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. 2021 Jun;25(39):1–74. doi: 10.3310/hta25390

Modelling of hypothetical SARS-CoV-2 point of care tests for routine testing in residential care homes: rapid cost-effectiveness analysis.

Matt Stevenson, Andrew Metry, Michael Messenger
PMCID: PMC8256324  PMID: 34142943

Abstract

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes coronavirus disease 2019 (COVID-19), which at the time of writing (January 2021) was responsible for more than 2.25 million deaths worldwide and over 100,000 deaths in the UK. SARS-CoV-2 appears to be highly transmissible and could rapidly spread in residential care homes.

OBJECTIVE

The work undertaken aimed to estimate the clinical effectiveness and cost-effectiveness of viral detection point-of-care tests for detecting SARS-CoV-2 compared with laboratory-based tests in the setting of a hypothetical care home facility for elderly residents.

PERSPECTIVE/SETTING

The perspective was that of the NHS in 2020. The setting was a hypothetical care home facility for elderly residents. Care homes with en suite rooms and with shared facilities were modelled separately.

METHODS

A discrete event simulation model was constructed to model individual residents and simulate the spread of SARS-CoV-2 once it had entered the residential care facility. The numbers of COVID-19-related deaths and critical cases were recorded in addition to the number of days spent in isolation. Thirteen strategies involving different hypothetical SARS-CoV-2 tests were modelled. Recently published desirable and acceptable target product profiles for SARS-CoV-2 point-of-care tests and for hospital-based SARS-CoV-2 tests were modelled. Scenario analyses modelled early release from isolation based on receipt of a negative SARS-CoV-2 test result and the impact of vaccination. Incremental analyses were undertaken using both incremental cost-effectiveness ratios and net monetary benefits.

RESULTS

Cost-effectiveness results depended on the proportion of residential care facilities penetrated by SARS-CoV-2. SARS-CoV-2 point-of-care tests with desirable target product profiles appear to have high net monetary benefit values. In contrast, SARS-CoV-2 point-of-care tests with acceptable target product profiles had low net monetary benefit values because of unnecessary isolations. The benefit of allowing early release from isolation depended on whether or not the facility had en suite rooms. The greater the assumed efficacy of vaccination, the lower the net monetary benefit values associated with SARS-CoV-2 point-of-care tests, when assuming that a vaccine lowers the risk of contracting SARS-CoV-2.

LIMITATIONS

There is considerable uncertainty in the values for key parameters within the model, although calibration was undertaken in an attempt to mitigate this. Some degree of Monte Carlo sampling error persists because of the timelines of the project. The example care home simulated will also not match those of decision-makers deciding on the clinical effectiveness and cost-effectiveness of introducing SARS-CoV-2 point-of-care tests. Given these limitations, the results should be taken as indicative rather than definitive, particularly the cost-effectiveness results when the relative cost per SARS-CoV-2 point-of-care test is uncertain.

CONCLUSIONS

SARS-CoV-2 point-of-care tests have considerable potential for benefit for use in residential care facilities, but whether or not this materialises depends on the diagnostic accuracy and costs of forthcoming SARS-CoV-2 point-of-care tests.

FUTURE WORK

More accurate results would be obtained when there is more certainty on the diagnostic accuracy of and the reduction in time to test result associated with SARS-CoV-2 point-of-care tests when used in the context of residential care facilities, the proportion of care home penetrated by SARS-CoV-2 and the levels of immunity once vaccination is administered. These parameters are currently uncertain.

FUNDING

This report was commissioned by the National Institute for Health Research (NIHR) Evidence Synthesis programme as project number 132154. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 39. See the NIHR Journals Library website for further project information.

Plain language summary

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes coronavirus disease 2019 (COVID-19). SARS-CoV-2 is highly infectious, and this can cause problems in care homes, where the virus can spread quickly. Laboratory-based tests can determine whether or not someone has SARS-CoV-2, but these tests are not perfect and can take a long time to provide a result. Point-of-care tests that can be performed quickly in the care home to detect SARS-CoV-2 are being developed and they may have much shorter times to get a result than laboratory-based tests, although with worse accuracy. The benefit of quicker tests is that decisions to put residents into or release them from isolation can be made sooner, reducing the risk of spreading SARS-CoV-2 and reducing time in isolation. The disadvantage of reduced accuracy is that wrong decisions could be made, resulting in either unnecessary isolation or increased spread of SARS-CoV-2. A computer model was built to explore the impact of using SARS-CoV-2 point-of-care tests for residents of care homes. The model estimated the number of SARS-CoV-2 infections, deaths due to COVID-19 and days in isolation. Strategies were run using different values, including the time to get a test result back, the accuracy of tests, the proportion of care homes where there is a case of SARS-CoV-2, whether residents were isolated individually or in groups and how well vaccines work. The results of the model indicated that point-of-care tests could be good if there was a large decrease in the time to get a test result back, if accuracy was high and if vaccination protection was moderate. However, the accuracy and speed of future point-of-care tests is uncertain. When newer SARS-CoV-2 tests are available, the model will allow an estimate of the clinical effectiveness and cost-effectiveness of the tests to be made.

