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Tolley A, Bansal A, Murerwa R, Howard Dicks J. Cost-effectiveness of point-of-care diagnostics for AMR: a systematic review. J Antimicrob Chemother 2024; 79:1248-1269. [PMID: 38498622 PMCID: PMC11144491 DOI: 10.1093/jac/dkae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 02/19/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a major threat to global health. By 2050, it is forecast that AMR will cause 10 million deaths and cost 100 trillion USD annually. Point-of-care tests (POCTs) may represent a cost-effective approach to reduce AMR. OBJECTIVES We systematically reviewed which POCTs addressing AMR have undergone economic evaluation in primary and secondary healthcare globally, how these POCTs have been economically evaluated, and which are cost-effective in reducing antimicrobial prescribing or the burden of AMR. Clinical cost-effectiveness was additionally addressed. METHODS This systematic review, accordant with PRISMA guidelines, was pre-registered on PROSPERO (CRD42022315192). MEDLINE, PubMed, Embase, Cochrane Library, and Google Scholar were searched from 2000 to 2023 for relevant publications. Quality assessment was performed using the Consensus of Health Economic Criteria. RESULTS The search strategy identified 1421 studies, of which 20 met the inclusion criteria. The most common POCTs assessed were for respiratory infections (n = 10), STIs (n = 3), and febrile patients in low- and middle-income countries (n = 3). All studies assessed costs from a healthcare provider perspective; five additionally considered the societal cost of AMR.Eighteen studies identified POCT strategies that reduced antimicrobial prescribing. Of these, 10 identified POCTs that would be considered cost-effective at a willingness-to-pay (WTP) threshold of £33.80 per antibiotic prescription avoided. Most POCT strategies improved clinical outcomes (n = 14); the remainder were clinically neutral. CONCLUSIONS There is evidence that some POCTs are cost-effective in reducing antimicrobial prescribing, with potential concomitant clinical benefits. Such interventions-especially CRP POCTs in both high- and low-income settings-merit further, large-scale clinical evaluation.
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Affiliation(s)
- Abraham Tolley
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Akhil Bansal
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Internal Medicine, St Vincent’s Hospital, Sydney, Australia
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Roope LSJ, Morrell L, Buchanan J, Ledda A, Adler AI, Jit M, Walker AS, Pouwels KB, Robotham JV, Wordsworth S. Overcoming challenges in the economic evaluation of interventions to optimise antibiotic use. COMMUNICATIONS MEDICINE 2024; 4:101. [PMID: 38796507 PMCID: PMC11127962 DOI: 10.1038/s43856-024-00516-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 05/02/2024] [Indexed: 05/28/2024] Open
Abstract
Bacteria are becoming increasingly resistant to antibiotics, reducing our ability to treat infections and threatening to undermine modern health care. Optimising antibiotic use is a key element in tackling the problem. Traditional economic evaluation methods do not capture many of the benefits from improved antibiotic use and the potential impact on resistance. Not capturing these benefits is a major obstacle to optimising antibiotic use, as it fails to incentivise the development and use of interventions to optimise the use of antibiotics and preserve their effectiveness (stewardship interventions). Estimates of the benefits of improving antibiotic use involve considerable uncertainty as they depend on the evolution of resistance and associated health outcomes and costs. Here we discuss how economic evaluation methods might be adapted, in the face of such uncertainties. We propose a threshold-based approach that estimates the minimum resistance-related costs that would need to be averted by an intervention to make it cost-effective. If it is probable that without the intervention costs will exceed the threshold then the intervention should be deemed cost-effective.
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Affiliation(s)
- Laurence S J Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK.
| | - Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Alice Ledda
- AMR Modelling and Evaluation, UK Health Security Agency, London, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Amanda I Adler
- Diabetes Trial Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK
| | - Mark Jit
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - A Sarah Walker
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Julie V Robotham
- AMR Modelling and Evaluation, UK Health Security Agency, London, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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3
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BALASUBRAMANIAN R, SHEARER K, MUDZENGI D, HIPPNER P, GOLUB JE, CHIHOTA V, HOFFMANN CJ, KENDALL EA. Modeling the impact of universal tuberculosis molecular testing and timing of tuberculosis preventive treatment during antiretroviral therapy initiation in South Africa. AIDS 2023; 37:2371-2379. [PMID: 37650763 PMCID: PMC10782927 DOI: 10.1097/qad.0000000000003707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
OBJECTIVES Targeted universal tuberculosis (TB) testing can improve TB detection among people with HIV. This approach is being scaled up in South Africa through Xpert MTB/RIF Ultra testing for individuals starting antiretroviral therapy and annually thereafter. Clarity is needed on how Universal Xpert testing may affect TB preventive treatment (TPT) provision, and on whether TPT should be delayed until TB is ruled out. DESIGN State-transition microsimulation. METHODS We simulated a cohort of South African patients being screened for TB while entering HIV care. We compared clinical and cost outcomes between four TB screening algorithms: symptom-based, C-reactive protein-based, and Universal Xpert testing with either simultaneous or delayed TPT initiation. RESULTS Prompt TB treatment initiation among simulated patients with TB increased from 26% (24-28%) under symptom screening to 53% (50-56%) with Universal Xpert testing. Universal Xpert testing led to increased TPT uptake when TPT initiation was simultaneous, but to approximately 50% lower TPT uptake if TPT was delayed. Universal Xpert with simultaneous TPT prevented incident TB compared to either symptom screening (median 17 cases averted per 5000 patients) or Universal Xpert with delayed TPT (median 23 averted). Universal Xpert with Simultaneous TPT cost approximately $39 per incremental TPT course compared to Universal Xpert with delayed TPT. CONCLUSIONS Universal Xpert testing can promote timely treatment for newly diagnosed people with HIV who have active TB. Pairing universal testing with immediate TPT will improve the promptness, uptake, and preventive effects of TPT. Simultaneous improvements to TB care cascades are needed to maximize impact.
