Economic evaluation of procalcitonin-guided antibiotic therapy in acute respiratory infections: a US health system perspective

Schuetz, Philipp; Balk, R.A.; Briel, Matthias; Kutz, Alexander; Christ‐Crain, Mirjam; Stolz, Daiana; Bouadma, Lila; Wolff, Michel; Kristoffersen, Kristina B; Long, Wei; Burkhardt, Olaf; Welte, Tobias; Schroeder, Stefan; Nobre, Vandack; Tamm, Michael; Bhatnagar, Neera; Bucher, Heiner C.; Luyt, Charles‐Édouard; Chastre, Jean; Tubach, Florence; Müeller, Beat; Lacey, Michael J.; Ohsfeldt, Robert L.; Scheibling, Cara M.; Schneider, John E.

doi:10.1515/cclm-2014-1015

Cited by 63 publications

(53 citation statements)

References 62 publications

(98 reference statements)

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“…The comparison was PCT-guided treatment versus non PCT-guided treatment in all studies, and considered (adult) patients with sepsis in the ICU, 45,80,81 hospitalised children with pneumonia, 79 adult patients admitted to the hospital with LRTI, 83 adult patients with suspected CAP admitted to the ED, 42 and patients with suspected ARTI in three different settings. 82 In contrast with the two full economic evaluations included in the review, the cost-minimisation studies in the more severe populations (sepsis, ARTI and pneumonia) reported cost-savings when using PCT-guided treatment, 45,[79][80][81][82] whereas the two studies 42,83 that focused on adult patients admitted to the hospital with LRTI 83 and adult patients with suspected CAP presenting to the ED 42 report additional costs when using PCT-guided treatment. The cost-effectiveness analysis by Cleves et al 83 reported, for patients with LRTI, an incremental cost-effectiveness ratio (ICER) of £51 per additional percentage of correctly treated patients with antibiotics.…”

Section: Overview Of Potentially Relevant Excluded Studiesmentioning

confidence: 98%

“…In addition to the included studies described above, seven potentially relevant studies 42,45,[79][80][81][82][83] that compared PCT testing with no PCT testing were excluded, as they were either cost-minimisation studies 42,45,[79][80][81][82] or a cost-effectiveness analysis 83 using other outcomes than survival or QALYs. For completeness, an overview of these studies is provided in Table 10.…”

Section: Overview Of Potentially Relevant Excluded Studiesmentioning

confidence: 99%

“…These analyses resulted in ICERs of US$90,000, US$40,000 and US$170,000 per QALY gained, respectively. Additionally, an overview of potentially relevant excluded studies (mainly cost-minimisation studies focused on the short term) indicated that PCT-guided treatment could result in cost-savings for adult patients with sepsis, ARTI and pneumonia, 45,[79][80][81][82] while additional costs for PCT-guided treatment were found for adults with LRTI 83 and suspected CAP. 42 In a de novo health-economic analysis, the cost-effectiveness of PCT testing in addition to current clinical practice was compared with current clinical practice for (1) adults with confirmed or highly suspected sepsis in an ICU setting; (2) adults with suspected bacterial infection presenting to the ED; and (3) children with suspected bacterial infection presenting to the ED.…”

Section: Cost-effectivenessmentioning

confidence: 99%

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Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

