BackgroundMany clinics in Southern Africa have long waiting times. The implementation of point-of-care (POC) tests to accelerate diagnosis and improve clinical management in resource-limited settings may improve or worsen clinic flow and waiting times. The objective of this study was to describe clinic flow with special emphasis on the impact of POC testing at a large urban public healthcare clinic in Durban, South Africa.MethodsWe used time and motion methods to directly observe patients and practitioners. We created patient flow maps and recorded individual patient waiting and consultation times for patients seeking STI, TB, or HIV care. We conducted semi-structured interviews with 20 clinic staff to ascertain staff opinions on clinic flow and POC test implementation.ResultsAmong 121 observed patients, the total number of queues ranged from 4 to 7 and total visit times ranged from 0:14 (hours:minutes) to 7:38. Patients waited a mean of 2:05 for standard-of-care STI management, and approximately 4:56 for STI POC diagnostic testing. Stable HIV patients who collected antiretroviral therapy refills waited a mean of 2:42 in the standard queue and 2:26 in the fast-track queue. A rapid TB test on a small sample of patients with the Xpert MTB/RIF assay and treatment initiation took a mean of 6:56, and 40% of patients presenting with TB-related symptoms were asked to return for an additional clinic visit to obtain test results. For all groups, the mean clinical assessment time with a nurse or physician was 7 to 9 min, which accounted for 2 to 6% of total visit time. Staff identified poor clinic flow and personnel shortages as areas of concern that may pose challenges to expanding POC tests in the current clinic environment.ConclusionsThis busy urban clinic had multiple patient queues, long clinical visits, and short clinical encounters. Although POC testing ensured patients received a diagnosis sooner, it more than doubled the time STI patients spent at the clinic and did not result in same-day diagnosis for all patients screened for TB. Further research on implementing POC testing efficiently into care pathways is required to make these promising assays a success.
IntroductionMost low- and middle-income countries (LMICs) rely on syndromic management to guide diagnosis and treatment of sexually transmitted infections (STIs). Syndromic management is less expensive but has poor diagnostic accuracy compared to conventional laboratory testing. The goal of this study was to determine the incremental cost of implementing a rapid, near-patient diagnostic care model at an infectious disease centre in Durban, South Africa.MethodsAs part of a cohort study to assess diagnostic point-of-care testing with expedited partner therapy (EPT), we compared cost incurred to standard-of-care syndromic management in the same clinic. Patients were tested with GeneXpert CT/NG assay, OSOM Rapid Trichomonas Test, and microscopy for candida and bacterial vaginosis, followed by specific treatment and EPT. Patients receiving standard-of-care were administered a symptom screen and broad STI treatment. An activity-based micro-costing approach, including time and motion studies, was used to estimate cost per patient treated. Costs were obtained from budgets, invoices, and staff interviews from 2016.ResultsThe mean incremental cost per patient when going from syndromic to diagnostic management was USD 36.69 ($28.15 excluding microscopy). The largest costs for diagnostic management came from Cepheid CT/NG cartridges ($14.37, 39%) and nurse time ($14.19, 39%). Average per-patient medication costs were higher for syndromic management than diagnostic testing ($11.00 vs. $1.74). Several costs of syndromic management were not accounted for, including potential misdiagnosis, overtreatment resulting in adverse reactions or drug resistance, lack of awareness of the specific STI, less effective partner notification with a greater risk of reinfection, and HIV acquisition.ConclusionDiagnostic management cost more than syndromic management per patient visit. However, health consequences of syndromic management should be further evaluated. Accurate, low-cost STI diagnostics are potentially a cost-effective intervention for STI control. Support: The CAPRISA 083 study was co-funded by the South African Medical Research Council and the NIH (AI116759). Cepheid loaned two 4-module Genexpert machines to the study team free-of-charge, but did not contribute to the preparation of this abstract
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