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Affiliation(s)
| | - Kate SHEARER
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Jonathan E. GOLUB
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Violet CHIHOTA
- Aurum Institute, Johannesburg, South Africa
- University of Witwatersrand, Johannesburg, South Africa
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University, Nashville, USA
| | - Christopher J HOFFMANN
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily A KENDALL
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ngwengi Y, Ngaba GP, Nida M, Enyama D. Evaluation of CRP as a marker for bacterial infection and malaria in febrile children at the Douala Gyneco-Obstetric and Pediatric Hospital. PLoS One 2023; 18:e0289012. [PMID: 37478118 PMCID: PMC10361518 DOI: 10.1371/journal.pone.0289012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 07/09/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND C reactive protein (CRP), a marker for the presence of inflammation, has been extensively studied for distinguishing bacterial from non-bacterial infection in febrile patients, but its role in excluding malaria in the febrile child has not been thoroughly evaluated. METHOD This was a cross-sectional study at the Douala Gyneco-Obstetric and Pediatric Hospital which included all patients between the ages of one month and 16 years presenting with fever. Consenting patients received complete clinical examinations, then venous blood samples were collected and tested for CRP values, bacterial infection and malaria. RESULTS Samples of 220 children were analyzed. 142/220 had viral infections, 50/220 had malaria and 49/220 had bacterial infections. 7/220 had both malaria and bacterial infection. There was no significant difference between mean CRP values in malaria and bacterial infection (p = 1), but CRP means were significantly higher in malaria/bacterial infection than in viral infection (p<0.0001). Area Under the Receiver Operating Characteristics Curve (AUROC) values were 0.94 for malaria and 0.86 for bacterial infection, with a calculated cut-off of 23.6mg/L for malaria and 36.2mg/L for bacterial infection. At these cut-offs, CRP had a Positive Predictive Value (PPV) of 68.75% and 85.00% for malaria and bacterial infection respectively, with a Negative Predictive Value (NPV) of 94.74% and 89.05% respectively. CONCLUSION CRP can effectively exclude malaria and bacterial infection in febrile children in low-resource settings without the need for additional tests.
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Affiliation(s)
- Yembu Ngwengi
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Littoral, Cameroon
| | - Guy Pascal Ngaba
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Littoral, Cameroon
- Department of Biochemistry, Hematology and Microbiology, Douala Gyneco-Obstetric and Pediatric Hospital, Littoral, Cameroon
| | - Martine Nida
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Littoral, Cameroon
- Department of Infectious Diseases and Dermatology, Douala Gyneco-Obstetric and Pediatric Hospital, Littoral, Cameroon
| | - Dominique Enyama
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, West, Cameroon
- Department of Pediatrics, Douala Gyneco-Obstetric and Pediatric Hospital, Littoral, Cameroon
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Walpole SC, Eii MN, Lyons T, Aldridge C. Improving Antimicrobial Use to Protect the Environment: What Is the Role of Infection Specialists? Antibiotics (Basel) 2023; 12:antibiotics12040640. [PMID: 37107002 PMCID: PMC10134973 DOI: 10.3390/antibiotics12040640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
Anthropogenic environmental changes are causing severe damage to the natural and social systems on which human health depends. The environmental impacts of the manufacture, use, and disposal of antimicrobials cannot be underestimated. This article explores the meaning of environmental sustainability and four sustainability principles (prevention, patient engagement, lean service delivery, and low carbon alternatives) that infection specialists can apply to support environmental sustainability in health systems. To prevent inappropriate use of antimicrobials and consequent antimicrobial resistance (AMR) requires international, national, and local surveillance plans and action supporting antimicrobial stewardship (AMS). Engaging patients in addressing environmental sustainability, for example through public awareness campaigns about the appropriate disposal of unused and expired antimicrobials, could drive environmentally sustainable changes. Streamlining service delivery may include using innovative methods such as C-reactive protein (CRP), procalcitonin (PCT), or genotype-guided point of care testing (POCT) to reduce unnecessary antimicrobial prescribing and risk of adverse effects. Infection specialists can assess and advise on lower carbon alternatives such as choosing oral (PO) over intravenous (IV) antimicrobials where clinically appropriate. By applying sustainability principles, infection specialists can promote the effective use of healthcare resources, improve care quality, protect the environment, and prevent harm to current and future generations.
