INTRODUCTION:Type 2 diabetes mellitus (T2D) and metabolic syndrome (MetS) have reached epidemic proportions for Indigenous populations globally. In Australia, disproportionate rates of T2D and MetS are inextricably tied to the experience of colonisation. As part of a growing shift towards strengths-based, Aboriginal-led initiatives, this project sought to co-design and assess the feasibility of a metabolic remission initiative, whereby Aboriginal people living on Ngarrindjeri Ruwe (Country) are supported to adopt a low-carbohydrate diet. METHODS AND ANALYSIS:This 28-week pilot takes the form of a non-randomised stepped-wedge design. Aboriginal adults (≥18 years) living on Ngarrindjeri Ruwe with T2D or MetS will be recruited to two sites in rural South Australia. Participants will transition through three phases (control phase, remission phase and maintenance phase) with repeated measures taken across five key time points (T1-T5). While centring on the adoption of a low-carbohydrate diet, participants will be equipped with continuous glucose and ketone monitors and meal boxes and offered ongoing support through weekly to fortnightly check-ins. The primary outcome is to assess the feasibility of Nra:gi Ya:yun in preparation for a large-scale clinical trial of similar design. Feasibility will be assessed through recruitment, retention and adherence rates. Self-reported dietary recall, out-of-pocket food costs and national pharmaceutical and medical benefits scheme data will also be examined. Qualitative data obtained using the Aboriginal research method of yarning will aid analysis and interpretation of results. Clinical measures (such as blood pressure, weight, waist circumference, capillary ketones and capillary glucose) and venous blood draws will assist in the evaluation of our secondary outcome, namely the initiatives' preliminary effect on participant metabolic health. ETHICS AND DISSEMINATION:Findings will be disseminated to Community, participants and policymakers in the form of digital posters, manuals, infographics and peer-reviewed publications. Lessons from this study have the potential to provide insights and benefits to Australian public health policy and research, as well as Indigenous populations globally who face similar metabolic challenges. Findings will be used to advise on an implementation strategy for a large-scale clinical trial. Pilot trial approved by the Aboriginal Health Research Ethics Committee (HREC), Flinders University HREC and Southern Adelaide Local Health Network HREC. TRIAL REGISTRATION NUMBER:Pilot prospectively registered with the Australian and New Zealand Clinical Trials Registry ACTRN12624001019594.

ISSUES ADDRESSED:Addressing the disproportionate burden of type 2 diabetes prevalence in Aboriginal communities is critical. Current literature on diabetes care for Aboriginal people is primarily focused on remote demographics and overwhelmingly dominated by Western biomedical models and deficit paradigms. This qualitative research project adopted a strengths-based approach to explore the barriers and enablers to diabetes care for Aboriginal people on Ngarrindjeri Country in rural South Australia. METHODS:Knowledge Interface methodology guided the research as Aboriginal and Western research methods were drawn upon. Data collection occurred using three yarning sessions held on Ngarrindjeri Country. Yarns were transcribed and deidentified before a qualitative thematic analysis was conducted, guided by Dadirri and a constructivist approach to grounded theory. RESULTS:A total of 15 participants attended the yarns. Major barriers identified by participants were underscored by the ongoing impacts of colonisation. This was combated by a current of survival as participants identified enablers to diabetes care, namely a history of healthy community, working at the knowledge interface, motivators for action, and an abundance of community skills and leadership. CONCLUSIONS:Despite the raft of barriers detailed by participants throughout the diabetes care journey, Aboriginal people on Ngarrindjeri Country were found to be uniquely positioned to address diabetes prevalence and management. SO WHAT?: Health promotion efforts with Aboriginal people on Ngarrindjeri Country must acknowledge the sustained impacts of colonisation, while building on the abundance of community enablers, skills and strengths. Opportunities present to do so by adopting holistic, community-led initiatives that shift away from the dominant biomedical approach to diabetes care.

