From chaos to clarity: how COVID-19 exposed the urgent need for better evidence synthesis

Abstract

The COVID-19 pandemic was unexpected and unprecedented. The novel SARS-CoV-2 had no diagnostic tests and was initially diagnosed based on clinical symptoms and exclusion of other pulmonary pathogens. As the biotech industry and biomedical research community shifted their focus to this new threat, many began to develop new products, such as rapid antigen tests (RATs) and polymerase chain reaction (PCR) tests targeting SARS-CoV-2. Three issues early in the pandemic emphasized the need for excellent evidence-based synthesis approaches for diagnostic tests: i) the wide variety of RATs and gold-standard PCR tests, ii) the limited number of available tests regardless of manufacturer, and iii) the use of a few published sequences for the development of the RATs.1 Each of these issues made identifying and using RATs in specific local communities difficult due to the shifting landscape of available tests and test types, and loss of test reliability with the emergence of new variants. Robust evidence synthesis projects can help to reduce the noise generated by these and similar issues, and lead to more reliable health care practices during times of crisis or calm. The lessons learned from the testing environment for COVID-19 in 2020–21 can be applied to current health care issues, particularly the need for evidence-based recommendations on diagnostic testing. Lesson 1: Poor testing availability leads to expensive alternatives in infectious disease control. As reported by Prasad et al.2 in 2023, the scarcity of reliable testing resulted in widespread community-level mitigation strategies, including the shutdown and remote relocation of almost all economic activities. Workers lost wages, jobs, and other essential resources because the risk of spreading the disease outweighed the benefit of continued work productivity. Lesson 2: Inaccurate testing leads to inappropriate treatment. As early as 2020, the outcomes of false-positive and false-negative test results were reported to lead to poor patient outcomes.3 Such outcomes included misallocation of resources and loss of worker productivity to patients without the infection and a delay or absence of treatment in patients with the infection. Lesson 3: The inability to accurately test for the disease results in reductions in primary, preventive, and screening care. A recent systematic review and meta-analysis demonstrated a delay in cancer diagnoses during the pandemic that may have increased the number of preventable cancer deaths.4 This is just one of many examples of severely reduced access to care when patients cannot be tested accurately and efficiently. In the systematic review “Comparison of diagnostic accuracy of rapid antigen tests for COVID-19 compared to the viral genetic test in adults: a systematic review and meta-analysis,” we located and synthesized more than 90 published articles that examined 53 different RATs to make a recommendation for the most accurate test to use in the primary care setting.5 Out of these, 50 were commercially available and 3 were in development. The meta-analysis revealed that, overall, RATs were excellent at predicting when a positive result means a positive diagnosis of COVID-19. However, it was also observed that the pooled sensitivity across the popular RATs was 67.1%, which suggested that negative test results likely needed to be retested through an additional method or with sequential testing over several days. Based on our findings, we recommend that Roche’s SARS-CoV-2 Rapid Antigen Test6 and Abbott’s BinaxNOW tests7 be used in primary care settings, with the understanding that negative results need to be confirmed through other methods. We also recommend that papers adhere to the STARD guidelines when reporting on diagnostic data, which would allow for improved data collection and meta-analysis.8 This evidence-based review demonstrates the heterogeneity of diagnostic tests as well as the studies developed to assess their performance during 2020–21. In current and future health care crises, the synthesis and communication of these data must be timely, thorough, and driven by the best available evidence. As we approach the fifth annual World Evidence-Based Healthcare Day on October 20, with a focus on “Health and beyond: from evidence to action,” this review highlights the need for collaborative and deliberate action to generate consistent and usable evidence in today’s health care system that impacts the local and global communities.9 The world needs adaptable evidence-based approaches that can be used in the current polycrisis for more significant cross-disciplinary challenges. The world needs more equitable and sustainable solutions for societies to survive and thrive. Our review is global in nature, using data from 44 countries across 6 continents. Health and health care impact every living being on the planet, from humans and animals to plants, microbes, and the environment as a whole. Building a better evidence-based support system with interdisciplinary and intersectoral action is key to creating equitable and sustainable societies.

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