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Affiliation(s)
- Sarah Catherine Walpole
- Newcastle University, Newcastle upon Tyne NE1 7RU, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
| | - Min Na Eii
- South Tyneside and Sunderland NHS Foundation Trust, Sunderland SR4 7TP, UK
| | - Tracy Lyons
- NHS Dorset Integrated Care Board, Bournemouth BH12 5AG, UK
| | - Catherine Aldridge
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK
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Determinants of the Empiric Use of Antibiotics by General Practitioners in South Africa: Observational, Analytic, Cross-Sectional Study. Antibiotics (Basel) 2022; 11:antibiotics11101423. [PMID: 36290081 PMCID: PMC9598257 DOI: 10.3390/antibiotics11101423] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/30/2022] Open
Abstract
The overuse of antibiotics is the main driver of antimicrobial resistance (AMR). However, there has been limited surveillance data on AMR and antibiotic prescribing at a primary healthcare level in South Africa. An observational, analytic, cross-sectional study was undertaken to assess key factors associated with empiric antibiotic prescribing among private sector general practitioners (GPs) in the eThekwini district in South Africa, particularly for patients with acute respiratory infections (ARIs). A semi-structured web-based questionnaire was used between November 2020−March 2021. One hundred and sixteen (55.5%) responding GPs prescribed antibiotics empirically for patients with ARIs more than 70% of the time, primarily for symptom relief and the prevention of complications. GPs between the ages of 35−44 years (OR: 3.38; 95%CI: 1.15−9.88), >55 years (OR: 4.75; 95% CI 1.08−21) and in practice < 15 years (OR: 2.20; 95%CI: 1.08−4.51) were significantly more likely to prescribe antibiotics empirically. Three factors—workload/time pressures; diagnostic uncertainty, and the use of a formulary, were significantly associated with empiric prescribing. GPs with more experience and working alone were slightly less likely to prescribe antibiotics empirically. These findings indicate that a combination of environmental factors are important underlying contributors to the development of AMR. As a result, guide appropriate interventions using a health system approach, which includes pertinent prescribing indicators and targets.
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Vicentini C, Vola L, Previti C, Brescia V, Dal Mas F, Zotti CM, Bert F. Antimicrobial Stewardship Strategies Including Point-of-Care Testing (POCT) for Pediatric Patients with Upper-Respiratory-Tract Infections in Primary Care: A Systematic Review of Economic Evaluations. Antibiotics (Basel) 2022; 11:antibiotics11081139. [PMID: 36010008 PMCID: PMC9404955 DOI: 10.3390/antibiotics11081139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/12/2022] [Accepted: 08/19/2022] [Indexed: 12/02/2022] Open
Abstract
Upper-respiratory-tract infections (URTIs) are among the main causes of antibiotic prescriptions in pediatric patients. Over one-third of all antibiotic prescriptions for URTIs in children are estimated to be inappropriate, as the majority of URTIs are caused by viral agents. Several strategies, including clinical scoring algorithms and different point-of-care tests (POCTs) have been developed to help discriminate bacterial from viral URTIs in the outpatient clinical setting. A systematic review of the literature was conducted following PRISMA guidelines with the objective of summarizing evidence from health–economic evaluations on the use of POCT for URTIs in pediatric outpatients. A total of 3375 records identified from four databases and other sources were screened, of which 8 met the inclusion criteria. Four studies were classified as being of high reporting quality, and three were of medium quality. Five out of eight studies concluded in favor of strategies that included POCTs, with an additional study finding several POCTs to be cost-effective compared to usual care but over an acceptable WTP threshold. This review found POCT could be a valuable tool for antimicrobial stewardship strategies targeted towards childhood URTIs in primary care.