Background Diabetes is a chronic health condition, disproportionally impacting Aboriginal people in Australia. It is also increasing injury risk, with the chance of falling much greater in older individuals with Diabetes. Remission of diabetes has been linked to decreasing risk of cardiovascular disease and is likely to decrease injury risk. Objective Focusing on recommendations for remission (ketogenic eating), we co-designed an eating program with Aboriginal people on Ngarrindjeri country. Which included important cultural and contextual factors, educational and motivational strategies, group-based activities and exercise for a ketogenic eating program, along with monitoring physiological, social and economic outcomes. Methods Indigenous knowledge were centred through 1. Knowledge Interface Methodology and 2. Strength-Based Approaches, and the leadership from Aboriginal consumers, researchers and health professionals across the project. Co-design occurred on Ngarrindjeri country where participants needed to be >18 years of age, identify as an Aboriginal person living on Ngarrindjeri country, have a diagnosis of Type 2 diabetes or metabolic syndrome. Community-led Participatory Action Research was employed, with decolonising actions through engaging Indigenous principles of consultation and reciprocity, and Indigenous research methods of yarning and deep listening. This occurred over eight workshops at two locations with >30 Elders and senior community members. Workshops were facilitated by the research team, all were recorded, de-identified, transcribed, and thematically analysed, focusing on protective factors for the Cultural Determinants of Health. Results A range of themes were identified from workshops, with desires for it to be community owned and built on Ngarrindjeri knowledge, encompassing local produce and cultural laws. Convenience and cost effectiveness were important factors highlighted, along with the need for connection. Community wanted regular catch ups through cooking classes and exercise groups. Co-design resulted in the Nragi Ya:yun initiative, a 28-week program with both a diabetes remission and maintenance phase for participants. During the presentation we will focus further on the co-design aspects and design on the overall Nragi Ya:yun initiative. Conclusions Aboriginal people on Ngarrindjeri Country are advantaged to address diabetes remission and management through the Nragi Ya:yun program. Co-designed is essential with Aboriginal communities to centralise Indigenous knowledges and create community ownership and capacity.

Point-of-care (POC) testing has proven to be a life-changing and transformational technology for patients with acute, chronic, and infectious diseases who live in regional and remote Australia. This technology facilitates patient-centred test results, of equivalent laboratory quality, that are rapidly available to inform clinical and public health decisions with immediate impact on case management. Traditionally, POC testing in high-middle income countries has been most widely used in tertiary or acute care settings to provide rapid diagnostic results for emergency departments, intensive care units, operating theatres and outpatient clinics. However, in low-middle income countries, POC tests are commonly used during antenatal and perinatal care for infectious disease detection, such as Human immunodeficiency virus (HIV) or syphilis, where laboratory services are too expensive, inaccessible, or non-existent. Similarly, the application of POC testing in primary care settings in Australia offers improved healthcare benefits to geographically isolated regional and remote communities, where access to laboratory-based pathology testing is poor and the burden of disease is high. Evidence-based data from research in established primary care POC testing networks for acute chronic, and infectious disease is used to describe the clinical, cultural, and economic effectiveness of POC technologies. Innovative solutions to address current barriers to the uptake of POC testing in primary care settings, which include clinical and cultural governance, high staff turnover, operator training and competency, device connectivity, quality testing, sustainable funding strategies, and the need for regulatory requirements are also discussed. POC testing can provide practical and resourceful opportunities to revolutionise the delivery of pathology services in rural and remote primary care sectors, where the clinical and community need for this technology is greatest. However, several barriers to the scale-up and sustainability of POC testing networks in these settings still exist, and the full potential of POC testing cannot be realised until these limitations are addressed and resolved.

The COVID-19 pandemic is growing rapidly, with over 37 million cases and more than 1 million deaths reported by mid-October, 2020, with true numbers likely to be much higher in the many countries with low testing rates. Many communities are highly vulnerable to the devastating effects of COVID-19 because of overcrowding in domestic settings, high burden of comorbidities, and scarce access to health care. Access to testing is crucial to globally recommended control strategies, but many communities do not have adequate access to timely laboratory services. Geographic dispersion of small populations across islands and other rural and remote settings presents a key barrier to testing access. In this Personal View, we describe a model for the implementation of decentralised COVID-19 point-of-care testing in remote locations by use of the GeneXpert platform, which has been successfully scaled up in remote Aboriginal and Torres Strait Islander communities across Australia. Implementation of the decentralised point-of-care testing model should be considered for communities in need, especially those that are undertested and socially vulnerable. The decentralised testing model should be part of the core global response towards suppressing COVID-19.

CONTEXT.—:Since 2008, the Northern Territory Point-of-Care Testing Program has improved patient access to pathology testing for acute and chronic disease management for remote health services.OBJECTIVE.—:To evaluate the analytical quality, service delivery, and clinical utility of an expanding remote point-of-care testing network.DESIGN.—:Four years (2016-2019) of data on analytical quality, test numbers, and training statistics and 6 months of clinical point-of-care testing data from Abbott i-STATs at remote health services throughout the Northern Territory were analyzed to assess analytical performance, program growth, and clinical utility.RESULTS.—:From 2016 to 2019, point-of-care test numbers increased, with chemistry and blood gas testing more than doubling to 8500 and 6000 tests, respectively, troponin I testing almost doubling (to 6000), and international normalized ratio testing plateauing at 8000 tests. Participation in quality control and proficiency testing was high, with quality comparable to laboratory-based analytical goals. A shift toward flexible training and communication modes was noted. An audit of point-of-care test results demonstrated elevated creatinine, associated with chronic kidney disease management, as the most common clinically actionable patient result.CONCLUSIONS.—:The Northern Territory Point-of-Care Testing Program provides high quality point-of-care testing within remote primary health services for acute and chronic patient management and care. Clinical need, sound analytical performance, flexibility in training provision, and effective support services have facilitated the sustainability of this expanding point-of-care testing model in the remote Northern Territory during the past 11 years.

