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Cost-Effectiveness of Procalcitonin-Guided Antibiotic Use in Community Acquired Pneumonia

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ABSTRACT

BACKGROUND

Although prior randomized trials have demonstrated that procalcitonin-guided antibiotic therapy effectively reduces antibiotic use in patients with community-acquired pneumonia (CAP), uncertainties remain regarding use of procalcitonin protocols in practice.

OBJECTIVE

To estimate the cost-effectiveness of procalcitonin protocols in CAP.

DESIGN

Decision analysis using published observational and clinical trial data, with variation of all parameter values in sensitivity analyses.

PATIENTS

Hypothetical patient cohorts who were hospitalized for CAP.

INTERVENTIONS

Procalcitonin protocols vs. usual care.

MAIN MEASURES

Costs and cost per quality adjusted life year gained.

KEY RESULTS

When no differences in clinical outcomes were assumed, consistent with clinical trials and observational data, procalcitonin protocols cost $10–$54 more per patient than usual care in CAP patients. Under these assumptions, results were most sensitive to variations in: antibiotic cost, the likelihood that antibiotic therapy was initiated less frequently or over shorter durations, and the likelihood that physicians were nonadherent to procalcitonin protocols. Probabilistic sensitivity analyses, incorporating procalcitonin protocol-related changes in quality of life, found that protocol use was unlikely to be economically reasonable if physician protocol nonadherence was high, as observational study data suggest. However, procalcitonin protocols were favored if they decreased hospital length of stay.

CONCLUSIONS

Procalcitonin protocol use in hospitalized CAP patients, although promising, lacks physician nonadherence and resource use data in routine care settings, which are needed to evaluate its potential role in patient care.

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REFERENCES

  1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(Suppl 2):S27–72.

    Article  PubMed  CAS  Google Scholar 

  2. Garcia-Vazquez E, Marcos MA, Mensa J, et al. Assessment of the usefulness of sputum culture for diagnosis of community-acquired pneumonia using the PORT predictive scoring system. Arch Intern Med. 2004;164:1807–11.

    Article  PubMed  Google Scholar 

  3. Reed WW, Byrd GS, Gates RH Jr, Howard RS, Weaver MJ. Sputum gram’s stain in community-acquired pneumococcal pneumonia. A meta-analysis. West J Med. 1996;165:197–204.

    PubMed  CAS  Google Scholar 

  4. Tacconelli E. Antimicrobial use: risk driver of multidrug resistant microorganisms in healthcare settings. Curr Opin Infect Dis. 2009;22:352–8.

    Article  PubMed  CAS  Google Scholar 

  5. Wenzel RP, Edmond MB. Managing antibiotic resistance. N Engl J Med. 2000;343:1961–3.

    Article  PubMed  CAS  Google Scholar 

  6. Schuetz P, Chiappa V, Briel M, Greenwald JL. Procalcitonin algorithms for antibiotic therapy decisions: a systematic review of randomized controlled trials and recommendations for clinical algorithms. Arch Intern Med. 2011;171:1322–31.

    Article  PubMed  Google Scholar 

  7. Becker KL, Nylen ES, White JC, Muller B, Snider RH Jr. Procalcitonin and the calcitonin gene family of peptides in inflammation, infection, and sepsis: a journey from calcitonin back to its precursors. J Clin Endocrinol Metab. 2004;89:1512–25.

    Article  PubMed  CAS  Google Scholar 

  8. Muller F, Christ-Crain M, Bregenzer T, et al. Procalcitonin levels predict bacteremia in patients with community-acquired pneumonia: a prospective cohort trial. Chest. 2010;138:121–9.

    Article  PubMed  CAS  Google Scholar 

  9. Albrich WC, Dusemund F, Bucher B, et al. Effectiveness and safety of procalcitonin-guided antibiotic therapy in lower respiratory tract infections in “Real Life”: an International, Multicenter Poststudy Survey (ProREAL). Arch Intern Med. 2012;172:715–22.

    Article  PubMed  CAS  Google Scholar 

  10. Yealy DM, Fine MJ. Measurement of serum procalcitonin: a step closer to tailored care for respiratory infections? JAMA. 2009;302:1115–6.

    Article  PubMed  CAS  Google Scholar 

  11. US Bureau of Labor Statistics. Consumer price index. http://www.bls.gov/cpi/#data (Accessed February 19, 2013)

  12. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336:243–50.

    Article  PubMed  CAS  Google Scholar 

  13. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58:377–82.

    Article  PubMed  CAS  Google Scholar 

  14. Fry AM, Zell ER, Schuchat A, Butler JC, Whitney CG. Comparing potential benefits of new pneumococcal vaccines with the current polysaccharide vaccine in the elderly. Vaccine. 2002;21:303–11.

    Article  PubMed  Google Scholar 

  15. Centers for Medicare & Medicaid Services. New Clinical Laboratory Fee Schedule Test Codes. Procalcitonin. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/CY2011-CLFS-New-Test-Codes.pdf. (Accessed February 19, 2013)

  16. Fine MJ, Pratt HM, Obrosky DS, et al. Relation between length of hospital stay and costs of care for patients with community-acquired pneumonia. Am J Med. 2000;109:378–85.