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Affiliation(s)
- Costanza Vicentini
- Department of Public Health Sciences and Pediatrics, University of Turin, 10126 Turin, Italy
| | - Lorenzo Vola
- Department of Public Health Sciences and Pediatrics, University of Turin, 10126 Turin, Italy
| | - Christian Previti
- Department of Public Health Sciences and Pediatrics, University of Turin, 10126 Turin, Italy
- Correspondence: ; Tel.: +39-011-670-5830; Fax: +39-011-670-5889
| | - Valerio Brescia
- Department of Management, University of Turin, 10126 Turin, Italy
| | - Francesca Dal Mas
- Department of Management, Ca’ Foscari University of Venice, Cannaregio, 873, 30100 Venice, Italy
| | - Carla Maria Zotti
- Department of Public Health Sciences and Pediatrics, University of Turin, 10126 Turin, Italy
| | - Fabrizio Bert
- Department of Public Health Sciences and Pediatrics, University of Turin, 10126 Turin, Italy
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8
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Wubishet BL, Merlo G, Ghahreman-Falconer N, Hall L, Comans T. Economic evaluation of antimicrobial stewardship in primary care: a systematic review and quality assessment. J Antimicrob Chemother 2022; 77:2373-2388. [PMID: 35724206 PMCID: PMC9410674 DOI: 10.1093/jac/dkac185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/02/2022] [Indexed: 11/28/2022] Open
Abstract
Background Primary care accounts for 80%–90% of antimicrobial prescriptions, making this setting an important focus for antimicrobial stewardship (AMS) interventions. Objectives To collate the findings and critically appraise the qualities of economic evaluation studies of AMS or related interventions aimed at reducing inappropriate antimicrobial prescribing in primary care. Methods A systematic review of economic evaluations of interventions aimed at reducing inappropriate antimicrobial prescribing in primary care was performed. Published literature were retrieved through a search of Medline, Embase, EconLit and Web of Science databases for the period 2010 to 2020. The quality of the studies was assessed using the Consensus on Health Economic Criteria checklist and Good Practice Guidelines for Decision-Analytic Modelling in Health Technology Assessment. Results Of the 2722 records identified, 12 studies were included in the review (8 trial-based and 4 modelled evaluations). The most common AMS interventions were communication skills training for health professionals and C-reactive protein point-of-care testing (CRP-POCT). Types of economic evaluations included in the review were cost-effectiveness (7 studies), cost-utility (1), cost-benefit (2), cost-effectiveness and cost-utility (1) and cost analysis (1). While six of the studies found AMS interventions to be cost-effective, the other six reported them as not cost-effective or inconclusive. The quality of the studies ranged from good to low. Conclusions There were significant variations in cost-effectiveness of AMS interventions across studies and depending on the inclusion of cost components such as the cost of antimicrobial resistance. However, communication skills training and CRP-POCT were frequently cost-effective or cost-beneficial for reducing inappropriate antimicrobial prescribing.
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Affiliation(s)
- Befikadu L Wubishet
- Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, 4072, Australia
| | - Gregory Merlo
- Primary Care Clinical Unit, The University of Queensland, Brisbane, Queensland, 4072, Australia
| | - Nazanin Ghahreman-Falconer
- Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, 4072, Australia.,Princess Alexandra Hospital, Metro South Health, Woolloongabba, Queensland, 4072, Australia.,School of Pharmacy, The University of Queensland, Brisbane, Queensland, 4072, Australia
| | - Lisa Hall
- School of Public Health, The University of Queensland, Brisbane, Queensland, 4072, Australia
| | - Tracy Comans
- Centre for Health Services Research, The University of Queensland, Brisbane, Queensland, 4072, Australia
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Janssen J, Afari-Asiedu S, Monnier A, Abdulai MA, Tawiah T, Wertheim H, Baltussen R, Asante KP. Exploring the economic impact of inappropriate antibiotic use: the case of upper respiratory tract infections in Ghana. Antimicrob Resist Infect Control 2022; 11:53. [PMID: 35365210 PMCID: PMC8973739 DOI: 10.1186/s13756-022-01096-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/17/2022] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Antibiotic consumption is increasing worldwide, particularly in low and middle-income countries (LMICs). Access to lifesaving antibiotics in LMICs is crucial while minimising inappropriate use. Studies assessing the economic impact of inappropriate antibiotic use in LMICs are lacking. We explored the economic impact of inappropriate antibiotic use using the example of upper respiratory tract infections (URIs) in Ghana, as part of the ABACUS (AntiBiotic ACcess and USe) project. METHODS A top-down, retrospective economic impact analysis of inappropriate antibiotic use for URIs was conducted. Two inappropriate antibiotic use situations were considered: (1) URIs treated with antibiotics, against recommendations from clinical guidelines; and (2) URIs that should have been treated with antibiotics according to clinical guidelines, but were not. The analysis included data collected in Ghana during the ABACUS project (household surveys and exit-interviews among consumers buying antibiotics), scientific literature and stakeholder consultations. Included cost types related to health care seeking behaviour for URIs. Additionally, cost saving projections were computed based on potential effects of future interventions that improve antibiotic use. RESULTS Health care costs related to inappropriate antibiotic use for URIs were estimated to be around 20 million (M) USD annually, including 18 M USD for situation 1 and 2 M USD for situation 2. Travel costs and lost income due to travel, together, were estimated to be around 44 M USD for situation 1 and 18 M USD for situation 2. Possible health care cost savings range from 2 to 12 M USD for situation 1 and from 0.2 to 1 M USD for situation 2. CONCLUSIONS This study indicates that inappropriate antibiotic use leads to substantial economic costs in a LMIC setting that could have been prevented. We recommend investment in novel strategies to counter these unnecessary expenditures. As the projections indicate, this may result in considerable cost reductions. By tackling inappropriate use, progress can be made in combatting antibiotic resistance.