In Australia's Northern Territory (NT), acute infections are highly prevalent within Indigenous remote communities and difficulties in diagnosing the aetiology of infection are exacerbated by limited access to diagnostic tests. The objective of this study was to investigate the clinical effectiveness of point-of-care (POC) testing for total and 5-part differential white blood cell (WBC DIFF) counts for the triage of patients with possible acute infection. The HemoCue WBC DIFF POC device was introduced into 13 remote health clinics over a 6 month period. A retrospective clinical audit of patient cases meeting the selection criteria for three acute infections (sepsis, respiratory infection and appendicitis) were examined by four registrars in duplicate; one with POC test results available and the other with POC test results removed to determine if WBC DIFF results changed or assisted in patient triage. The number of changed outcomes provided a preliminary cost-benefit analysis. Sixty (23%) patient cases met the selection criteria for the clinical effectiveness analysis. POC test results changed the triage decision for 24 (41%) patients, of which 20 (34%) led to the prevention of an unnecessary medical retrieval and four (7%) indicated the patient had an acute infection which required a medical retrieval. POC test results assisted decision making for a further 13 (22%) patients. Cost savings related to avoiding unnecessary medical retrievals were estimated to be AU$481,440. Extrapolated NT-wide cost savings are projected to be AU$5.33 million per annum. POC testing for WBC DIFF counts aided clinical decision making for triaging patients with three common acute infections.

AIM:To determine the cost-effectiveness of utilizing point-of-care testing (POCT) on the Abbott i-STAT device as a support tool to aid decisions regarding the emergency medical retrievals of patients at remote health centers in the Northern Territory (NT) of Australia.METHODS:A decision analytic simulation model-based economic evaluation was conducted using data from patients presenting with three common acute conditions (chest pain, chronic renal failure due to missed dialysis session(s), and acute diarrhea) at six remote NT health centers from July to December 2015. The specific outcomes measured in this study were the number of unnecessary emergency medical retrieval prevented through POCT. Cost savings through prevented unnecessary medical retrievals for each presentation type were then determined and extrapolated to give per annum NT-wide estimates.RESULTS:POCT prevented 60 unnecessary medical evacuations from a total of 200 patient cases meeting the selection criteria (48/147 for chest pain, 10/28 for missed dialysis, and 2/25 for acute diarrhea). The associated cost savings were AUD $4,674, $8,034, and $786 per patient translating to NT-wide savings of AUD $13.72 million, $6.45 million, and $1.57 million per annum (AUD $21.75 million in total) for chest pain, missed dialysis, and acute diarrhea presentations, respectively.CONCLUSION:This study demonstrated that POCT when used to aid decision making for acutely ill patients delivered significant cost savings for the NT health care system by preventing unnecessary emergency medical retrievals.

Background: Point-of-care testing (POCT) enables immediate pathology results to be used for timely clinical action during the patient presentation. While many benefits of POCT for chronic and infectious conditions have been welldocumented, few studies have focussed on the clinical benefits of POCT for acutely ill patients in remote communities. Aim: To determine the clinical effectiveness of POCT as a decision support tool for triaging acutely ill patients in remote Australia. Methods: An audit examined three acute medical presentations (patients with acute chest pain, patients with acute exacerbation of renal failure due to a missed dialysis session(s) and patients with acute diarrhoea) at six remote health centres in the Northern Territory where POCT was routinely available. The main clinical outcome was the percentage (%) of patients with each acute presentation who did or did not require evacuation (as a result of POCT measurement). Results: 200 patient cases met the selection criteria for the presentation types. Of 147 patients with chest pain, 126 patients were not evacuated due to on-site POCT for troponin I; from this latter group, 48 patients (38%) would have been evacuated if POCT was not available. Of 28 patients who missed dialysis sessions, 17 were evacuated, Three of seven patients (43%) identified with non-STEMI through POCT would not have been evacuated if POCT was unavailable. Of 17 patients evacuated with acute renal disease, four (24%) had initial potassium results >6.5 mmol/L; all four received calcium gluconate/resonium medication and serial POCT with decreased potassium levels at evacuation. All 10 patients evacuated with acute diarrhoea received rehydration therapy prior to evacuation. Conclusion: POCT enabled more informed triaging of acutely ill patients requiring evacuation to a tertiary hospital as well as ruling out the need for evacuation for patients who could remain in the community and be stabilised safely using POCT.

