An Interrupted Time Series Analysis
BACKGROUND: The World Health Organization recommends that all suspected malaria cases receive a parasitological diagnosis prior to treatment with artemisinin-based combination therapy. A recent meta-analysis of clinical trials evaluating RDTs for the management of patients with fever found substantial reductions in anti-malarial prescriptions when health workers adhered to treatment protocols based on test results. However few studies have reported on the impact of RDTs on health systems outside research settings. METHODS: The study comprised a retrospective interrupted time series analysis, comparing rates of malaria diagnosis, treatment, and resource utilization before and after introduction of RDTs at a peripheral health facility in rural Western Uganda. The use of malaria diagnostic tests was graphically depicted throughout the study period and fit regression models to identify correlates of three outcomes of interest: (1) length of stay (2) the proportion of patients referred to a higher-level health facility, and (3) administration of antibiotics. RESULTS: Over the course of the study period, 14,357 individuals underwent diagnostic testing for malaria with either a RDT (9,807) or microscopy (4,550). The proportion of patients with parasite-based diagnoses more than tripled to 34% after the introduction of RDTs. RDTs largely replaced microscopy as the diagnostic method of choice. Compared to patients admitted during the pre-RDT period, patients admitted to the health centre with malaria in the post-RDT period had significantly reduced odds of being referred to another health centre (AOR=0.49, P=0.038), receiving antibiotics (AOR=0.42, P<0.001), and a significantly shorter mean length of stay (β=-0.32 days, 95%CI -0.52 to -0.13). CONCLUSIONS: This study is one of the few to demonstrate significant improvement in clinical outcomes and process measures following the introduction of RDTs for the diagnosis of malaria at a rural health facility in Uganda. The results show a reduction in referrals and shorter mean inpatient LOS even as antibiotics were prescribed less frequently. This change greatly increased laboratory throughput and the resultant proportion of patients receiving a parasite-based diagnosis.