Westwood

Ramaekers

Whiting

et al. 2015

Health Technol Assess

111

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BackgroundDetermination of the presence or absence of bacterial infection is important to guide appropriate therapy and reduce antibiotic exposure. Procalcitonin (PCT) is an inflammatory marker that has been suggested as a marker for bacterial infection.ObjectivesTo assess the clinical effectiveness and cost-effectiveness of adding PCT testing to the information used to guide antibiotic therapy in adults and children (1) with confirmed or highly suspected sepsis in intensive care and (2) presenting to the emergency department (ED) with suspected bacterial infection.MethodsTwelve databases were searched to June 2014. Randomised controlled trials were assessed for quality using the Cochrane Risk of Bias tool. Summary relative risks (RRs) and weighted mean differences (WMDs) were estimated using random-effects models. Heterogeneity was assessed visually using forest plots and statistically using theI2andQstatistics and investigated through subgroup analysis. The cost-effectiveness of PCT testing in addition to current clinical practice was compared with current clinical practice using a decision tree with a 6 months’ time horizon.ResultsEighteen studies (36 reports) were included in the systematic review. PCT algorithms were associated with reduced antibiotic duration [WMD –3.19 days, 95% confidence interval (CI) –5.44 to –0.95 days,I2 = 95.2%; four studies], hospital stay (WMD –3.85 days, 95% CI –6.78 to –0.92 days,I2 = 75.2%; four studies) and a trend towards reduced intensive care unit (ICU) stay (WMD –2.03 days, 95% CI –4.19 to 0.13 days,I2 = 81.0%; four studies). There were no differences for adverse clinical outcomes. PCT algorithms were associated with a reduction in the proportion of adults (RR 0.77, 95% CI 0.68 to 0.87; seven studies) and children (RR 0.86, 95% CI 0.80 to 0.93) receiving antibiotics, reduced antibiotic duration (two studies). There were no differences for adverse clinical outcomes. All but one of the studies in the ED were conducted in people presenting with respiratory symptoms.Cost-effectiveness: the base-case analyses indicated that PCT testing was cost-saving for (1) adults with confirmed or highly suspected sepsis in an ICU setting; (2) adults with suspected bacterial infection presenting to the ED; and (3) children with suspected bacterial infection presenting to the ED. Cost-savings ranged from £368 to £3268. Moreover, PCT-guided treatment resulted in a small quality-adjusted life-year (QALY) gain (ranging between < 0.001 and 0.005). Cost-effectiveness acceptability curves showed that PCT-guided treatment has a probability of ≥ 84% of being cost-effective for all settings and populations considered (at willingness-to-pay thresholds of £20,000 and £30,000 per QALY).ConclusionsThe limited available data suggest that PCT testing may be effective and cost-effective when used to guide discontinuation of antibiotics in adults being treated for suspected or confirmed sepsis in ICU settings and initiation of antibiotics in adults presenting to the ED with respiratory symptoms and suspected bacterial infection. However, it is not clear that observed costs and effects are directly attributable to PCT testing, are generalisable outside people presenting with respiratory symptoms (for the ED setting) and would be reproducible in the UK NHS. Further studies are needed to assess the effectiveness of adding PCT algorithms to the information used to guide antibiotic treatment in children with suspected or confirmed sepsis in ICU settings. Additional research is needed to examine whether the outcomes presented in this report are fully generalisable to the UK.Study registrationThis study is registered as PROSPERO CRD42014010822.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Section: Overview Of Potentially Relevant Excluded Studiesmentioning

confidence: 98%

Section: Overview Of Potentially Relevant Excluded Studiesmentioning

confidence: 99%

Section: Cost-effectivenessmentioning

confidence: 99%

See 1 more Smart Citation

Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

Westwood

Ramaekers

Whiting

et al. 2015

Health Technol Assess

111

View full text Add to dashboard Cite

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“…Both CRP [27,28] and PCT [29,30] have demonstrated utility in differentiating bacterial from viral acute respiratory infection (ARI) in developed countries, and for PCT its use has been estimated to confer substantial economic gains (USD1.6 billion (ZAR18.8 billion) savings if used across the US health sector) in HICs. [31] In a high tuberculosis-prevalence country such as SA, the utility of CRP and PCT is less clear for ARI, as both are increased in tuberculosis. Furthermore, in a resourcechallenged healthcare setting, PCT, which currently costs in excess of ZAR300 per test, is costly, particularly when used incorrectly.…”

Section: Antibiotic Stewardship At the Individual Patient Levelmentioning

confidence: 99%

Role of antibiotic stewardship in extending the age of modern medicine

Mendelson

2015

S Afr Med J

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Antibiotic resistance is threatening modern medicine. Overuse and misuse of antibiotics is driving resistance to such an extent that we have entered the post-antibiotic era, where some multidrug-and pandrug-resistant bacterial infections are no longer treatable. If the situation is not reversed, 10 million people will die annually of drug-resistant infections by 2050. More than just a question of mortality, such infections are causing the closure of wards, cancellation of operations, and interference with other common medical procedures that rely on antibiotics for their success. The response to this crisis requires co-ordinated international action with increased surveillance of bacterial resistance, infection prevention, and antibiotic stewardship, i.e. access to affordable, quality-assured antibiotics prescribed appropriately. This review describes antibiotic stewardship at the individual patient and programmatic level, which must be adopted by every prescriber if we are to preserve modern medicine for future generations.

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“…The paper by Phillip Schuetz and Colleagues, which is published in this issue of Clinical Chemistry and Laboratory Medicine, therefore, is very welcome as it adds further evidence of the substantial cost savings associated with PCT protocols of ARI in comparison to usual care [11]. The cost impact model built by the authors was evaluated in three US clinical settings: 1) Hospital Ward/ED, 2) Hospital ICU, and 3) Outpatient Clinic/ED.…”

mentioning

confidence: 99%

Procalcitonin-guided antibiotic therapy: a potentially effective and efficient strategy

Plebani

Fabbri

2015

Clinical Chemistry and Laboratory Medicine (CCLM)

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Economic evaluation of procalcitonin-guided antibiotic therapy in acute respiratory infections: a US health system perspective

Cited by 63 publications

References 62 publications

Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis

Role of antibiotic stewardship in extending the age of modern medicine

Procalcitonin-guided antibiotic therapy: a potentially effective and efficient strategy

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