In-vitro diagnostic point-of-care tests in paediatric ambulatory care: A systematic review and meta-analysis

Abstract

Introduction: Paediatric consultations form a significant proportion of all consultations in ambulatory care. Point-of-care tests (POCTs) may offer a potential solution to improve clinical outcomes for children by reducing diagnostic uncertainty in acute illness, and streamlining management of chronic diseases. However, their clinical impact in paediatric ambulatory care is unknown. We aimed to describe the clinical impact of all in-vitro diagnostic POCTs on patient outcomes and healthcare processes in paediatric ambulatory care.

Methods: We searched MEDLINE, EMBASE, Pubmed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science from inception to 29 January 2020 without language restrictions. We included studies of children presenting to ambulatory care settings (general practice, hospital outpatient clinics, or emergency departments, walk-in centres, registered drug shops delivering healthcare) where in-vitro diagnostic POCTs were compared to usual care. We included all quantitative clinical outcome data across all conditions or infection syndromes reporting on the impact of POCTs on clinical care and healthcare processes. Where feasible, we calculated risk ratios (RR) with 95% confidence intervals (CI) by performing meta-analysis using random effects models.

Results: We included 35 studies. Data relating to at least one outcome were available for 89,439 children of whom 45,283 had a POCT across six conditions or infection syndromes: malaria (n = 14); non-specific acute fever 'illness' (n = 7); sore throat (n = 5); acute respiratory tract infections (n = 5); HIV (n = 3); and diabetes (n = 1). Outcomes centred around decision-making such as prescription of medications or hospital referral. Pooled estimates showed that malarial-POCTs (Plasmodium falciparum) better targeted antimalarial treatment by reducing over-treatment by a third compared to usual care (RR 0.67; 95% CI [0.58 to 0.77], n = 36,949). HIV-POCTs improved initiating earlier antiretroviral therapy compared to usual care (RR, 3.11; 95% CI [1.55 to 6.25], n = 912). Across the other four conditions, there was limited evidence for the benefit of POCTs in paediatric ambulatory care except for acute respiratory tract infections (RTI) in low-and-middle-income countries (LMICs), where POCT C-Reactive Protein (CRP) may reduce immediate antibiotic prescribing by a third (risk difference, -0.29 [-0.47, -0.11], n = 2,747). This difference was shown in randomised controlled trials in LMICs which included guidance on interpretation of POCT-CRP, specific training or employed a diagnostic algorithm prior to POC testing.

Conclusion: Overall, there is a paucity of evidence for the use of POCTs in paediatric ambulatory care. POCTs help to target prescribing for children with malaria and HIV. There is emerging evidence that POCT-CRP may better target antibiotic prescribing for children with acute RTIs in LMIC, but not in high-income countries. Research is urgently needed to understand where POCTs are likely to improve clinical outcomes in paediatric settings worldwide.

Fig 1. PRISMA flowchart of included and excluded studies.

Abbreviations: POCTs, point-of-care tests; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT, randomised controlled trials.

Fig 2. Risk of bias summary for 24 randomised controlled trials across all conditions.

Fig 3. Risk of bias summary for 11 non-randomised studies across all conditions.

Fig 4. Recovery between day 3 to 7.

Forest plot of meta-analyses of randomised trials and non-randomised studies reporting recovery after antimalarial treatment comparing POCT vs usual care. Abbreviations: CI, confidence interval; POCT, point-of-care test; RCT, randomised controlled trial.

Fig 5. Effect of malaria-POCT on antimalarial prescriptions in suspected malaria.

Forest plot of meta-analyses of randomised trials and non-randomised studies reporting a reduction in antimalarial treatment comparing POCT vs usual care. Abbreviations: CI, confidence interval; POCT, point-of-care test; RCT, randomised controlled trial.

Fig 6. Antibiotic prescribing in suspected malaria.

Forest plot of meta-analyses of randomised trials and non-randomised studies of the likelihood of antibiotic treatment in malaria comparing POCT vs usual care. Abbreviations: CI, confidence interval; POCT, point-of-care test; RCT, randomised controlled trial.

Fig 7. POCT impact on reducing hospital attendance for non-specific acute illness.

Forest plot of meta-analyses of randomised trials and non-randomised studies reporting hospital attendance (immediate hospital assessment and/or admission) comparing POCT vs usual care. Abbreviations: CI, confidence interval; POCT, point-of-care test; RCT, randomised controlled trial.

Fig 8. Immediate antibiotic prescribing for non-specific acute fever illness.

Forest plot of meta-analyses of randomised trials and non-randomised studies reporting immediate antibiotic prescribing comparing POCT vs usual care. Abbreviations: CI, confidence interval; POCT, point-of-care test; RCT, randomised controlled trial.

Fig 9. Immediate antibiotic prescribing for acute respiratory tract infections.

Forest plot of meta-analyses of randomised trials and non-randomised studies reporting immediate antibiotic prescribing comparing POCT vs usual care. Abbreviations: CI, confidence interval; POCT, point-of-care test; RCT, randomised controlled trial.

Fig 10. Immediate antibiotic prescribing in sore throat.

Forest plot of meta-analyses of randomised trials and non-randomised studies reporting immediate antibiotic prescribing comparing POCT vs usual care. Abbreviations: CI, confidence interval; POCT, point-of-care test; RCT, randomised controlled trial.