Cost-Effectiveness of Point-of-Care C-Reactive Protein Tests for Respiratory Tract Infection in Primary Care in England

ObjectivesUtilisation of point-of-care C-reactive protein testing for lower respiratory tract infection has been limited in UK primary care, with costs and funding suggested as important barriers. We aimed to use existing National Health Service funding and policy mechanisms to alleviate these barriers and engage with clinicians and healthcare commissioners to encourage implementation.DesignA mixed-methods study design was adopted, including a qualitative survey to identify clinicians’ and commissioners’ perceived benefits, barriers and enablers post-implementation, and quantitative analysis of results from a real-world implementation study.InterventionsWe developed a funding specification to underpin local reimbursement of general practices for test delivery based on an item of service payment. We also created training and administrative materials to facilitate implementation by reducing organisational burden. The implementation study provided intervention sites with a testing device and supplies, training and practical assistance.ResultsDespite engagement with several groups, implementation and uptake of our funding specification were limited. Survey respondents confirmed costs and funding as important barriers in addition to physical and operational constraints and cited training and the value of a local champion as enablers.ConclusionsAlthough survey respondents highlighted the clinical benefits, funding remains a barrier to implementation in UK primary care and appears not to be alleviated by the existing financial incentives available to commissioners. The potential to meet incentive targets using lower cost methods, a lack of policy consistency or competing financial pressures and commissioning programmes may be important determinants of local priorities. An implementation champion could help to catalyse support and overcome operational barriers at the local level, but widespread implementation is likely to require national policy change. Successful implementation may reproduce antibiotic prescribing reductions observed in research studies.

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Evaluating the evidence for the implementation of C-reactive protein measurement in adult patients with suspected lower respiratory tract infection in primary care: a systematic review

Family Practice ◽

10.1093/fampra/cmr119 ◽

2011 ◽

Vol 29 (4) ◽

pp. 383-393 ◽

Cited By ~ 33

Author(s):

M. F. Engel ◽

F. P. Paling ◽

A. I. M. Hoepelman ◽

V. van der Meer ◽

J. J. Oosterheert

Keyword(s):

Systematic Review ◽

Primary Care ◽

Tract Infection ◽

Respiratory Tract ◽

Respiratory Tract Infection ◽

Lower Respiratory Tract Infection ◽

Lower Respiratory Tract ◽

C Reactive Protein ◽

Reactive Protein ◽

Protein Measurement

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Cost-Effectiveness Analysis of the Use of Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing in Primary Care

Antibiotics ◽

10.3390/antibiotics7040106 ◽

2018 ◽

Vol 7 (4) ◽

pp. 106 ◽

Cited By ~ 6

Author(s):

Emily Holmes ◽

Sharman Harris ◽

Alison Hughes ◽

Noel Craine ◽

Dyfrig Hughes

Keyword(s):

Primary Care ◽

Cost Effectiveness ◽

Respiratory Tract ◽

Clinical Guidelines ◽

Antibiotic Prescription ◽

Point Of Care ◽

Cost Effective ◽

Routine Practice ◽

C Reactive Protein ◽

Reactive Protein

More appropriate and measured use of antibiotics may be achieved using point-of-care (POC) C-reactive protein (CRP) testing, but there is limited evidence of cost-effectiveness in routine practice. A decision analytic model was developed to estimate the cost-effectiveness of testing, compared with standard care, in adults presenting in primary care with symptoms of acute respiratory tract infection (ARTI). Analyses considered (1) pragmatic use of testing, reflective of routine clinical practice, and (2) testing according to clinical guidelines. Threshold and scenario analysis were performed to identify cost-effective scenarios. In patients with symptoms of ARTI and based on routine practice, the incremental cost-effectiveness ratios of CRP testing were £19,705 per quality-adjusted-life-year (QALY) gained and £16.07 per antibiotic prescription avoided. Following clinical guideline, CRP testing in patients with lower respiratory tract infections (LRTIs) cost £4390 per QALY gained and £9.31 per antibiotic prescription avoided. At a threshold of £20,000 per QALY, the probabilities of POC CRP testing being cost-effective were 0.49 (ARTI) and 0.84 (LRTI). POC CRP testing as implemented in routine practice is appreciably less cost-effective than when adhering to clinical guidelines. The implications for antibiotic resistance and Clostridium difficile infection warrant further investigation.