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Affiliation(s)
- Jip Janssen
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Samuel Afari-Asiedu
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Kintampo North Municipality, Bono East Region, Ghana
| | - Annelie Monnier
- Department of Medical Microbiology, Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Martha Ali Abdulai
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Kintampo North Municipality, Bono East Region, Ghana
| | - Theresa Tawiah
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Kintampo North Municipality, Bono East Region, Ghana
| | - Heiman Wertheim
- Department of Medical Microbiology, Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Rob Baltussen
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Kwaku Poku Asante
- Kintampo Health Research Centre, Research and Development Division, Ghana Health Service, Kintampo North Municipality, Bono East Region, Ghana
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10
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Dickinson S, Yi Chong H, Leslie T, Rowland M, Schultz Hansen K, Boyers D. Cost-effectiveness of point-of-care C-Reactive Protein test compared to current clinical practice as an intervention to improve antibiotic prescription in malaria-negative patients in Afghanistan. PLoS One 2021; 16:e0258299. [PMID: 34748558 PMCID: PMC8575266 DOI: 10.1371/journal.pone.0258299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 09/17/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a global health problem requiring a reduction in inappropriate antibiotic prescribing. Point-of-Care C-Reactive Protein (POCCRP) tests could distinguish between bacterial and non-bacterial causes of fever in malaria-negative patients and thus reduce inappropriate antibiotic prescribing. However, the cost-effectiveness of POCCRP testing is unclear in low-income settings. METHODS A decision tree model was used to estimate cost-effectiveness of POCCRP versus current clinical practice at primary healthcare facilities in Afghanistan. Data were analysed from healthcare delivery and societal perspectives. Costs were reported in 2019 USD. Effectiveness was measured as correctly treated febrile malaria-negative patient. Cost, effectiveness and diagnostic accuracy parameters were obtained from primary data from a cost-effectiveness study on malaria rapid diagnostic tests in Afghanistan and supplemented with POCCRP-specific data sourced from the literature. Incremental cost-effectiveness ratios (ICERs) reported the additional cost per additional correctly treated febrile malaria-negative patient over a 28-day time horizon. Univariate and probabilistic sensitivity analyses examined the impact of uncertainty of parameter inputs. Scenario analysis included economic cost of AMR per antibiotic prescription. RESULTS The model predicts that POCCRP intervention would result in 137 fewer antibiotic prescriptions (6%) with a 12% reduction (279 prescriptions) in inappropriate prescriptions compared to current clinical practice. ICERs were $14.33 (healthcare delivery), $11.40 (societal), and $9.78 (scenario analysis) per additional correctly treated case. CONCLUSIONS POCCRP tests could improve antibiotic prescribing among malaria-negative patients in Afghanistan. Cost-effectiveness depends in part on willingness to pay for reductions in inappropriate antibiotic prescribing that will only have modest impact on immediate clinical outcomes but may have long-term benefits in reducing overuse of antibiotics. A reduction in the overuse of antibiotics is needed and POCCRP tests may add to other interventions in achieving this aim. Assessment of willingness to pay among policy makers and donors and undertaking operational trials will help determine cost-effectiveness and assist decision making.
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Affiliation(s)
- Simon Dickinson
- Mott MacDonald Ltd, London, United Kingdom
- Health Economics Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Huey Yi Chong
- Health Economics Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | | | - Mark Rowland
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, United Kingdom
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11
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Lam TT, Dang DA, Tran HH, Do DV, Le H, Negin J, Jan S, Marks GB, Nguyen TA, Fox GJ, Beardsley J. What are the most effective community-based antimicrobial stewardship interventions in low- and middle-income countries? A narrative review. J Antimicrob Chemother 2021; 76:1117-1129. [PMID: 33491090 DOI: 10.1093/jac/dkaa556] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Antimicrobial resistance (AMR) is a major global issue and antimicrobial stewardship is central to tackling its emergence. The burden of AMR disproportionately impacts low- and middle-income countries (LMICs), where capacity for surveillance and management of resistant pathogens is least developed. Poorly regulated antibiotic consumption in the community is a major driver of AMR, especially in LMICs, yet community-based interventions are neglected in stewardship research, which is often undertaken in high-income settings and/or in hospitals. We reviewed the evidence available to researchers and policymakers testing or implementing community-based antimicrobial stewardship strategies in LMICs. We critically appraise that evidence, deliver recommendations and identify outstanding areas of research need. We find that multifaceted, education-focused interventions are likely most effective in our setting. We also confirm that the quality and quantity of community-based stewardship intervention research is limited, with research on microbiological, clinical and economic sustainability most urgently needed.
