patient confidentiality.
It is also important during the consultation that, “you are sending, not rushing, information”, says Dr Patel. Consider the different ways of delivering information, such as using leaflets and pictorial resources, and signpost people to additional NHS services when necessary.
Given the financial constraints on the NHS, self-tests can offer good value by reducing appointments and improving disease prevention. “Managing your blood pressure effectively can actually help to reduce costs in the NHS. If you have complications, such as a stroke or heart attack, that is very expensive for the NHS and there is research that shows that managing your blood pressure at home is very valuable if you
do it in conjunction with a clinician,” says Charles Fox.
A blood pressure monitor is an affordable home healthcare device that lasts for a long period of time, he says. “It is very low-cost compared to the serious consequences of unmanaged hypertension. There is no cost using one at home – you push a button and can capture the results with the latest smart phone technology”.
Dr Patel says self-diagnostic tests “are of value if used correctly in the right setting, for the right person”. Such tests can help ease pressures on a NHS that is “bursting beyond its seams” by, for example, leading to targeted MURs for diabetes or cardiovascular disease, or patients being given advice about living a healthy lifestyle.
Pharmacy is an “ideal setting” for patients who have taken a self-test, he says, given their ease of accessibility and availability for providing advice to patients, which means they don’t have to wait for an appointment to talk about the results. The downside is that self-testing can also lead to unnecessary health checks, such as those carried out by the ‘worried well’, which can then lead to increased demand and cost for health services that are already over-stretched.
Self-testing can also lead to unnecessary testing, such as when a patient repetitively tests for the same condition in case they get a positive result, says Jay Badenhorst. “Not only does this place a financial burden on the patient but it can also put an additional strain on pharmacy”, he says.
And he believes tests can sometimes add another step in the whole process of patient care. “For example, if a test for cholesterol has a border line result, the patient will still need to make an appointment to see their GP to be tested,” he maintains.
Francis White, vice president of sales and business development for AliveCor, which offers mobile and watch-based ECG devices and services, says self-testing can result in ‘false positives’ leading to people believing they have a certain condition when they don’t. “This can lead to a lot of follow-up appointments, additional tests and procedures – you need to work hard to tell people that they definitely don’t have a condition,” he says.
Another potential difficulty associated with self-testing is the possibility of it shifting control of care too far towards the patient and away from the expertise of healthcare professionals.
For Omron’s Charles Fox, self-testing is about “everyone working together to get a good decision and to manage an ongoing condition, and not about shifting responsibility from the doctor to the patient”. In terms of monitoring blood pressure, self-testing “doesn’t shift control too far away at all because the patient is taking the blood pressure on their own, which is valuable as it allows them to provide more information to the doctor or pharmacist”, he says.
To get the patient-healthcare professional balance right, Jay Badenhorst says that, whatever a patient has self-tested for, “it is important they take control of their condition and manage it appropriately as long as they have input from a healthcare professional such as a pharmacist”.
Having that professional input is crucial because without it, patients who self-test “may be too scared to ask further questions – something this market sometimes fails to address”, he says. The danger is that, rather than seeking advice from healthcare professionals, people self-testing resort to managing their conditions via a search engine like Google – which could be to the detriment of their health.
With demand outstripping supply in health provision, Francis White says that delegating responsibility, control and ownership of health “is a good thing”. Self-testing becomes problematic, he says, when it gives people undue concern that requires them to ask a healthcare professional to confirm or deny what is being alluded to by the test. “That can end up creating unnecessary visits to an already overstretched system.”
While the rise of self-testing presents healthcare professionals with challenges, it also offers opportunities for them to use their skills and training to explain test results and their implications when counselling patients.
Pharmacists could play a greater role in the self-testing arena, says Dr Patel. “With more responsibility shifting towards patients and away from institutionalised care, pharmacy should be doing more to provide information in order for patients to do self-tests.” They are “highly trained, and good communicators, and therefore tend to give advice very carefully”. They can use and promote these skills when a patient comes into the pharmacy to purchase a self-testing kit, he says.
“Rather than letting them just pick a kit off the shelf, put a note by it to ‘ask your pharmacist’ for advice,” he suggests. Pharmacists can talk to customers about how to get the most from using these tests, and offer their services to support them in the use and interpretation of their results, as well as the wider aspects of treating and managing conditions.
More than half (51 per cent) of adults in the UK self-diagnose when feeling unwell, according to a national survey released by the Royal Pharmaceutical Society in 2016.
The self-testing market is a really good fit for community pharmacy, says Francis White, “because pharmacists have the necessary expertise to work with people directly to help them understand their results and make appropriate decisions about their care”.
As well as maximising the opportunities to use their skills in the self-diagnostic testing arena, there are also commercial opportunities for the sector, he says. But to make the most of those opportunities, pharmacists “need to be more involved in the diagnostic journey of the patient, whether administering tests or helping interpret them” and should be “encouraged and funded by [the NHS] where appropriate”.
Diagnostic kits empower the public to self-diagnose and enable healthcare professionals to expand on that knowledge, and support the management of conditions. But they also have the potential to make the ‘worried well’ even more worried, adding to an ever-increasing workload in pharmacy.
To make the most of self-diagnosis tests, Francis White believes that the technology needs to offer results that mean users can make something new happen – either through medication or lifestyle changes. “People need the choice to do something differently otherwise, if the result is not actionable, it is just going to cause concern.”
Healthcare professionals need to be mindful of how best to discuss the results