Cost-effectiveness of procalcitonin testing to guide antibiotic treatment duration in critically ill patients: results from a randomised controlled multicentre trial in the Netherlands

Abstract

Background: Procalcitonin (PCT) testing can help in safely reducing antibiotic treatment duration in intensive care patients with sepsis. However, the cost-effectiveness of such PCT guidance is not yet known.

Methods: A trial-based analysis was performed to estimate the cost-effectiveness of PCT guidance compared with standard of care (without PCT guidance). Patient-level data were used from the SAPS trial in which 1546 patients were randomised. This trial was performed in the Netherlands, which is a country with, on average, low antibiotic use and a short duration of hospital stay. As quality of life among sepsis survivors was not measured during the SAPS, this was derived from a Dutch follow-up study. Outcome measures were (1) incremental direct hospital cost and (2) incremental cost per quality-adjusted life year (QALY) gained from a healthcare perspective over a one-year time horizon. Uncertainty in outcomes was assessed with bootstrapping.

Results: Mean in-hospital costs were €46,081/patient in the PCT group compared with €46,146/patient with standard of care (i.e. - €65 (95% CI - €6314 to €6107); - 0.1%). The duration of the first course of antibiotic treatment was lower in the PCT group with 6.9 vs. 8.2 days (i.e. - 1.2 days (95% CI - 1.9 to - 0.4), - 14.8%). This was accompanied by lower in-hospital mortality of 21.8% vs. 29.8% (absolute decrease 7.9% (95% CI - 13.9% to - 1.8%), relative decrease 26.6%), resulting in an increase in mean QALYs/patient from 0.47 to 0.52 (i.e. + 0.05 (95% CI 0.00 to 0.10); + 10.1%). However, owing to high costs among sepsis survivors, healthcare costs over a one-year time horizon were €73,665/patient in the PCT group compared with €70,961/patient with standard of care (i.e. + €2704 (95% CI - €4495 to €10,005), + 3.8%), resulting in an incremental cost-effectiveness ratio of €57,402/QALY gained. Within this time frame, the probability of PCT guidance being cost-effective was 64% at a willingness-to-pay threshold of €80,000/QALY.

Conclusions: Although the impact of PCT guidance on total healthcare-related costs during the initial hospitalisation episode is likely negligible, the lower in-hospital mortality may lead to a non-significant increase in costs over a one-year time horizon. However, since uncertainty remains, it is recommended to investigate the long-term cost-effectiveness of PCT guidance, from a societal perspective, in different countries and settings.

Keywords: Cost-effectiveness; Intensive care; Procalcitonin; Sepsis.

Fig. 1

Incremental cost-effectiveness plane for procalcitonin (PCT) guidance compared with standard of care for costs during the hospitalisation episode. This incremental cost-effectiveness plane shows the impact of the use of a PCT-guided antibiotic treatment algorithm, as compared to standard of care, on the difference in in-hospital mortality and accompanying costs within this (initial) hospitalisation episode. The result is based on 10,000 bootstrap samples

Fig. 2

Incremental cost-effectiveness plane for procalcitonin (PCT) guidance compared with standard of care for costs until one year after ICU admission. This incremental cost-effectiveness plane shows the impact of the use of a PCT-guided antibiotic treatment algorithm, as compared to standard of care, on the difference in quality-adjusted life years (QALYs) (until one year after ICU admission) and accompanying healthcare-related costs within this one-year time period. In addition, the willingness-to-pay (WTP) thresholds of €20,000/QALY and €80,000/QALY are shown. The result is based on 10,000 bootstrap samples

Fig. 3

Cost-effectiveness acceptability curve. This cost-effectiveness acceptability curve shows the probability that the use of PCT-guided antibiotic treatment is cost-effective compared to standard of care, for a willingness-to-pay threshold ranging from €0/quality-adjusted life year (QALY) to €200,000/QALY. This analysis incorporates all healthcare-related costs over a one-year time horizon