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References

  1. Worldometer. COVID-19 Coronavirus Pandemic. 2020. URL: www.worldometers.info/coronavirus/ (accessed 15 November 2020).
  2. National Institute for Health and Care Excellence (NICE). Exploratory Economic Modelling of SARS-CoV-2 Viral Detection Point of Care Tests and Serology Tests. Final Scope. London: NICE; 2020.
  3. Medicines and Healthcare products Regulatory Agency. Target Product Profile. Point of Care SARS-CoV-2 Detection Tests. 2020. URL: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/895745/TPP_Point_of_Care_SARS-CoV-2_Detection_Tests.pdf (accessed 16 July 2020).
  4. British Geriatrics Society. COVID-19: Managing the COVID-19 Pandemic in Care Homes for Older People. 2020. URL: www.bgs.org.uk/resources/covid-19-managing-the-covid-19-pandemic-in-care-homes (accessed 15 November 2020).
  5. CONDOR. CONDOR-CH Care Homes. 2020. URL: www.condor-platform.org/condor_workstreams/condor-ch (accessed 15 November 2020).
  6. National Institute for Health and Care Excellence. Guide to the Methods of Technology Appraisal 2013. 2013. URL: www.nice.org.uk/process/pmg9/ (accessed 7 September 2020). [PubMed]
  7. Department of Health and Social Care (DHSC). Admission and Care of Residents in a Care Home During COVID-19. London: DHSC; 2020.
  8. Department of Health and Social Care. About the Adult Social Care Infection Control Fund. 2020. URL: www.gov.uk/government/publications/adult-social-care-infection-control-fund/about-the-adult-social-care-infection-control-fund (accessed 15 November 2020).
  9. Micocci M, Gordon AL, Allen AJ, Hicks T, Kierkegaard P, McLister A, et al. Understanding COVID-19 Testing Pathways in English Care Homes to Identify the Role of Point-of-Care Testing: An Interview-Based Process Mapping Study. 2020. URL: www.medrxiv.org/content/10.1101/2020.11.02.20224550v1 (accessed 5 May 2021).
  10. AVID-CC. Adalimumab for Coronavirus in Community Care. 2020. URL: https://avid-cc.octru.ox.ac.uk/avid-cc-adalimumab-coronavirus-community-care (accessed 6 May 2021).
  11. Office for National Statistics. Care Home and Non-Care Home Populations Used in the Deaths Involving COVID-19 in the Care Sector Article, England and Wales. 2020. URL: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/adhocs/12215carehomeandnoncarehomepopulationsusedinthedeathsinvolvingcovid19inthecaresectorarticleenglandandwales (accessed 15 November 2020).
  12. Smith DRM, Duval A, Pouwels KB, Guillemot D, Fernandes J, Huynh BT, et al. Optimizing COVID-19 surveillance in long-term care facilities: a modelling study. BMC Med 2020;18:386. https://doi.org/10.1186/s12916-020-01866-6 doi: 10.1186/s12916-020-01866-6. [DOI] [PMC free article] [PubMed]
  13. Department of Health and Social Care (DHSC). Vivaldi 1: COVID-19 Care Homes Study Report. London: DHSC; 2020.
  14. Patel MC, Chaisson LH, Borgetti S, Burdsall D, Chugh RK, Hoff CR, et al. Asymptomatic SARS-CoV-2 infection and COVID-19 mortality during an outbreak investigation in a skilled nursing facility. Clin Infect Dis 2020;71:2920–6. https://doi.org/10.1093/cid/ciaa763 doi: 10.1093/cid/ciaa763. [DOI] [PMC free article] [PubMed]
  15. Ladhani SN, Chow JY, Janarthanan R, Fok J, Crawley-Boevey E, Vusirikala A, et al. Investigation of SARS-CoV-2 outbreaks in six care homes in London, April 2020. EClinicalMedicine 2020;26:100533. https://doi.org/10.1016/j.eclinm.2020.100533 doi: 10.1016/j.eclinm.2020.100533. [DOI] [PMC free article] [PubMed]
  16. Office for National Statistics. Coronavirus (COVID-19) Infections in the Community in England: July 2020. Characteristics of People Testing Positive for the Coronavirus (COVID-19) in England from the COVID-19 Infection Survey. 2020. URL: www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronaviruscovid19infectionsinthecommunityinengland/july2020 (accessed 26 November 2020).
