Suggestions for managing patients taking advantage of home lab tests
Your patient has been feeling extremely tired, with aching joints, loss of appetite, nausea, and yellow skin. The patient goes online to a medical information site and learns the symptoms could mean Hepatitis C. What does he do next?
For more and more people, the answer is no longer to reach for the phone to schedule an appointment with you. Instead, they're grabbing the phone to order home healthcare tests. Just as online do-it-yourself medical diagnosis sites have proliferated in recent years, sites that offer home tests for a wide range of diseases, conditions, and other risks are finding a receptive audience among people who feel that, as informed adults, they are capable of playing an active role in diagnosing and treating their illnesses.
Type "home health test" into an Internet search engine and you'll find thousands of links to sites that sell hundreds of tests: date-rape drink tests, hazardous chemical detection strips, male and female infertility tests, a range of allergy and cancer tests, menopause monitors, cholesterol tests, urinary drug tests, HIV tests, and many more.
Power to the people
What's behind the boom in this industry? The factors cited most often are privacy, convenience, cost, and control. Home health testing is anonymous, can be done at will without a long wait for an appointment, is cheaper than lab tests done through a physician's office, and puts decision-making about what is wrong, what should be done, and when -- or whether -- to consult a doctor into the patient's hands. Americans who consider themselves better informed about health issues feel that home testing levels the playing field when they do see their doctor.
The success of the home pregnancy test, which came out in the late 1970s, spurred the development of other tests and led to oversight by the FDA, which evaluates home tests and certifies those that can be trusted to provide accurate results when administered correctly. The FDA maintains a list of approved home test kits sold online and over the counter at drugstores and pharmacies at www.fda.gov/cdrh/ode/otclist.html, and provides consumer advice at www.fda.gov/oc/buyonline.
There are basically two types of home test: diagnostic tests used to discover existing conditions, and monitoring kits used to manage a known condition. But despite the growing popularity of both types, home testing is not on the radar for many physicians.
Often patients don't tell their doctor that they've scheduled an appointment on the basis of home test results. They may want to avoid appearing as if they've gone behind their doctor's back. And while some physicians disregard home test results, there are many doctors who approve of and encourage home testing, for the same reasons of privacy and convenience.
Frannie Kronenberg, MD, a primary-care and internal medicine physician and medical director of Brigham and Women's Physicians Group at Brigham and Women's Hospital in Boston, is one of them.
"I see home testing as a helpful way to facilitate a partnership between patients and physicians," says Kronenberg. "As people get more access to information they want to have a more active role in managing their care. I see home testing as facilitating self-care, and enhancing the patient's role in healthcare overall. For example, take what glucose monitoring has done for diabetes patients: they can change their dosing and have tighter control of blood sugar to prevent complications."
Medical associations, including the American Academy of Family Physicians (AAFP), have also endorsed home health testing; the AAFP states that it "recognizes the proliferation of home diagnostic test kits for a variety of diseases and conditions ... [and] encourages patients to consult with their physicians regarding selection, use, and interpretation of these tests."
Can patients handle it?
But can laypeople be trusted to conduct and interpret home tests correctly? And does home testing challenge the importance of the doctor-patient relationship?
"People have a responsibility to do their own research and learn about the condition they're testing for," says Ken Adams, president of Home Health Testing in Melbourne, Fla., a retail company that sells home health tests online. "Many tests are simple, and so long as the instructions are clear, the FDA has said there's no reason not to do them at home."
If a test is not administered correctly and turns up positive for a condition, it's a mistake that's easy to correct -- and it's very likely to be corrected. "You take a test, then you go to the doctor and say, 'This test indicates that I may have this problem,'" Adams says. "The doctor may give you the same test again since he may not know if you did it correctly. But that's OK, because the whole point is to get you in to see the doctor. Better to self-test and then be re-tested than never to find out that you have a condition.
"Do you really think that if someone takes a test and gets a positive result that they're not going to see their doctor? If you get a positive test result, you go to your doctor to see why."
Kronenberg agrees. "Home testing is only harmful when tests are unreliable and falsely alarm people," she says. "But overall, that's not as common as you'd think."
Tests are time-savers
Susan J. Kalota, MD, of Arizona Urologic Specialists in Tucson, Ariz., says home testing is a part of her practice.
"As a urologist, I see basically two types of patients: older patients with complicated urinary tract infections; and young, sexually active women with frequent, simple infections. The latter are ideal self-test candidates. Established patients who take a home UTI test and get a positive result can drop off a urine sample any time, and if it comes back from our lab positive, I'll have a prescription on hand for them so they can just get their antibiotic. They don't have to come in to get a prescription. If their symptoms persist after three days, then they can come in for an exam."
People who resist coming in for testing or treatment often misuse home testing. "I've had patients call up and say, 'I know what I've got, just treat me,'" says Kalota. "I say, ethically, I can't do that. I have to see a urine sample so I can see that it was a clean catch and that it's a viable sample. We added a [physician assistant] so these people can come right in and get a full evaluation as soon as possible, without waiting for an appointment with me."
Kronenberg agrees that home testing must be verified by a doctor. "While I would use home test results as a starting point for evaluating what's going on with a patient, I would want to verify them, and as a matter of course I'd ask the patient all the relevant questions about history and symptoms. I wouldn't rely on test results and just medicate them. I would repeat the test and do other tests."
What you can do
Clearly, physicians who have not already would do well to become more aware of the role home testing may be playing in their patients' care decisions.
The first step is the simplest: when it seems appropriate, ask your patients if they are basing an appointment on the results of a home test, and, importantly, whether they have already self-medicated on the basis of that test. If patients balk at re-testing, remind them that to ethically treat them, you must personally verify that their test results are accurate. Then, see if there is a viable way to incorporate home testing or monitoring into the patient's healthcare plan.
Physicians can also follow Kalota's example and alter their practice to allow for home test verification outside normal appointments. Finally, letting patients know the risks of relying on home tests in place of an active relationship with their doctor will cut down on incorrect self-diagnoses and self-medications.
In short, the more you know about your patients' home testing and the reasons behind it, the better off you and your patients will be. It's clear home testing is a factor to reckon with in the ever-evolving doctor-patient relationship.
Lori Rogers-Stokes can be reached at firstname.lastname@example.org.
This article originally appeared in the April 2004 issue of Physicians Practice.