Improving prescribing practices with rapid diagnostic tests (RDTs): synthesis of 10 studies to explore reasons for variation in malaria RDT uptake and adherence

Burchett, Helen; Leurent, Baptiste; Baiden, Frank; Baltzell, Kimberly; Björkman, Anders; Bruxvoort, Katia; Clarke, Siân E.; DiLiberto, Deborah; Elfving, Kristina; Goodman, Catherine; Hopkins, Heidi; Lal, Sham; Liverani, Marco; Magnussen, Pascal; Mårtensson, Andreas; Mbacham, Wilfred Fon; Mbonye, Anthony K.; Onwujekwe, Obinna; Allen, Denise Roth; Shakely, Delér; Staedke, Sarah G.; Vestergaard, Lasse S; Whitty, Christopher J. M.; Wiseman, Virginia; Chandler, Clare I R

doi:10.1136/bmjopen-2016-012973

Cited by 47 publications

(50 citation statements)

References 62 publications

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“…To date, research into the reasons for this phenomenon has been limited, although ACT Consortium study results presented elsewhere suggest that provider motivations, stability of ACT supplies and preexisting antimalarial preferences account for some of this underprescription. 39 Missed or ineffective treatment of malaria presents a risk to patients; a balance between reducing unnecessary antimalarial use while ensuring ACTs are provided to all malaria-positive cases needs to be integrated in future research, training, and implementation programs.…”

Section: Discussionmentioning

confidence: 99%

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The Impact of Introducing Malaria Rapid Diagnostic Tests on Fever Case Management: A Synthesis of Ten Studies from the ACT Consortium

Bruxvoort

Leurent

Chandler

et al. 2017

The American Journal of Tropical Medicine and Hygiene

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Abstract.Since 2010, the World Health Organization has been recommending that all suspected cases of malaria be confirmed with parasite-based diagnosis before treatment. These guidelines represent a paradigm shift away from presumptive antimalarial treatment of fever. Malaria rapid diagnostic tests (mRDTs) are central to implementing this policy, intended to target artemisinin-based combination therapies (ACT) to patients with confirmed malaria and to improve management of patients with nonmalarial fevers. The ACT Consortium conducted ten linked studies, eight in sub-Saharan Africa and two in Afghanistan, to evaluate the impact of mRDT introduction on case management across settings that vary in malaria endemicity and healthcare provider type. This synthesis includes 562,368 outpatient encounters (study size range 2,400–432,513). mRDTs were associated with significantly lower ACT prescription (range 8–69% versus 20–100%). Prescribing did not always adhere to malaria test results; in several settings, ACTs were prescribed to more than 30% of test-negative patients or to fewer than 80% of test-positive patients. Either an antimalarial or an antibiotic was prescribed for more than 75% of patients across most settings; lower antimalarial prescription for malaria test-negative patients was partly offset by higher antibiotic prescription. Symptomatic management with antipyretics alone was prescribed for fewer than 25% of patients across all scenarios. In community health worker and private retailer settings, mRDTs increased referral of patients to other providers. This synthesis provides an overview of shifts in case management that may be expected with mRDT introduction and highlights areas of focus to improve design and implementation of future case management programs.

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Section: Discussionmentioning

confidence: 99%

“…Factors which may explain variations in mRDT use are examined with additional qualitative data sources elsewhere. 39 …”

Section: Methodsmentioning

confidence: 99%

The Impact of Introducing Malaria Rapid Diagnostic Tests on Fever Case Management: A Synthesis of Ten Studies from the ACT Consortium

Bruxvoort

Leurent

Chandler

et al. 2017

The American Journal of Tropical Medicine and Hygiene

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“…ACT Consortium studies were designed collaboratively to form a multifaceted investigation of the impact of interventions to improve the use of ACT antimalarials. This analysis examines in more detail data on patients in ACT Consortium study areas in Africa who tested positive for malaria by mRDT but who were not prescribed ACT antimalarials [18,19]. The primary studies were designed to measure the impact of mRDT implementation on fever case management across a variety of settings.…”

Section: Studies Included In the Analysismentioning

confidence: 99%

“…Uga2 and Uga3 included availability of rectal artesunate (an artemisinin monotherapy) as a pre-referral treatment; for the purposes of this analysis, patients who received this treatment were dropped (n = 22 for Uga2, and n = 45 for Uga3). Detailed descriptions of the specific interventions are included in individual study reports, and an overview is presented in Burchett et al [19].…”

Section: Outcome Descriptionmentioning

confidence: 99%

“…Relatively little is known about what might contribute to underprescription for test-positive patients. This paper presents an analysis of ACT Consortium data, focusing specifically on this potentially dangerous phenomenon which was previously identified across multiple settings [18,19]. We aim to help define the potential scale of under-prescription and to identify factors associated with ACT non-prescription.…”

Section: Introductionmentioning

confidence: 99%

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Patients with positive malaria tests not given artemisinin-based combination therapies: a research synthesis describing under-prescription of antimalarial medicines in Africa

