Does test-based prescription of evidence-based treatment for malaria improve treatment seeking and satisfaction? Findings of repeated cross-sectional surveys in Papua New Guinea

Introduction: The presumptive treatment of febrile illness with antimalarial medication is becoming less common in low- and middle-income countries as access to reliable diagnostic tests improves. We explore whether the shift towards test-based antimalarial prescription, and the introduction of highly efficacious artemisinin combination therapies (ACTs), reduces critical delays in seeking treatment for febrile illness or increases patient satisfaction.

Methods: We conducted countrywide repeat, cross-sectional surveys in 118 randomly selected primary healthcare services in Papua New Guinea. The clinical case management of 1765 consecutively presenting febrile patients was observed and exit interviews were completed at discharge. This was done prior to implementation of test-based ACT prescription (2011) and at 12- (2012) and 60-months (2016) post implementation. We conducted multiple logistic regressions. Treatment response time was dichotomised as <24 hours from symptom onset vs. 24+ hours. Satisfaction was dichotomised as a ‘high’ vs. ‘low’ rating based on participant response to a visual, 7-point likert-type scale.

Results: 62% (322/517) of febrile patients reported seeking treatment within 24 hours of symptom onset in 2011 compared to 53% (230/434) in 2012 and 42% (339/814) in 2016. Adjusted odds ratios for reporting a treatment response time <24 hours in the post-implementation surveys were 0.77 (95% CI 0.48, 1.26) and 0.45 (%% CI 0.31, 0.65), respectively when compared with the pre-implementation period. 53% (230/533) of febrile patients reported ‘high’ satisfaction with the service received in 2011 compared to 32% (143/449) in 2012 and 35% (278/803) in 2016. Adjusted odds ratios for reporting high satisfaction in the post-implementation surveys were 0.52 (95% CI 0.32, 0.85) and 0.65 (95% CI 0.39, 1.10), respectively when compared with the pre-implementation period.

Conclusion: Nationwide implementation of test-based ACT prescription in Papua New Guinea has increased the likelihood of critical treatment seeking delays and decreased patient satisfaction with the service received.