The impact of response to the results of diagnostic tests for malaria: cost-benefit analysis

doi:10.1136/bmj.39395.696065.47

BMJ, doi: 10.1136/bmj.39395.696065.47, (Published 16 January 2008)

Research

The impact of response to the results of diagnostic tests for malaria: cost-benefit analysis

Yoel Lubell, health economist¹, Hugh Reyburn, clinical senior lecturer², Hilda Mbakilwa, clinical officer³, Rose Mwangi, social scientist³, Semkini Chonya, data manager³, Christopher J M Whitty, professor of international health², Anne Mills, professor of health economics¹

¹ Health Economics and Financing Programme, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT, ² Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, ³ Joint Malaria Programme, Kilimanjaro Christian Medical Centre, PO Box 2228, Moshi, Tanzania

Correspondence to: Y Lubell yoel.lubell{at}lshtm.ac.uk

Objective Rapid diagnostic tests for malaria seem cost effectivein standard analyses, but these do not take account of clinicians’response to test results. This study tested the impact of clinicians’response to rapid diagnostic test or microscopy results on thecosts and benefits of testing at different levels of malariatransmission and in different age groups.

Design Cost-benefit analysis using a decision tree model andclinical data on the effectiveness of diagnostic tests for malaria,their costs, and clinicians’ response to test results.

Setting Tanzania.

Methods Data were obtained from a clinical trial of 2425 patientscarried out in three settings of varying transmission.

Results At moderate and low levels of malaria transmission,rapid diagnostic tests were more cost beneficial than microscopy,and both more so than presumptive treatment, but only whereresponse was consistent with test results. At the levels ofprescription of antimalarial drugs to patients with negativetests that have been found in observational studies and trials,neither test methodis likely to be cost beneficial, incurringcosts 10-250% higher, depending on transmission rate, than wouldhave been the case with fully consistent responses to all testresults. Microscopy becomes more cost beneficial than rapiddiagnostic tests when its sensitivity under operational conditionsapproaches that of rapid diagnostic tests.

Conclusions Improving diagnostic methods, including rapid diagnostictests, can reduce costs and enhance the benefits of effectiveantimalarial drugs, but only if the consistency of responseto test results is also improved. Investing in methods to improverational response to tests is essential. Economic evaluationsof diagnostic tests should take into account whether clinicians’response is consistent with test results.

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