Rapid tests to inform triage and antibiotic prescribing decisions for adults presenting with suspected acute respiratory infection: a rapid evidence synthesis of clinical effectiveness and cost-utility studies.

Abstract

Background: This review assessed the clinical- and cost-effectiveness of point-of-care tests to guide the initial management of people presenting with suspected acute respiratory infection.

Methods: Searches for systematic reviews, randomised controlled trials and cost-utility studies were conducted in May 2023. Sources included MEDLINE, Epistemonikos, EMBASE, Cochrane Central Register of Controlled Trials, the Cost-effectiveness Analysis Registry and reference checking. Eligible studies included people (≥ 16 years) making initial contact with the health system with symptoms suggestive of acute respiratory infection. Risk of bias in randomised controlled trials was assessed using the Cochrane risk-of-bias tool. The Drummond checklist was used for cost-utility studies. Meta-analyses of clinical outcomes were conducted to estimate summary risk ratios with 95% confidence intervals. Study characteristics and main results were summarised narratively and tabulated.

Results: Fourteen randomised controlled trials were included; all had a high risk of bias. Ten randomised controlled trials analysed point-of-care tests for C-reactive protein. Compared with usual care, the effects on hospital admissions and mortality were highly uncertain due to sparse data. Three randomised controlled trials had heterogeneous findings on the resolution of symptoms/time to full recovery. The risk of re-consultations increased in patients receiving C-reactive protein point-of-care tests (pooled risk ratio 1.61, 95% confidence interval 1.07 to 2.41; four studies). There was a reduction in antibiotics initially prescribed (C-reactive protein point-of-care tests vs. usual care: pooled risk ratio 0.75, 95% confidence interval 0.68 to 0.84; nine studies). The effects of procalcitonin point-of-care tests compared with usual care on hospital admission, escalation of care, and duration of symptoms were very uncertain as only one randomised controlled trial was included. The study found a large reduction in antibiotic prescriptions within 7 days. Two studies revealed a large reduction in initial antibiotic prescriptions for Group A streptococcus point-of-care tests versus usual care. Only one study compared an influenza point-of-care test with usual care. The effect of the antibiotics prescribed was very uncertain. No deaths occurred in either treatment group.

Cost-effectiveness: Six of the 17 included cost-utility studies were judged to be directly applicable to our review, 4 of which focused on the C-reactive protein point-of-care test. The results suggested that the C-reactive protein point-of-care test is potentially cost-effective; these studies were generally limited to capturing only short-term costs and consequences. One study evaluated 14 different point-of-care tests for Group A streptococcus; none were cost-effective compared with usual care. A further study evaluated two rapid tests (Quidel for influenza [Quidel Corp, San Diego, CA, USA], and BinaxNOW [Binax, Inc., Portland, ME, USA]) for the pneumococcal antigen) compared to culture/serology and found that they were not cost-effective.

Limitations: Rapid synthesis methods were used, so relevant studies may have been missed. No evidence was identified for several review questions.

Conclusion: C-reactive protein point-of-care test may reduce the number of patients given an antibiotic prescription but could increase the rate of re-consultations. C-reactive protein point-of-care test may potentially be cost-effective but existing estimates were based on very small and uncertain gains in quality-adjusted life-years and only accounted for short-term costs and consequences. There was very limited or an absence of evidence for other point-of-care tests.

Future work: Research is needed to explore the impact of point-of-care tests on triaging decisions across different clinical settings and to quantify the longer-term health and cost consequences.

Study registration: This study is registered as PROSPERO CRD42023429515.

Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR159946) and is published in full in Health Technology Assessment; Vol. 29, No. 13. See the NIHR Funding and Awards website for further award information.