Department of Community Medicine, University of Nigeria, Nigeria.
Malar J. 2009 Nov 23;8:265. doi: 10.1186/1475-2875-8-265.
The diagnosis and treatment of malaria is often based on syndromic presentation (presumptive treatment) and microscopic examination of blood films. Treatment based on syndromic approach has been found to be costly, and contributes to the development of drug resistance, while microscopic diagnosis of malaria is time-consuming and labour-intensive. Also, there is lack of trained microscopists and reliable equipment especially in rural areas of Nigeria. However, although rapid diagnostic tests (RDTs) have improved the ease of appropriate diagnosis of malaria diagnosis, the cost-effectiveness of RDTs in case management of malaria has not been evaluated in Nigeria. The study hence compares the cost-effectiveness of RDT versus syndromic diagnosis and microscopy.
A total of 638 patients with fever, clinically diagnosed as malaria (presumptive malaria) by health workers, were selected for examination with both RDT and microscopy. Patients positive on RDT received artemisinin-based combination therapy (ACT) and febrile patients negative on RDT received an antibiotic treatment. Using a decision tree model for a hypothetical cohort of 100,000 patients, the diagnostic alternatives considered were presumptive treatment (base strategy), RDT and microscopy. Costs were based on a consumer and provider perspective while the outcome measure was deaths averted. Information on costs and malaria epidemiology were locally generated, and along with available data on effectiveness of diagnostic tests, adherence level to drugs for treatment, and drug efficacy levels, cost-effectiveness estimates were computed using TreeAge programme. Results were reported based on costs and effects per strategy, and incremental cost-effectiveness ratios.
The cost-effectiveness analysis at 43.1% prevalence level showed an incremental cost effectiveness ratio (ICER) of 221 per deaths averted between RDT and presumptive treatment, while microscopy is dominated at that level. There was also a lesser cost of RDT ($0.34 million) compared to presumptive treatment ($0.37 million) and microscopy ($0.39 million), with effectiveness values of 99,862, 99,735 and 99,851 for RDT, presumptive treatment and microscopy, respectively. Cost-effectiveness was affected by malaria prevalence level, ACT adherence level, cost of ACT, proportion of non-malaria febrile illness cases that were bacterial, and microscopy and RDT sensitivity.
RDT is cost-effective when compared to other diagnostic strategies for malaria treatment at malaria prevalence of 43.1% and, therefore, a very good strategy for diagnosis of malaria in Nigeria. There is opportunity for cost savings if rapid diagnostic tests are introduced in health facilities in Nigeria for case management of malaria.
疟疾的诊断和治疗通常基于综合征表现（推定治疗）和血液涂片的显微镜检查。基于综合征方法的治疗已被发现成本高昂，并导致药物耐药性的发展，而疟疾的显微镜诊断既费时又费力。此外，尼日利亚农村地区缺乏训练有素的显微镜检查人员和可靠的设备。然而，尽管快速诊断测试（RDT）改善了疟疾诊断的适当诊断的便利性，但尚未在尼日利亚评估 RDT 在疟疾病例管理中的成本效益。因此，本研究比较了 RDT 与综合征诊断和显微镜检查的成本效益。
共选择了 638 名发热患者，由卫生工作者临床诊断为疟疾（推定疟疾），并用 RDT 和显微镜检查。RDT 阳性的患者接受青蒿素为基础的联合治疗（ACT），RDT 阴性的发热患者接受抗生素治疗。使用决策树模型对 100,000 名患者的假设队列进行分析，考虑的诊断替代方案包括推定治疗（基础策略）、RDT 和显微镜检查。成本基于消费者和提供者的角度，而结果衡量标准是避免死亡。成本和疟疾流行病学信息是本地生成的，并且与诊断测试的有效性、药物治疗的依从性水平以及药物疗效水平的可用数据一起，使用 TreeAge 程序计算成本效益估计值。根据每种策略的成本和效果报告结果，并报告增量成本效益比。
在 43.1%的患病率水平下的成本效益分析显示，RDT 与推定治疗相比，每避免一次死亡的增量成本效益比（ICER）为 221，而在该水平下显微镜检查占主导地位。RDT 的成本也低于推定治疗（370 万美元）和显微镜检查（390 万美元），其有效性值分别为 RDT 的 99,862、99,735 和 99,851。成本效益受到疟疾流行水平、ACT 依从性水平、ACT 成本、非疟疾发热病例中细菌的比例以及显微镜检查和 RDT 敏感性的影响。
在疟疾流行率为 43.1%的情况下，与其他疟疾治疗诊断策略相比，RDT 具有成本效益，因此是尼日利亚疟疾诊断的一个非常好的策略。如果在尼日利亚的卫生设施中引入快速诊断测试来管理疟疾病例，将有机会节省成本。
