Evaluation of Triage Tests When Existing Test Capacity Is Constrained: Application to Rapid Diagnostic Testing in COVID-19

OBJECTIVES: A triage test is used to determine which patients will undergo an existing or “reference” test. This article explores the potential value of using triage tests before reference tests when the capacity of the reference test is constrained. METHODS: We developed a simple model with inputs: prevalence, sensitivity, specificity, and reference test capacity. We included a case study of rapid diagnostic tests for SARS-CoV-2 antigens used as triage tests before a reference polymerase chain reaction test. Performance data were obtained from an evaluation performed by an academic center on 425 samples from testing centers in the United Kingdom and Germany. RESULTS: When reference test capacity is constrained, the use of a triage test leads to a relative expansion of the population tested and cases identified; both are higher with a high-specificity triage test. When reference test capacity is not constrained, the potential advantages of introducing a triage test can be assessed using a standard cost-utility framework, balancing the utility of the reduction in the number of reference tests required against the disutility of missed cases associated with the use of a lower-sensitivity triage test. In the constrained case, the advantage of a triage testing strategy in terms of population covered and cases identified is reduced as the prevalence increases. In the unconstrained case, the reduction in reference tests required is reduced and the number of cases missed increase as the prevalence rises. CONCLUSION: When the availability of the reference test is constrained, tests added in a triage position do not need high levels of accuracy to increase the number of cases diagnosed. This has implications in many disease areas, including COVID-19.