Objective
There is a paucity of randomised diagnostic studies in women with suspected coronary artery disease(CAD). This study sought to assess the relative value of exercise stress echocardiography (ESE) compared with exercise ECG (Ex-ECG) in women with CAD.
Methods
Accordingly, 416 women with no prior CAD and intermediate probability of CAD (mean pre-test probability 41%), were randomized to undergo either Ex-ECG or ESE. The primary endpoints were the positive predictive value (PPV) for the detection of significant CAD and downstream resource utilisation.
Results
The PPV of ESE and Ex-ECG were 33% and 30% (p = 0.87) respectively for the detection of CAD. There were similar clinic visits (36 vs 29, p = 0.44) and emergency visits with chest pain (28 vs 25, p = 0.55) in the Ex-ECG and ESE arms respectively. At 2.9 years,cardiac events were 6 Ex-ECG vs 3 ESE, p = 0.31. Although initial diagnosis costs were higher for ESE, more women underwent further CAD testing in the Ex-ECG arm compared to the ESE arm (37 vs 17, p = 0.003). Overall, there was higher downstream resource utilisation (hospital attendances and investigations) in the Ex-ECG arm (p=0.002). Using National Health Service tariffs 2020/21 (British pounds) the cumulative diagnostic costs were 7.4% lower for Ex-ECG compared with ESE, but this finding is sensitive to the cost differential between ESE and Ex-ECG.
Conclusion
In intermediate-risk women who are able to exercise, Ex-ECG had similar efficacy to an ESE strategy, with higher resource utilisation whilst providing cost savings.
Background
Screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) at genital and extragenital sites is needed for most key populations, but molecular diagnostic tests for CT/NG are costly. We aimed to determine the accuracy of pooled samples from multiple anatomic sites from one individual to detect CT/NG using the testing of a single sample from one anatomic site as the reference.
Methods
In this systematic review and meta-analysis, we searched five databases for articles published from January 1, 2000, to February 4, 2021. Studies were included if they contained original data describing the diagnostic accuracy of pooled testing compared with single samples, resource use, benefits and harms of pooling, acceptability, and impact on health equity. We present the pooled sensitivities and specificities for CT and NG using a bivariate mixed-effects logistic regression model. The study protocol is registered in PROSPERO, an international database of prospectively registered systematic reviews (CRD42021240793). We used GRADE to evaluate the quality of evidence.
Results
Our search yielded 7814 studies, with 17 eligible studies included in our review. Most studies were conducted in high-income countries (82.6%, 14/17) and focused on men who have sex with men (70.6%, 12/17). Fourteen studies provided 15 estimates for the meta-analysis for CT with data from 5891 individuals. The pooled sensitivity for multisite pooling for CT was 93.1% [95% confidence intervals (CI) 90.5–95.0], I2=43.3, and pooled specificity was 99.4% [99.0–99.6], I2=52.9. Thirteen studies provided 14 estimates for the meta-analysis for NG with data from 6565 individuals. The pooled sensitivity for multisite pooling for NG was 94.1% [95% CI 90.9–96.3], I2=68.4, and pooled specificity was 99.6% [99.1–99.8], I2=83.6. Studies report significant cost savings (by two thirds to a third).
Conclusion
Multisite pooled testing is a promising approach to improve testing coverage for CT/NG in resource-constrained settings with a small compromise in sensitivity but with a potential for significant cost savings.
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