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Early procalcitonin testing reduced ICU costs for sepsis patients

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Real-world evidence supports use of procalcitonin

The significant findings of Balk et al. suggest that “real world” evidence may support procalcitonin as an effective tool to improve antibiotic management and reduce costs of health care for critically ill patients. Data from public databases and patient registries can play key roles in evaluating biomarkers, since physicians preparing randomized trials may behave differently than in typical care settings.

Results of the recent randomized [Simplified Acute Physiology Score] trial in connection with real-life data reported by Dr. Balk and colleagues are convincing and should lead physicians to more widespread use of PCT protocols for management of patients in the critical care settings.

The study findings also add the U.S. experience to the knowledge base as most of the interventional research has been done in Europe and Asia.

Given the promising results from the randomized trials, it is important to know how PCT impacts the clinical management of patients in real-world settings. Such information can be used to further broaden and expand the findings from the randomized trials to usual care.

Philipp Schuetz, MD, MPH, of the University of Basel, Switzerland, receives research support from Thermo Fisher and bioMerieux, which make PCT tests. Peter M. Wahl, ScD, is a full-time employee of Covance Inc., of Princeton, N.J., which makes diagnostic tests and owns clinical laboratories. Their comments were made in an editorial accompanying Dr. Balk’s report (Chest. 2017;151[1]:6-8. doi:10.1016/j.chest.2016.07.014).



Procalcitonin (PCT) testing on the first day of ICU admission for adult patients with sepsis is associated with reduced length of stay, less antibiotic exposure, and reduced hospital and pharmacy costs, Robert A. Balk, MD, and his associates reported.

After propensity matching to reduce potential bias, a total of 33,569 patients who had received PCT testing on ICU day 1 were identified; a control group of 98,543 non-PCT tested patients were identified as well. Hospital costs were $2,759 lower for PCT-tested patients ($30,454 vs. $33,213), ICU costs were $1,310 lower ($20,155 vs. $21,465), and pharmacy costs were $331 lower ($4,238 vs. $4,568). PCT-tested patients also were more commonly discharged to home (44.1% vs. 41.3%).

The PCT-tested patients had less total antibiotic exposure, (16.2 days vs. 16.9 days) but higher laboratory costs, according to Dr. Balk, director of the division of pulmonary and critical care medicine at Rush Medical College, Chicago, and his colleagues. Laboratory costs of the PCT-tested patients were $81 greater ($1,807 vs. $1,726).

While PCT testing is cleared by the Food and Drug Administration to assist in identifying patients who are highly likely to develop sepsis, there is no approved sepsis test, Dr. Balk and his colleagues noted.

“This study is important in the validation of the ability of PCT testing to favorably impact the outcome of critically ill patients when used according to the FDA cleared guidelines,” the investigators said. “The cost savings were real and consequential, exceeding the potential increased costs of laboratory testing associated with PCT testing on ICU admission.”

All-patient analysis showed a statistically significant, but slightly increased (0.7%) risk of mortality in PCT-tested patients; however, the finding was not seen in an enhanced risk-adjusted analysis of 96% of patients, the investigators pointed out. This finding is consistent with other large prospective studies showing no difference in mortality or other clinical outcomes using PCT guidances.

PCT testing has not been uniformly adopted despite its inclusion in the 2012 Surviving Sepsis Guidelines, in part, due to cost. The lack of a “gold standard” sepsis test has resulted in diagnostic dilemmas, delayed treatment, and poor outcomes, Dr. Balk and colleagues noted.

Because patients were not randomized to PCT testing or non-PCT testing groups, additional variables could have over- or underestimated the effect of PCT on patient outcomes, the researchers added.

Dr. Balk has received advisory board fees from bioMerieux USA, Roche Diagnostics, and ThermoFisher Scientific; Zhun Cao, PhD, Craig Lipkin, MS, and Scott B. Robinson MA, MPH, are employees of Premier Research Services, in Charlotte. Samuel Bozzette is an employee of bioMerieux, which provided funding for the study.

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