O’Boyle

Bruxvoort

Ansah

et al. 2020

BMC Med

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Background: There has been a successful push towards parasitological diagnosis of malaria in Africa, mainly with rapid diagnostic tests (mRDTs), which has reduced over-prescribing of artemisinin-based combination therapies (ACT) to malaria test-negative patients. The effect on prescribing for test-positive patients has received much less attention. Malaria infection in endemic Africa is often most dangerous for young children and those in low-transmission settings. This study examined non-prescription of antimalarials for patients with malaria infection demonstrated by positive mRDT results, and in particular these groups who are most vulnerable to poor outcomes if antimalarials are not given. Methods: Analysis of data from 562,762 patients in 8 studies co-designed as part of the ACT Consortium, conducted 2007-2013 in children and adults, in Cameroon, Ghana, Nigeria, Tanzania, and Uganda, in a variety of public and private health care sector settings, and across a range of malaria endemic zones. Results: Of 106,039 patients with positive mRDT results (median age 6 years), 7426 (7.0%) were not prescribed an ACT antimalarial. The proportion of mRDT-positive patients not prescribed ACT ranged across sites from 1.3 to 37.1%. For patients under age 5 years, 3473/44,539 (7.8%) were not prescribed an ACT, compared with 3833/60,043 (6.4%) of those aged ≥ 5 years. The proportion of < 5-year-olds not prescribed ACT ranged up to 41.8% across sites. The odds of not being prescribed an ACT were 2-32 times higher for patients in settings with lower-transmission intensity (using test positivity as a proxy) compared to areas of higher transmission. mRDT-positive children in low-transmission settings were especially likely not to be prescribed ACT, with proportions untreated up to 70%. Of the 7426 mRDTpositive patients not prescribed an ACT, 4121 (55.5%) were prescribed other, non-recommended non-ACT antimalarial medications, and the remainder (44.5%) were prescribed no antimalarial. Conclusions: In eight studies of mRDT implementation in five African countries, substantial proportions of patients testing mRDT-positive were not prescribed an ACT antimalarial, and many were not prescribed an antimalarial at all. Patients most vulnerable to serious outcomes, children < 5 years and those in low-transmission settings, were most likely to not be prescribed antimalarials, and young children in low-transmission settings were least likely to be treated for malaria. This major public health risk must be addressed in training and practice.

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Adding rapid diagnostic tests to community-based programmes for treating malaria

Allen

Wiyeh

McCaul

2022

Cochrane Database of Systematic Reviews

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Background The World Health Organization (WHO) recommends parasitological testing of all suspected malaria cases using malaria rapid diagnostic tests (mRDTs) or microscopy prior to treatment. Some governments have extended this responsibility to community health workers (CHWs) to reduce malaria morbidity and mortality through prompt and appropriate treatment. This is an update of a Cochrane Review first published in 2013. Objectives To evaluate community‐based management strategies for treating malaria or fever that incorporate both a definitive diagnosis with an mRDT and appropriate antimalarial treatment. Search methods We searched CENTRAL, MEDLINE, Embase, five other databases, and three trials registers up to 14 September 2021. Selection criteria We included individually randomized trials and cluster‐randomized controlled trials (cRCTs), controlled before‐after studies, and controlled interrupted time series studies in people living in malaria‐endemic areas, comparing programmes that train CHWs and drug shop vendors to perform mRDTs and provide appropriate treatment versus similar programmes that do not use mRDTs, and versus routine health facility care. Data collection and analysis We used standard Cochrane methods. For each dichotomous outcome, we extracted the number of participants with the event and the total number of participants in each group, unless studies presented results at a population level only. Primary outcomes were all‐cause mortality, hospitalizations, and number of people receiving an antimalarial within 24 hours. Secondary outcomes were malaria‐specific mortality, severe malaria, outcomes related to antimalarial treatments, antibiotic prescribing to people with a negative microscopy or polymerase chain reaction (PCR) result, parasitaemia, anaemia, and all adverse events. Main results We included eight studies from several African countries, Afghanistan, and Myanmar. Staff included CHWs and drug shop vendors. Community use of malaria rapid diagnostic tests compared to clinical diagnosis Compared to clinical diagnosis, mRDT diagnosis results in reduced prescribing of antimalarials to people who are found to be malaria parasite‐negative by microscopy or PCR testing (71 fewer per 100 people, 95% confidence interval (CI) 79 to 51 fewer; risk ratio (RR) 0.17, 95% CI 0.07 to 0.40; 3 cRCTs, 7877 participants; moderate‐certainty evidence). This reduction may be greater among CHWs compared to drug shop vendors. People diagnosed by mRDT are more likely to receive appropriate treatment; that is, an antimalarial if they are microscopy‐ or PCR‐positive and no antimalarial if they are microscopy‐ or PCR‐negative (RR 3.04, 95% CI 2.46 to 3.74, 3 cRCTs, 9332 participants; high‐certainty evidence). Three studies found that a small percentage of people with a negative mRDT result (as read by the CHW ...

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Improving prescribing practices with rapid diagnostic tests (RDTs): synthesis of 10 studies to explore reasons for variation in malaria RDT uptake and adherence

Cited by 47 publications

References 62 publications

The Impact of Introducing Malaria Rapid Diagnostic Tests on Fever Case Management: A Synthesis of Ten Studies from the ACT Consortium

The Impact of Introducing Malaria Rapid Diagnostic Tests on Fever Case Management: A Synthesis of Ten Studies from the ACT Consortium

Patients with positive malaria tests not given artemisinin-based combination therapies: a research synthesis describing under-prescription of antimalarial medicines in Africa

Adding rapid diagnostic tests to community-based programmes for treating malaria

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