Cost-effectiveness analysis of point-of-care tests for causes of non-malarial febrile illnesses in low-resource settings: a case study from Lao PDR.

Introduction: In many low- and middle-income countries, there is widespread use of point-of-care tests (POCTs) to diagnose a variety of infectious diseases, even in hospitals due to weak laboratory capacity. Often, POCT use is unregulated and expensive while the use of substandard tests is common. A cost-effectiveness analysis was conducted to investigate which POCTs for non-malarial febrile illness (NMFI) represent the best use of resources in Lao PDR in outpatient settings, assuming best-in-class POCTs are used. Methods: A decision-tree cost-effectiveness analysis was conducted to simulate use of POCTs of interest for outpatients presenting with NMFI, compared to clinical assessment alone. The analyses were performed from both healthcare provider's perspective and a limited societal perspective, which included cost estimates of the contribution of antibiotic consumption by class to future AMR costs. Deterministic and probabilistic analyses were performed. Results: In probabilistic and deterministic analyses, dengue and rickettsia POCTs were consistently cost-effective and the most cost-effective of the four POCTs evaluated. Deterministic analyses estimated that typhoid and leptospirosis POCTs were cost-effective compared with clinical assessment alone. However, in probabilistic analyses, clinical assessment was more likely to be cost-effective than typhoid or leptospirosis POCTs at the estimated cost-effectiveness threshold in the Lao PDR. Conclusions: This evaluation was able to make use of comprehensive primary data from fever studies in Lao PDR, giving an understanding of the aetiology and prescribing behaviour of physicians for undifferentiated NMFI. However, sensitivity analyses showed that there was substantial uncertainty about which strategy would be most cost-effective and if substandard POCTs were analysed then it is more likely that clinical assessment alone would be the most cost-effective strategy. This research shows that there is good reason to be cautious about the overuse of POCTs for NMFI and whether they represent good value for money in low-income contexts compared with clinical assessment alone.