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Affiliation(s)
- Thanh Tuan Lam
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam
| | - Duc Anh Dang
- National Institute of Hygiene and Epidemiology, Hai Ba Trung, Hanoi, Vietnam
| | - Huy Hoang Tran
- National Institute of Hygiene and Epidemiology, Hai Ba Trung, Hanoi, Vietnam
| | - Dung Van Do
- The University of Medicine and Pharmacy, Hong Bang, Q5, Ho Chi Minh City, Vietnam
| | - Hien Le
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam
| | - Joel Negin
- The Sydney School of Public Health, University of Sydney, NSW 2006, Australia
| | - Stephen Jan
- The George Institute for Global Health, Sydney, NSW 2042, Australia
| | - Guy B Marks
- The University of New South Wales, Sydney, NSW 2052, Australia
| | - Thu Anh Nguyen
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam.,The Central Clinical School, The Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Greg J Fox
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam.,The Central Clinical School, The Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Justin Beardsley
- The Marie Bashir Institute, Westmead Institute for Medical Research, The University of Sydney, NSW 2145, Australia.,Oxford University Clinical Research Unit, Vo Van Kiet, Q5, Ho Chi Minh City, Vietnam
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Escadafal C, Incardona S, Fernandez-Carballo BL, Dittrich S. The good and the bad: using C reactive protein to distinguish bacterial from non-bacterial infection among febrile patients in low-resource settings. BMJ Glob Health 2021; 5:bmjgh-2020-002396. [PMID: 32467355 PMCID: PMC7259834 DOI: 10.1136/bmjgh-2020-002396] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 12/29/2022] Open
Abstract
C reactive protein (CRP), a marker for the presence of an inflammatory process, is the most extensively studied marker for distinguishing bacterial from non-bacterial infections in febrile patients. A point-of-care test for bacterial infections would be of particular use in low-resource settings where other laboratory diagnostics are not always available, antimicrobial resistance rates are high and bacterial infections such as pneumonia are a leading cause of death. This document summarises evidence on CRP testing for bacterial infections in low-income and middle-income countries (LMICs). With a push for universal health coverage and prevention of antimicrobial resistance, it is important to understand if CRP might be able to do the job. The use of CRP polarised the global health community and the aim of this document is to summarise the ‘good and the bad’ of CRP in multiple settings in LMICs. In brief, the literature that was reviewed suggests that CRP testing may be beneficial in low-resource settings to improve rational antibiotic use for febrile patients, but the positive predictive value is insufficient to allow it to be used alone as a single tool. CRP testing may be best used as part of a panel of diagnostic tests and algorithms. Further studies in low-resource settings, particularly with regard to impact on antibiotic prescribing and cost-effectiveness of CRP testing, are warranted.
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Affiliation(s)
- Camille Escadafal
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Sandra Incardona
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | | | - Sabine Dittrich
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland .,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Lingervelder D, Koffijberg H, Kusters R, IJzerman MJ. Health Economic Evidence of Point-of-Care Testing: A Systematic Review. PHARMACOECONOMICS - OPEN 2021; 5:157-173. [PMID: 33405188 PMCID: PMC8160040 DOI: 10.1007/s41669-020-00248-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/12/2020] [Indexed: 05/05/2023]
Abstract
OBJECTIVE Point-of-care testing (POCT) has become an essential diagnostic technology for optimal patient care. Its implementation, however, still falls behind. This paper reviews the available evidence on the health economic impact of introducing POCT to assess if poor POCT uptake may be related to lacking evidence. STUDY DESIGN The Scopus and PubMed databases were searched to identify publications describing a health economic evaluation of a point-of-care (POC) test. Data were extracted from the included publications, including general and methodological characteristics as well as the study results summarized in either cost, effects or an incremental cost-effectiveness ratio. Results were sorted into six groups according to the POC test's purpose (diagnosis, screening or monitoring) and care setting (primary care or secondary care). The reporting quality of the publications was determined using the CHEERS checklist. RESULTS The initial search resulted in 396 publications, of which 44 met the inclusion criteria. Most of the evaluations were performed in a primary care setting (n = 31; 70.5%) compared with a secondary care setting (n = 13; 29.5%). About two thirds of the evaluations were on POC tests implemented with a diagnostic purpose (n = 28; 63.6%). More than 75% of evaluations concluded that POCT is recommended for implementation, although in some cases only under specific circumstances and conditions. Compliance with the CHEERS checklist items ranged from 20.8% to 100%, with an average reporting quality of 72.0%. CONCLUSION There were very few evaluations in this review that advised against the implementation of POCT. However, the uptake of POCT in many countries remains low. Even though the evaluations included in this review did not always include the full long-term benefits of POCT, it is clear that health economic evidence across a few dimensions of value already indicate the benefits of POCT. This suggests that the lack of evidence on POCT is not the primary barrier to its implementation and that the low uptake of these tests in clinical practice is due to (a combination of) other barriers. In this context, aspects around organization of care, support of clinicians and quality management may be crucial in the widespread implementation of POCT.
