Impact of rapid diagnostic tests for the diagnosis and treatment of malaria at a peripheral health facility in Western Uganda: an interrupted time series analysis.

Ross M Boyce,Moses Ntaro,Anthony Muiru,Edgar Mulogo,Raquel Reyes,Mark J Siedner,Michael Matte

doi:10.1186/s12936-015-0725-0

Abstract

BackgroundThe World Health Organization recommends that all suspected malaria cases receive a parasitological diagnosis prior to treatment with artemisinin-based combination therapy. A recent meta-analysis of clinical trials evaluating RDTs for the management of patients with fever found substantial reductions in anti-malarial prescriptions when health workers adhered to treatment protocols based on test results. However few studies have reported on the impact of RDTs on health systems outside research settings.MethodsThe study comprised a retrospective interrupted time series analysis, comparing rates of malaria diagnosis, treatment, and resource utilization before and after introduction of RDTs at a peripheral health facility in rural Western Uganda. The use of malaria diagnostic tests was graphically depicted throughout the study period and fit regression models to identify correlates of three outcomes of interest: (1) length of stay (2) the proportion of patients referred to a higher-level health facility, and (3) administration of antibiotics.ResultsOver the course of the study period, 14,357 individuals underwent diagnostic testing for malaria with either a RDT (9,807) or microscopy (4,550). The proportion of patients with parasite-based diagnoses more than tripled to 34 % after the introduction of RDTs. RDTs largely replaced microscopy as the diagnostic method of choice. Compared to patients admitted during the pre-RDT period, patients admitted to the health centre with malaria in the post-RDT period had significantly reduced odds of being referred to another health centre (AOR = 0.49, P = 0.038), receiving antibiotics (AOR = 0.42, P < 0.001), and a significantly shorter mean length of stay (β = −0.32 days, 95 %CI −0.52 to −0.13).ConclusionsThis study is one of the few to demonstrate significant improvement in clinical outcomes and process measures following the introduction of RDTs for the diagnosis of malaria at a rural health facility in Uganda. The results show a reduction in referrals and shorter mean inpatient LOS even as antibiotics were prescribed less frequently. This change greatly increased laboratory throughput and the resultant proportion of patients receiving a parasite-based diagnosis.

Highlights

The World Health Organization recommends that all suspected malaria cases receive a parasitological diagnosis prior to treatment with artemisinin-based combination therapy
The vast majority of malaria episodes occur in rural areas of sub-Saharan Africa, where microscopy is often unavailable and shortages of trained personnel further limit its use as a valid diagnostic method [2,3,4,5,6,7,8,9,10]
A recent Cochrane Review of clinical trials evaluating rapid diagnostic test (RDT) for the management of patients with fever found substantial reductions in anti-malarial prescriptions when health workers adhered to treatment protocols based on test results [12]

Summary

Introduction

The World Health Organization recommends that all suspected malaria cases receive a parasitological diagnosis prior to treatment with artemisinin-based combination therapy. A recent meta-analysis of clinical trials evaluating RDTs for the management of patients with fever found substantial reductions in anti-malarial prescriptions when health workers adhered to treatment protocols based on test results. Since 2010, the World Health Organization (WHO) has recommended that all suspected malaria cases receive a parasitological diagnosis, either by microscopy or a rapid diagnostic test (RDT), prior to treatment with artemisinin-based combination therapy (ACT) [1]. A recent Cochrane Review of clinical trials evaluating RDTs for the management of patients with fever found substantial reductions in anti-malarial prescriptions when health workers adhered to treatment protocols based on test results [12]. The authors concluded that while the introduction of RDTs did not clearly improve health outcomes, adherence to the test result did not seem to result in worse outcomes than presumptive treatment strategies

Methods

Results

Conclusion