Cost-Effectiveness Analysis of Test-Based versus Presumptive Treatment of Uncomplicated Malaria in Children under Five Years in an Area of High Transmission in Central Ghana.
BACKGROUND
The presumptive approach of confirming malaria in health facilities leads to over-diagnosis of malaria, over use of anti-malaria drugs and the risk of drug resistance development. WHO recommends parasitological confirmation before treatment with artemisinin-based combination therapy (ACT) in all suspected malaria patients. The use of malaria rapid diagnostic tests (mRDTs) would make it possible for prescribers to diagnose malaria at point-of-care and better target the use of antimalarials. Therefore, a cost-effectiveness analysis was performed on the introduction of mRDTs for management of malaria in under-five children in a high transmission area in Ghana where presumptive diagnosis was the norm in public health centres.


METHODS
A cluster-randomised controlled trial where thirty-two health centres were randomised into test-based diagnosis of malaria using mRDTs (intervention) or clinical judgement (control) was used to measure the effect of mRDTs on appropriate treatment: 'a child with a positive reference diagnosis prescribed a course of ACT or a child with a negative reference diagnosis not given an ACT'. Cost data was collected from five purposively selected health centres and used to estimate the health sector costs of performing an mRDT and treat children for malaria and other common febrile illnesses. Costs of training healthcare personnel and supervision in the study period were also collected. A sample of caregivers to children participating in the trial was interviewed about household cost incurred on transport, drugs, fees, and special food during a period of one week after the health centre visit as well as days unable to work. A decision model approach was used to calculate the incremental cost-effectiveness ratios (ICERs). Univariate and multivariate sensitivity analyses were applied to assess the robustness of ICERs.


RESULTS
The availability of mRDTs for malaria diagnosis resulted in fewer ACT treatments compared to the clinical judgement approach (73% versus 81%) and more children appropriately treated (70% versus 57%). The introduction of mRDT-based diagnosis would cost the Ministry of Health US$18.6 per extra appropriately treated child under five compared to clinical judgement while the ICER from a societal perspective was lower at US$11.0 per appropriately treated child. ICERs were sensitive to a decrease in adherence to negative mRDTs, malaria positivity rate and specificity of the mRDT.


CONCLUSIONS
The introduction of mRDTs is likely to be considered cost-effective in this high transmission setting as this intervention increased the number of appropriately treated children at low cost.


BACKGROUND
ClinicalTrials.gov NCT00832754.
Kintampo Health Research Centre, Kintampo, Brong Ahafo Region, Ghana.
Theresa
T
Tawiah
Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom.|Section of Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
Kristian Schultz
KS
Hansen
Epidemiology Unit, Ensign College of Public Health, Kpong, Eastern Region, Ghana.
Frank
F
Baiden
Department for Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Jane
J
Bruce
Kintampo Health Research Centre, Kintampo, Brong Ahafo Region, Ghana.
Mathilda
M
Tivura
Kintampo Health Research Centre, Kintampo, Brong Ahafo Region, Ghana.
Rupert
R
Delimini
Kintampo Health Research Centre, Kintampo, Brong Ahafo Region, Ghana.
Seeba
S
Amengo-Etego
Department for Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Daniel
D
Chandramohan
Kintampo Health Research Centre, Kintampo, Brong Ahafo Region, Ghana.
Seth
S
Owusu-Agyei
Department for Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Jayne
J
Webster
Stat Methods Med Res. 2002 Dec;11(6):455-68
12516984
Trop Med Int Health. 2006 Apr;11(4):432-40
16553926
Malar J. 2008 Jan 28;7:21
18226224
Value Health. 2014 Dec;17(8):783-91
25498773
Bull World Health Organ. 2008 Feb;86(2):101-10
18297164
PLoS One. 2011;6(12):e28944
22174932
Health Econ. 2004 May;13(5):405-15
15127421
Health Aff (Millwood). 2015 Jul;34(7):1196-203
26153315
Malar J. 2012 Dec 12;11:414
23231707
Med Decis Making. 1985 Summer;5(2):157-77
3831638
Am J Trop Med Hyg. 2010 Dec;83(6):1238-41
21118927
Trop Med Int Health. 2005 Jun;10(6):530-6
15941415
BMJ. 2008 Jan 26;336(7637):202-5
18199700
Malar J. 2015 May 28;14:217
26016871
Malar J. 2009 Nov 23;8:265
19930666
BMJ. 2004 Jun 26;328(7455):1511-2
15217846
Malar J. 2009 Sep 28;8:220
19785766
PLoS One. 2016 Apr 07;11(4):e0152960
27055275
Cost Eff Resour Alloc. 2011 Feb 08;9:2
21303500
Health Econ. 2000 Oct;9(7):623-30
11103928
Cost Eff Resour Alloc. 2009 Apr 08;7:5
19356225
BMJ. 2004 Nov 20;329(7476):1212
15542534
Trop Med Int Health. 2001 Jun;6(6):423-8
11422955
Health Policy Plan. 2002 Mar;17 (1):112-8
11861593
Malar J. 2011 Aug 04;10:226
21816087
Malar J. 2010 Nov 07;9:314
21054895
Malar J. 2011 Dec 19;10:372
22182735
Health Policy Plan. 2004 Mar;19(2):127-35
14982891
J Exp Biol. 2003 Nov;206(Pt 21):3761-9
14506211
Malar J. 2008 Nov 05;7:232
18986520
J Postgrad Med. 2004 Jan-Mar;50(1):35-9
15047997
Am J Trop Med Hyg. 2013 Oct;89(4):724-36
23980131