  17. Bird S. Expert Reaction to First Results from the Vivaldi Study Looking at COVID-19 Infections Care Homes. 2020. URL: www.sciencemediacentre.org/expert-reaction-to-first-results-from-the-vivaldi-study-looking-at-covid-19-infections-care-homes/ (accessed 26 November 2020).
  18. Hayward AC, Harling R, Wetten S, Johnson AM, Munro S, Smedley J, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 2006;333:1241. https://doi.org/10.1136/bmj.39010.581354.55 doi: 10.1136/bmj.39010.581354.55. [DOI] [PMC free article] [PubMed]
  19. Fouillet A, Bousquet V, Pontais I, Gallay A, Schönemann CC. The French Emergency Department OSCOUR Network: evaluation after a 10-year existence. Online J Public Health Inform 2015;7:e74. https://doi.org/10.5210/ojphi.v7i1.5740 doi: 10.5210/ojphi.v7i1.5740. [DOI]
  20. Stevenson M, Metry A, Messenger A. Modelling of hypothetical SARS-CoV-2 point-of-care tests on admission to hospital from A&E: rapid cost-effectiveness analysis. Health Technol Assess 2021;25:(21). doi: 10.3310/hta25210. [DOI] [PMC free article] [PubMed]
  21. Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L, et al. Features of 20,133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study. BMJ 2020;369:m1985. https://doi.org/10.1136/bmj.m1985 doi: 10.1136/bmj.m1985. [DOI] [PMC free article] [PubMed]
  22. Office for National Statistics. Deaths Involving COVID-19, England and Wales: Deaths Occurring in June 2020. 2020. URL: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19englandandwales/deathsoccurringinjune2020 (accessed 6 May 2021).
  23. Doshi P. Covid-19: do many people have pre-existing immunity? BMJ 2020;370:m3563. https://doi.org/10.1136/bmj.m3563 doi: 10.1136/bmj.m3563. [DOI] [PubMed]
  24. Koh W, Naing L, Rosledzana M, Alikhan M, Chaw L, Griffith M, et al. What do we know about SARS-CoV-2 transmission? A systematic review and meta-analysis of the secondary attack rate, serial interval, and asymptomatic infection. PLOS ONE 2020;15:e0240205. https://doi.org/10.1371/journal.pone.0240205 doi: 10.1371/journal.pone.0240205. [DOI] [PMC free article] [PubMed]
  25. Grassly NC, Pons-Salort M, Parker EPK, White PJ, Ferguson NM, Imperial College COVID-19 Response Team. Comparison of molecular testing strategies for COVID-19 control: a mathematical modelling study. Lancet Infect Dis 2020;20:1381–9. https://doi.org/10.1016/S1473-3099(20)30630-7 doi: 10.1016/S1473-3099(20)30630-7. [DOI] [PMC free article] [PubMed]
  26. Clifford S, Quilty B, Russell T, Liu Y, Chan Y-W, Pearson C, et al. Strategies to Reduce The Risk of SARS-CoV-2 Reintroduction From International Travellers. 2020. URL: www.medrxiv.org/content/10.1101/2020.07.24.20161281v2. (accessed 26 November 2020).
  27. He X, Lau EHY, Wu P, Deng X, Wang J, Hao X, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nat Med 2020;26:672–5. doi: 10.1038/s41591-020-0869-5. [DOI] [PubMed]
  28. Singanayagam A, Patel M, Charlett A, Lopez Bernal J, Saliba V, Ellis J, et al. Duration of infectiousness and correlation with RT-PCR cycle threshold values in cases of COVID-19, England, January to May 2020. Euro Surveill 2020;25. https://doi.org/10.2807/1560-7917.ES.2020.25.32.2001483 doi: 10.2807/1560-7917.ES.2020.25.32.2001483. [DOI] [PMC free article] [PubMed]
  29. Kim H, Hong H, Yoon SH. Diagnostic performance of CT and reverse transcriptase polymerase chain reaction for coronavirus disease 2019: a meta-analysis. Radiology 2020;296:E145–55. https://doi.org/10.1148/radiol.2020201343 doi: 10.1148/radiol.2020201343. [DOI] [PMC free article] [PubMed]
  30. GOV.UK. NHS Test and Trace (England) and Coronavirus Testing (UK) Statistics: 15 October to 21 October. 2020. URL: www.gov.uk/government/publications/nhs-test-and-trace-england-and-coronavirus-testing-uk-statistics-15-october-to-21-october (accessed 6 May 2021).