OBJECTIVE To use point-of-care testing to screen and facilitate treatment for anaemia and to establish an estimate of the prevalence of anaemia in the local population. DESIGN An uncontrolled before and after study design was used to evaluate the effectiveness of the intervention on the anaemia status of participants. SETTING This study took place in a rural mountain community (population approximately 1000) in the Haripur district in northern Pakistan. PARTICIPANTS Women of child-bearing age (15-49 years) and children (12-14 years) were included in this study. INTERVENTIONS The intervention included point-of-care testing for haemoglobin, treatment with mebendazole and oral iron supplementation, and an education campaign about anaemia delivered by community health workers and medical students. MAIN OUTCOME MEASURES The main outcome measure was an increase in blood haemoglobin over the study period. A secondary outcome measure was a positive change in anaemia status or classification post-intervention. RESULTS Anaemia was initially detected in 64 (53%) women and 15 (47%) children. The mean haemoglobin concentration increased significantly (P < 0.001) from 118 to 130 g L-1 (women) and 120 to 130 g L-1 (children) post-intervention. Overall prevalence of anaemia in women (P < 0.001) and children (P < 0.001) decreased significantly (by 30% and 34%, respectively) post-intervention. CONCLUSIONS Point-of-care testing used for the detection of anaemia in this rural community helped to identify the burden of disease and to reduce this significantly by way of rapid diagnosis, education and immediate medical intervention.

The United Nations Office on Drug and Crime (UNODC) estimated that 246 million people between the ages of 15 and 64 years used an illicit drug in 2013. The advantages of point-of-care testing (POCT) for drugs of abuse are the ability to have results without delay and reduced cost of testing. Urine and oral fluid (saliva) are the preferred matrix analysed by POCT drugs of abuse devices, which use immunochromatography to detect the drug or drug metabolite. A range of devices is available for POC drug testing, from simple dipsticks, to cups with incorporated test strips, to instrument-based readers. POCT for drugs of abuse can be used in roadside drugs testing, workplace testing, judicial drug testing and rehabilitation clinics. The limitation of POCT for drugs of abuse is that a positive result needs confirmatory testing by a laboratory.

Connectivity encompasses the electronic capture of test results from a POCT device and the transfer of those results to a local computer, systems databases or electronic medical records. The introduction of an international connectivity standard in 2002 helped to provide the framework for engineers to design devices and work station interfaces that allowed multiple types of POCT devices to communicate bidirectionally with data management systems or laboratory information systems. For connectivity to be successful, the set-up process must be seamless, reliable and involve both clinical and technical professional staff. Attributes of a connectivity solution should allow control and management of all aspects of remote POCT, from quality control, calibration and maintenance protocols through to result validation, and include training records for all certified operators, POCT site accounts and workload statistics, a complete audit trail and traceability of testing pathways for individual POCT sites.

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 to measure 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.

There are a number of key stakeholders involved in the day-to-day operation of point-of-care testing (POCT) in primary care and hospital settings. Depending on the size/scope of the POCT program, stakeholders may include: the doctor actively managing the patient based on the POCT result; the POCT Coordinator or Regional Supervisor responsible for the organisation and management of POCT services at the network/regional level; the POCT operator who performs the POC test in situ; the patient, who is the consumer of the POCT service; and the industry partner who provided the POCT device and consumables for testing. This chapter provides a brief personal perspective from a representative of each of these stakeholders.

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Background: Chronic kidney disease (CKD) is a major contemporary global health problem. Creatinine measurement for the calculation of estimated glomerular filtration rate is an important component of assessing CKD risk. A point-of-care test for creatinine using capillary sampling is required as part of a screening assessment. Objectives: Evaluate the analytical performance of a modified point-of-care testing method for whole blood creatinine (Nova Biomedical StatSensor whole blood creatinine analyser) relative to a laboratory method. Design and methods: Conduct a patient comparison study between the point-of-care testing and laboratory methods in a rural community setting. Calculate measures of imprecision and assess the ability of the POCT method to determine staging of CKD compared to the laboratory. Results: Between-device imprecision averaged 8.8%. The StatSensor devices showed a positive bias of approximately 14% for whole blood creatinine measurement compared to the laboratory method, leading to more than 40% of community patients being staged differently for CKD risk with approximately 25% more abnormal results. Conclusions: The StatSensor whole blood creatinine point-of-care device remains analytically unsound for use as a screening device for CKD.