The use of a standardized PCT-algorithm reduces costs in intensive care in septic patients - a DRG-based simulation model

Abstract

IntroductionThe management of bloodstream infections especially sepsis is a difficult task. An optimal antibiotic therapy (ABX) is paramount for success. Procalcitonin (PCT) is a well investigated biomarker that allows close monitoring of the infection and management of ABX. It has proven to be a cost-efficient diagnostic tool. In Diagnoses Related Groups (DRG) based reimbursement systems, hospitals get only a fixed amount of money for certain treatments. Thus it's very important to obtain an optimal balance of clinical treatment and resource consumption namely the length of stay in hospital and especially in the Intensive Care Unit (ICU). We investigated which economic effects an optimized PCT-based algorithm for antibiotic management could have.Materials and methodsWe collected inpatient episode data from 16 hospitals. These data contain administrative and clinical information such as length of stay, days in the ICU or diagnoses and procedures. From various RCTs and reviews there are different algorithms for the use of PCT to manage ABX published. Moreover RCTs and meta-analyses have proven possible savings in days of ABX (ABD) and length of stay in ICU (ICUD). As the meta-analyses use studies on different patient populations (pneumonia, sepsis, other bacterial infections), we undertook a short meta-analyses of 6 relevant studies investigating in sepsis or ventilator associated pneumonia (VAP). From this analyses we obtained savings in ABD and ICUD by calculating the weighted mean differences. Then we designed a new PCT-based algorithm using results from two very recent reviews. The algorithm contains evidence from several studies. From the patient data we calculated cost estimates using German National standard costing information for the German G-DRG system.We developed a simulation model where the possible savings and the extra costs for (in average) 8 PCT tests due to our algorithm were brought into equation.ResultsWe calculated ABD savings of -4 days and ICUD reductions of -1.8 days. our algorithm contains recommendations for ABX onset (PCT ≥ 0.5 ng/ml), validation whether ABX is appropriate or not (Delta from day 2 to day 3 ≥ 30% indicates inappropriate ABX) and recommendations for discontinuing ABX (PCT ≤ 0.25 ng/ml).We received 278, 264 episode datasets where we identified by computer-based selection 3, 263 cases with sepsis. After excluding cases with length of stay (LOS) too short to achieve the intended savings, we ended with 1, 312 cases with ICUD and 268 cases without ICUD. Average length of stay of ICU-patients was 27.7 ± 25.7 days and for Non-ICU patients 17.5 ± 14.6 days respectively. ICU patients had an average of 8.8 ± 8.7 ICUD.After applying the simulation model on this population we calculated possible savings of € -1, 163, 000 for ICU-patients and € -36, 512 for Non-ICU patients.DiscussionOur findings concerning the savings from the reduction of ABD are consistent with other publications. Savings ICUD had never been economically evaluated so far. our algorithm is able to possibly set a new ...

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

“…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.…”

“…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.…”

“…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.…”

Procalcitonin: a valuable markerfor assessment of the success of antimicrobial therapy for severe sepsis An analysis using routine clinical data

“…In addition, rules for when therapy should commence and end, and cut off values to evaluate successful treatment have been established. Implementation of this system may introduce savings for the German diagnosis-related group (G-DRG) system [8].…”

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

“…PCT has the potential to improve the management of health care resources a number of ways, including: 1) reducing unnecessary antibiotic prescriptions and supporting improved antibiotic stewardship; 2) reducing hospital LOS; 3) improving the timing of diagnosis and treatment; and 4) improving the ability of clinicians to optimally match diagnosis and treatment [5,34,51,[54][55][56][57][58][59][60].…”