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Affiliation(s)
- Deon Lingervelder
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, 7500 AE, The Netherlands
| | - Hendrik Koffijberg
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, 7500 AE, The Netherlands
| | - Ron Kusters
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, 7500 AE, The Netherlands
- Laboratory for Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Maarten J IJzerman
- Health Technology and Services Research Department, Technical Medical Centre, University of Twente, P.O. Box 217, Enschede, 7500 AE, The Netherlands.
- Cancer Health Services Research Unit, School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.
- Victorian Comprehensive Cancer Centre, Melbourne, Australia.
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14
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Holloway B, Mathur A, Pathak A, Bergström A. Utilisation of diagnostics in India: a rapid ethnographic study exploring context and behaviour. BMJ Open 2020; 10:e041087. [PMID: 33243808 PMCID: PMC7692986 DOI: 10.1136/bmjopen-2020-041087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/21/2020] [Accepted: 11/08/2020] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To explore factors that influence behaviour in the utilisation of diagnostics by caregivers of sick children. Utilisation is defined as a caregiver assisting a child to get diagnostic tests done and return for follow-up of results. Understanding these experiences may help inform the development of interventions and implementation strategies to improve the use of diagnostics, thereby target treatment and optimise antibiotic use. DESIGN A rapid ethnographic qualitative study using 3 months of unstructured observations, 1 month of structured observations of diagnostic utilisation and 43 semi-structured interviews. Transcripts were coded and analysed using inductive thematic analysis. Findings were explored from a behavioural perspective through the lens of the 'Capability, Opportunity, Motivation and Behaviour' (COM-B) model for understanding behaviour. The multiple methods of investigation applied allowed for triangulation and cross-validation of the findings. SETTING The paediatric outpatient department of a teaching hospital in rural, central India. PARTICIPANTS Caregivers of sick children attending the paediatric outpatient department who were sent for one or more diagnostic test. RESULTS Three key themes were identified that influenced caregivers' behaviour. Caregivers trusted and understood the importance of diagnostics but their acceptance wavered depending on the severity of illness and preference to treat their child directly with medicines. Caregivers struggled to access diagnostics, describing delays in testing, receiving results and follow-up, further complicated by travel time, distance and competing priorities such as work. Diagnostics were relatively cheap compared with other healthcare facilities however, the cost of the test, travel expenses and wages lost for missing work, were barriers to getting the tests done and returning for follow-up. CONCLUSIONS Diagnostics are generally accepted and their purpose understood, however, the organisation of diagnostic services, direct and indirect costs hinder caregivers from using diagnostics. Improvements in accessibility and affordability may increase caregiver motivation to use diagnostics and return for follow-up.
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Affiliation(s)
- Bronwen Holloway
- Department of Womens and Childrens Health, Uppsala Global Health Research on Implementation and Sustainability, Uppsala University, Uppsala, Sweden
| | - Aditya Mathur
- Department of Pediatrics, Ruxmaniben Deepchand Gardi Medical College, Ujjain, India
| | - Ashish Pathak
- Department of Pediatrics, Ruxmaniben Deepchand Gardi Medical College, Ujjain, India
- Department of Global Public Health, Health Systems and Policy: Medicines, Focusing Antibiotics, Karolinska Institutet, Stockholm, Sweden
| | - Anna Bergström
- Department of Womens and Childrens Health, Uppsala Global Health Research on Implementation and Sustainability, Uppsala University, Uppsala, Sweden
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15
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Martínez-González NA, Keizer E, Plate A, Coenen S, Valeri F, Verbakel JYJ, Rosemann T, Neuner-Jehle S, Senn O. Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials. Antibiotics (Basel) 2020; 9:antibiotics9090610. [PMID: 32948060 PMCID: PMC7559694 DOI: 10.3390/antibiotics9090610] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 11/16/2022] Open
Abstract
C-reactive protein (CRP) point-of-care testing (POCT) is increasingly being promoted to reduce diagnostic uncertainty and enhance antibiotic stewardship. In primary care, respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing, which is a major driver for antibiotic resistance. We systematically reviewed the available evidence on the impact of CRP-POCT on antibiotic prescribing for RTIs in primary care. Thirteen moderate to high-quality studies comprising 9844 participants met our inclusion criteria. Meta-analyses showed that CRP-POCT significantly reduced immediate antibiotic prescribing at the index consultation compared with usual care (RR 0.79, 95%CI 0.70 to 0.90, p = 0.0003, I2 = 76%) but not during 28-day (n = 7) follow-up. The immediate effect was sustained at 12 months (n = 1). In children, CRP-POCT reduced antibiotic prescribing when CRP (cut-off) guidance was provided (n = 2). Meta-analyses showed significantly higher rates of re-consultation within 30 days (n = 8, 1 significant). Clinical recovery, resolution of symptoms, and hospital admissions were not significantly different between CRP-POCT and usual care. CRP-POCT can reduce immediate antibiotic prescribing for RTIs in primary care (number needed to (NNT) for benefit = 8) at the expense of increased re-consultations (NNT for harm = 27). The increase in re-consultations and longer-term effects of CRP-POCT need further evaluation. Overall, the benefits of CRP-POCT outweigh the potential harms (NNTnet = 11).