  31. Public Health England. Preliminary Report From the Joint PHE Porton Down & University of Oxford SARS-CoV-2 Test Development and Validation Cell: Rapid Evaluation of Lateral Flow Viral Antigen Detection Devices (LFDs) for Mass Community Testing. 2020. URL: www.ox.ac.uk/sites/files/oxford/media_wysiwyg/UK%20evaluation_PHE%20Porton%20Down%20%20University%20of%20Oxford_final.pdf (accessed 6 May 2021).
  32. Dinnes J, Deeks JJ, Berhane S, Taylor M, Adriano A, Davenport C, et al. Rapid, point of care antigen and molecular based tests for diagnosis of SARS CoV 2 infection (review). Cochrane Database Syst Rev 2021;3:CD013705. https://doi.org/10.1002/14651858.CD013705 doi: 10.1002/14651858.CD013705. [DOI] [PMC free article] [PubMed]
  33. Jarvis KF, Kelley JB. Temporal dynamics of viral load and false negative rate influence the levels of testing necessary to combat COVID19 spread. medRxiv 2020:2020.08.12.20173831. https://doi.org/10.1101/2020.08.12.20173831 doi: 10.1101/2020.08.12.20173831. [DOI]
  34. Medicines and Healthcare products Regulatory Agency (MHRA). Target Product Profile. Laboratory-Based SARS-CoV-2 Viral Detection Tests. London: MHRA; 2020.
  35. Medicines and Healthcare products Regulatory Agency (MHRA). Target Product Profile. Point of Care SARS-CoV-2 Detection Tests. London: MHRA; 2020.
  36. Collier DA, Assennato SM, Warne B, Sithole N, Sharrocks K, Ritchie A, et al. Point of care nucleic acid testing for SARS-CoV-2 in hospitalized patients: a clinical validation trial and implementation study. Cell Rep Med 2020;1:100062. https://doi.org/10.1016/j.xcrm.2020.100062 doi: 10.1016/j.xcrm.2020.100062. [DOI] [PMC free article] [PubMed]
  37. Dinnes J, Deeks JJ, Adriano A, Berhane S, Davenport C, Dittrich S, et al. Rapid, point-of-care antigen and molecular-based tests for diagnosis of SARS-CoV-2 infection. Cochrane Database Syst Rev 2020;8:CD013705. https://doi.org/10.1002/14651858.CD013705 doi: 10.1002/14651858.CD013705. [DOI] [PMC free article] [PubMed]
  38. Tulloch J, Micocci M, Buckle P, Lawrenson K, Kierkegaard P, McLister A, et al. Enhanced Lateral Flow Testing Strategies in Care Homes Are Associated with Poor Adherence and Were Insufficient to Prevent COVID-19 Outbreaks: Results from a Mixed Methods Implementation Study. 2021. URL: https://ssrn.com/abstract=3822257 (accessed 6 May 2021). doi: 10.1093/ageing/afab162. [DOI] [PMC free article] [PubMed]
  39. Scheuber A. 90 Minute COVID-19 Tests: Government Orders 5.8 Million DnaNudge Kits. 2020. URL: www.imperial.ac.uk/news/201073/90-minute-covid-19-tests-government-orders/ (accessed 14 September 2020).
  40. Brazzelli M, Aucott L, Aceves-Martins M, Robertson C, Jacobsen E, Imamura M, et al. Biomarkers for assessing acute kidney injury for people who are being considered for admission to critical care: a systematic review and cost-effectiveness analysis. Health Technol Assess 2021; in press. doi: 10.3310/UGEZ4120. [DOI] [PMC free article] [PubMed]
  41. Office for National Statistics (ONS). Dataset. National Life Tables: UK. London: ONS; 2019.
  42. Ara R, Brazier JE. Populating an economic model with health state utility values: moving toward better practice. Value Health 2010;13:509–18. https://doi.org/10.1111/j.1524-4733.2010.00700.x doi: 10.1111/j.1524-4733.2010.00700.x. [DOI] [PubMed]
  43. Szende A, Oppe M, Devlin N. EQ5D Value Sets: Inventory, Comparative Review and User Guide. New York, NY: Springer; 2007. https://doi.org/10.1007/1-4020-5511-0 doi: 10.1007/1-4020-5511-0. [DOI]
  44. Office for National Statistics (ONS). Impact of Coronavirus in Care Homes in England: 26 May to 19 June 2020. London: ONS; 2020.
  45. Stinnett AA, Mullahy J. Net health benefits: a new framework for the analysis of uncertainty in cost-effectiveness analysis. Med Decis Making 1998;18:68–80. https://doi.org/10.1177/0272989X98018002S09 doi: 10.1177/0272989X98018002S09. [DOI] [PubMed]
  46. GOV.UK. COVID-19: Deaths of People With Learning Disabilities. 2020. URL: www.gov.uk/government/publications/covid-19-deaths-of-people-with-learning-disabilities (accessed 6 May 2021).

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