Cost-Effectiveness of Procalcitonin-Guided Antibiotic Therapy for Outpatient Management of Acute Respiratory Tract Infections in Adults

Abstract

BACKGROUND:Two clinical trials suggest that procalcitonin-guided antibiotic therapy can safely reduce antibiotic prescribing in outpatient management of acute respiratory tract infections (ARTIs) in adults. Yet, it remains unclear whether procalcitonin testing is cost-effective in this setting. OBJECTIVE: To evaluate the cost-effectiveness of procalcitonin-guided antibiotic therapy in outpatient management of ARTIs in adults. DESIGN: Cost-effectiveness model based on results from two published European clinical trials, with all parameters varied widely in sensitivity analyses. PATIENTS: Two hypothetical cohorts were modeled in separate trial-based analyses: adults with ARTIs judged by their physicians to require antibiotics and all adults with ARTIs. INTERVENTIONS: Procalcitonin-guided antibiotic therapy protocols versus usual care. MAIN MEASURES: Costs and cost per antibiotic prescription safely avoided. KEY RESULTS: We estimated the health care system willingness-to-pay threshold as $43 (range $0-$333) per antibiotic safely avoided, reflecting the estimated cost of antibiotic resistance per outpatient antibiotic prescribed. In the cohort including all adult ARTIs judged to require antibiotics by their physicians, procalcitonin cost $31 per antibiotic prescription safely avoided and the likelihood of procalcitonin use being favored compared to usual care was 58.4 % in a probabilistic sensitivity analysis. In the analysis that included all adult ARTIs, procalcitonin cost $149 per antibiotic prescription safely avoided and the likelihood of procalcitonin use being favored was 2.8 %. CONCLUSIONS: Procalcitonin-guided antibiotic therapy for outpatient management of ARTIs in adults would be cost-effective when the costs of antibiotic resistance are considered and procalcitonin testing is limited to adults with ARTIs judged by their physicians to require antibiotics.

Cost-Effectiveness of Decision Support Strategies in Acute Bronchitis

“…4,8 Our results suggest that a simple, low cost, safe, and modestly effective intervention to reduce antibiotic overuse in acute bronchitis is likely to be cost saving. This finding is in concordance with prior work suggesting that 'antibiotic-restrictive' strategies for management of acute bronchitis 21 and acute respiratory tract infections, 9 in general, are likely to be cost-effective, provided that there is no impact of antibiotic restriction on clinical outcomes. Both the PDS and CDS interventions evaluated here compare favorably to education, audit and feedback and delayed antibiotic prescription interventions with regard to effectiveness, cost and ease of deployment.…”

“…10 We compared strategies in Published online April 4, 2015 terms of cost per antibiotic prescription safely avoided, a previously described outcome measure that is particularly useful in evaluating the cost-effectiveness of interventions to improve the appropriateness of antibiotic prescribing where the primary goal is to reduce antibiotic use without negatively impacting patients' quality or quantity of life. 9 The model structure was identical across all three strategies (Fig. 1).…”

“…20 In our analysis, which compared strategies in terms of cost per antibiotic safely avoided, we assumed that the societal WTP threshold equaled $43 per antibiotic safely avoided, based on prior estimates of the downstream societal costs of antibiotic resistance attributable to an antibiotic prescription. 9 The underlying concept is that society should be willing to pay $43 to safely avoid an antibiotic prescription, because the total downstream societal costs of antibiotic resistance attributable to an antibiotic prescription equal $43.…”

“…8 Yet, even modestly effective interventions may be economically reasonable for use if implementation costs are low. 9 An intervention that is safe, at least modestly effective, low cost and feasible for wide deployment has the potential to be a cost-effective component of a multi-component quality improvement approach to reduce antibiotic overuse in the ambulatory setting.…”

Personalized Medicine Without the “Omics”

“…The article by Michaelidis et al considers whether treatment of outpatient respiratory infections can be improved through collection of more precise clinical data-in this case, the use of procalcitonin as a marker of bacterial infection. 2 They conclude that procalcitonin testing can reduce antibiotic use, but is not cost-effective unless societal costs owing to antibiotic resistance are considered. In an entirely different clinical realm, Stephens et al ask similar questions about alcoholic detoxification, specifically evaluating a new, more patientspecific, protocol.…”