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Affiliation(s)
- Nahara Anani Martínez-González
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, PO Box 4466, CH-6002 Lucerne, Switzerland
- Correspondence:
| | - Ellen Keizer
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Samuel Coenen
- Centre for General Practice, Department of Family Medicine & Population Health (FAMPOP), University of Antwerp-Campus Drie Eiken, Doornstraat 331, 2610 Antwerp (Wilrijk), Belgium;
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp-Campus Drie Eiken, Universiteitsplein 1, 2610 Antwerp (Wilrijk), Belgium
| | - Fabio Valeri
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Jan Yvan Jos Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven (University of Leuven), Kapucijnenvoer 33, 3000 Leuven, Belgium;
- Nuffield Department of Primary Care Health Sciences, NIHR Community Healthcare MIC, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (E.K.); (A.P.); (F.V.); (T.R.); (S.N.-J.); (O.S.)
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17
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Tillekeratne LG, Bodinayake C, Nagahawatte A, Kurukulasooriya R, Orlando LA, Simmons RA, Park LP, Woods CW, Reed SD. Use of clinical algorithms and rapid influenza testing to manage influenza-like illness: a cost-effectiveness analysis in Sri Lanka. BMJ Glob Health 2019; 4:e001291. [PMID: 30997171 PMCID: PMC6441298 DOI: 10.1136/bmjgh-2018-001291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/02/2019] [Accepted: 03/09/2019] [Indexed: 01/21/2023] Open
Abstract
Background Acute respiratory infections are a common reason for antibiotic overuse. We previously showed that providing Sri Lankan clinicians with positive rapid influenza test results was associated with a reduction in antibiotic prescriptions. The economic impact of influenza diagnostic strategies is unknown. Methods We estimated the incremental cost per antibiotic prescription avoided with three diagnostic strategies versus standard care when managing Sri Lankan outpatients with influenza-like illness (ILI): (1) influenza clinical prediction tool, (2) targeted rapid influenza testing and (3) universal rapid influenza testing. We compared findings with literature-based estimates of the cost of antimicrobial resistance attributable to each antibiotic prescription. Results Standard care was less expensive than other strategies across all parameter values in one-way sensitivity analyses. The incremental cost per antibiotic prescription avoided with clinical prediction versus standard care was US$3.0, which was lower than the base-case estimate of the cost of antimicrobial resistance per ILI antibiotic prescription (US$12.5). The incremental cost per antibiotic prescription avoided with targeted testing and universal testing versus standard care were both higher than the base-case cost of antimicrobial resistance per ILI antibiotic prescription: US$49.1 and US$138.3, respectively. To obtain a cost-effectiveness ratio lower than US$12.5 with targeted testing versus standard care, the test price must be <US$2.6. At a higher threshold of US$28.7, the test price must be <US$7.7. Conclusion Clinical prediction tools and targeted rapid influenza testing may be cost-saving strategies in Sri Lanka when accounting for the societal cost of antimicrobial resistance.
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Affiliation(s)
- L Gayani Tillekeratne
- School of Medicine, Duke University, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA
| | | | | | | | - Lori A Orlando
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - Ryan A Simmons
- Duke Global Health Institute, Durham, North Carolina, USA
| | - Lawrence P Park
- School of Medicine, Duke University, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA
| | - Christopher W Woods
- School of Medicine, Duke University, Durham, North Carolina, USA.,Duke Global Health Institute, Durham, North Carolina, USA
| | - Shelby D Reed
- School of Medicine, Duke University, Durham, North Carolina, USA
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