    Article  PubMed  CAS  Google Scholar 

  17. Gold MR, Franks P, McCoy KI, Fryback DG. Toward consistency in cost-utility analyses: using national measures to create condition-specific values. Med Care. 1998;36:778–92.

    Article  PubMed  CAS  Google Scholar 

  18. Coley CM, Li YH, Medsger AR, et al. Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia. Arch Intern Med. 1996;156:1565–71.

    Article  PubMed  CAS  Google Scholar 

  19. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362:1225–30.

    Article  PubMed  Google Scholar 

  20. Sharpe BA. Putting a critical pathway into practice: the devil is in the implementation details: comment on “effect of a 3-step critical pathway to reduce duration of intravenous antibiotic therapy and length of stay in community-acquired pneumonia”putting a critical pathway into practice. Arch Intern Med. 2012;172:928–9.

    Article  PubMed  Google Scholar 

  21. Agarwal R, Schwartz DN. Procalcitonin to guide duration of antimicrobial therapy in intensive care units: a systematic review. Clin Infect Dis. 2011;53:379–87.

    Article  PubMed  Google Scholar 

  22. Layios N, Lambermont B, Canivet JL, et al. Procalcitonin usefulness for the initiation of antibiotic treatment in intensive care unit patients*. Crit Care Med. 2012;40:2304–9.

    Article  PubMed  CAS  Google Scholar 

  23. Fine MJ, Medsger AR, Stone RA, et al. The hospital discharge decision for patients with community-acquired pneumonia. Results from the Pneumonia Patient Outcomes Research Team cohort study. Arch Intern Med. 1997;157:47–56.

    Article  PubMed  CAS  Google Scholar 

  24. Fine MJ, Stone RA, Lave JR, et al. Implementation of an evidence-based guideline to reduce duration of intravenous antibiotic therapy and length of stay for patients hospitalized with community-acquired pneumonia: a randomized controlled trial. Am J Med. 2003;115:343–51.

    Article  PubMed  Google Scholar 

  25. Fine MJ, Stone RA, Singer DE, et al. Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study. Arch Intern Med. 1999;159:970–80.

    Article  PubMed  CAS  Google Scholar 

  26. Carratala J, Garcia-Vidal C, Ortega L, et al. Effect of a 3-step critical pathway to reduce duration of intravenous antibiotic therapy and length of stay in community-acquired pneumonia: a randomized controlled trialA 3-step critical pathway for CAP. Arch Intern Med. 2012;172:922–8.

    Article  PubMed  Google Scholar 

  27. Schnoor M, Meyer T, Suttorp N, Raspe H, Welte T, Schafer T. Development and evaluation of an implementation strategy for the German guideline on community-acquired pneumonia. Qual Saf Health Care. 2010;19:498–502.

    Article  PubMed  CAS  Google Scholar 

  28. Mundy LM, Leet TL, Darst K, Schnitzler MA, Dunagan WC. Early mobilization of patients hospitalized with community-acquired pneumonia. Chest. 2003;124:883–9.

    Article  PubMed  Google Scholar 

  29. Rhew DC, Tu GS, Ofman J, Henning JM, Richards MS, Weingarten SR. Early switch and early discharge strategies in patients with community-acquired pneumonia: a meta-analysis. Arch Intern Med. 2001;161:722–7.

    Article  PubMed  CAS  Google Scholar 

  30. Li JZ, Winston LG, Moore DH, Bent S. Efficacy of short-course antibiotic regimens for community-acquired pneumonia: a meta-analysis. Am J Med. 2007;120:783–90.

    Article  PubMed  CAS  Google Scholar 

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Acknowledgements

Funding

Supported by the NIAID (R01AI 076256)

Prior presentations

Presented in part at the 2012 Annual Meeting of the Society of General Internal Medicine.

Conflict of interest

Dr. Zimmerman and Dr. Nowalk have a research grant from Merck to study the HPV vaccine.

Author information

Authors and Affiliations

  1. Department of Medicine, University of Pittsburgh School of Medicine, 200 Meyran Ave, Suite 200, Pittsburgh, PA, 15213, USA

    Kenneth J. Smith MD, MS, Angela Wateska MPH, Bruce Y. Lee MD, MBA & Michael J. Fine MD, MSc

  2. Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    M. Patricia Nowalk PhD, RD, Mahlon Raymund PhD & Richard K. Zimmerman MD, MPH

  3. Center for Health Equity and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA

    Michael J. Fine MD, MSc

Authors
  1. Kenneth J. Smith MD, MS
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  2. Angela Wateska MPH
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  3. M. Patricia Nowalk PhD, RD
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  4. Mahlon Raymund PhD
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  5. Bruce Y. Lee MD, MBA
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  6. Richard K. Zimmerman MD, MPH
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  7. Michael J. Fine MD, MSc
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Corresponding author

Correspondence to Kenneth J. Smith MD, MS.

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Smith, K.J., Wateska, A., Nowalk, M.P. et al. Cost-Effectiveness of Procalcitonin-Guided Antibiotic Use in Community Acquired Pneumonia. J GEN INTERN MED 28, 1157–1164 (2013). https://doi.org/10.1007/s11606-013-2400-x

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  • DOI: https://doi.org/10.1007/s11606-013-2400-x

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