Cost-effectiveness of a faecal calprotectin-guided referral strategy for children with chronic abdominal symptoms: a cluster randomised controlled trial

Sophie M Ansems; Marjolein Y Berger; Patrick F van Rheenen; Karin M Vermeulen; Michiel R de Boer; Gea A Holtman

doi:10.3399/BJGP.2025.0334

Cost-effectiveness of a faecal calprotectin-guided referral strategy for children with chronic abdominal symptoms: a cluster randomised controlled trial

Br J Gen Pract. 2026 Apr 30;76(766):e385-e397. doi: 10.3399/BJGP.2025.0334. Print 2026 May 1.

Authors

Sophie M Ansems¹, Marjolein Y Berger¹, Patrick F van Rheenen², Karin M Vermeulen³, Michiel R de Boer¹, Gea A Holtman⁴

Affiliations

¹ Department of Primary and Long-term Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
² Department of Paediatric Gastroenterology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
³ Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
⁴ Department of Primary and Long-term Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands g.a.holtman@umcg.nl.

PMID: 41218993
DOI: 10.3399/BJGP.2025.0334

Abstract

Background: Triaging children with chronic abdominal symptoms who might benefit from paediatric specialist care is challenging for GPs.

Aim: To evaluate the (cost) effectiveness of faecal calprotectin (FCal) testing to guide referral to specialist care in children with chronic abdominal symptoms.

Design & setting: This pragmatic, cluster-randomised controlled trial with 1:1 randomisation of Dutch GP practices was conducted between October 2019 and July 2021. GPs in the intervention group followed an FCal-guided referral strategy and the control group adhered to Dutch GP guidelines, which do not recommend FCal testing. Eighty-four GP practices included 405 children aged 4-18 years with chronic abdominal pain and/or diarrhoea.

Method: The primary outcome was specialist referral within 6 months after the baseline consultation. Incremental cost-effectiveness ratios (ICERs) were calculated from the societal perspective based on parental concern. Intention-to-treat (ITT) analyses and per-protocol (PP) analyses (strategy adherence in the intervention group and no FCal use in the control group) were conducted.

Results: Adherence to the FCal strategy was 59%. Alarm symptoms for inflammatory bowel disease were more prevalent in the intervention group (26.6%) than the control group (8.9%). Referral rates were similar in the ITT analysis (22.8% versus 21.9%; adjusted odds ratio (AOR) = 0.94; 95% confidence interval [CI] = 0.57 to 1.54) and there were fewer referrals for the intervention group in the PP analysis (5.8% versus 20.3%; AOR = 0.21; 95% CI = 0.09 to 0.50). The intervention was not cost effective in the ITT analysis (ICER = €1534; 95% CI = -€9019 to €9579), but was cost effective in the PP analysis (ICER = -€344; 95% CI = -€4609 to €3096).

Conclusion: The results do not justify recommending FCal testing in children in primary care without proper implementation. Additional research should focus on improving adherence to the FCal strategy.

Keywords: child; faecal calprotectin; functional gastrointestinal disease; inflammatory bowel diseases; primary health care.

Publication types

Randomized Controlled Trial
Pragmatic Clinical Trial
Research Support, Non-U.S. Gov't

MeSH terms

Abdominal Pain* / diagnosis
Abdominal Pain* / economics
Abdominal Pain* / etiology
Adolescent
Child
Child, Preschool
Chronic Disease
Cost-Benefit Analysis
Diarrhea* / diagnosis
Diarrhea* / economics
Diarrhea* / etiology
Feces* / chemistry
Female
Humans
Inflammatory Bowel Diseases* / diagnosis
Leukocyte L1 Antigen Complex* / analysis
Male
Netherlands
Referral and Consultation* / economics

Substances

Leukocyte L1 Antigen Complex