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SHOULD WE USE THE POINT-OF-CARE FOR TESTING C-REACTIVE PROTEIN IN ORDER TO DIAGNOSE THE RESPIRATORY TRACT INFECTION IN PRIMARY HEALTH CARE?

Russian Family Doctor ◽

10.17816/rfd2012237-41 ◽

2012 ◽

Vol 16 (2) ◽

pp. 37

Author(s):

E A Andreeva

Keyword(s):

Health Care ◽

Primary Health Care ◽

Tract Infection ◽

Respiratory Tract ◽

Respiratory Tract Infection ◽

Point Of Care ◽

C Reactive Protein ◽

Reactive Protein ◽

Primary Health

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Point-of-Care C-Reactive Protein Testing to Reduce Antibiotic Prescribing for Respiratory Tract Infections in Primary Care: Systematic Review and Meta-Analysis of Randomised Controlled Trials

Antibiotics ◽

10.3390/antibiotics9090610 ◽

2020 ◽

Vol 9 (9) ◽

pp. 610

Author(s):

Nahara Anani Martínez-González ◽

Ellen Keizer ◽

Andreas Plate ◽

Samuel Coenen ◽

Fabio Valeri ◽

...

Keyword(s):

Primary Care ◽

Respiratory Tract ◽

Usual Care ◽

Respiratory Tract Infections ◽

Point Of Care ◽

Antibiotic Prescribing ◽

C Reactive Protein ◽

Reactive Protein ◽

Meta Analyses ◽

Tract Infections

C-reactive protein (CRP) point-of-care testing (POCT) is increasingly being promoted to reduce diagnostic uncertainty and enhance antibiotic stewardship. In primary care, respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing, which is a major driver for antibiotic resistance. We systematically reviewed the available evidence on the impact of CRP-POCT on antibiotic prescribing for RTIs in primary care. Thirteen moderate to high-quality studies comprising 9844 participants met our inclusion criteria. Meta-analyses showed that CRP-POCT significantly reduced immediate antibiotic prescribing at the index consultation compared with usual care (RR 0.79, 95%CI 0.70 to 0.90, p = 0.0003, I2 = 76%) but not during 28-day (n = 7) follow-up. The immediate effect was sustained at 12 months (n = 1). In children, CRP-POCT reduced antibiotic prescribing when CRP (cut-off) guidance was provided (n = 2). Meta-analyses showed significantly higher rates of re-consultation within 30 days (n = 8, 1 significant). Clinical recovery, resolution of symptoms, and hospital admissions were not significantly different between CRP-POCT and usual care. CRP-POCT can reduce immediate antibiotic prescribing for RTIs in primary care (number needed to (NNT) for benefit = 8) at the expense of increased re-consultations (NNT for harm = 27). The increase in re-consultations and longer-term effects of CRP-POCT need further evaluation. Overall, the benefits of CRP-POCT outweigh the potential harms (NNTnet = 11).

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Enhanced Communication Skills and C-reactive Protein Point-of-Care Testing for Respiratory Tract Infection: 3.5-year Follow-up of a Cluster Randomized Trial

The Annals of Family Medicine ◽

10.1370/afm.1477 ◽

2013 ◽

Vol 11 (2) ◽

pp. 157-164 ◽

Cited By ~ 51

Author(s):

J. W. L. Cals ◽

L. de Bock ◽

P.-J. H. W. Beckers ◽

N. A. Francis ◽

R. M. Hopstaken ◽

...

Keyword(s):

Tract Infection ◽

Respiratory Tract ◽

Communication Skills ◽

Point Of Care ◽

Cluster Randomized Trial ◽

Point Of Care Testing ◽

C Reactive Protein ◽

Reactive Protein ◽

Cluster Randomized

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Respiratory tract infections (RTIs) in primary care: narrative review of C reactive protein (CRP) point-of-care testing (POCT) and antibacterial use in patients who present with symptoms of RTI

BMJ Open Respiratory Research ◽

10.1136/bmjresp-2020-000624 ◽

2020 ◽

Vol 7 (1) ◽

pp. e000624

Author(s):

Jonathan Cooke ◽

Carl Llor ◽

Rogier Hopstaken ◽

Matthew Dryden ◽

Christopher Butler

Keyword(s):

Primary Care ◽

Respiratory Tract ◽

Respiratory Tract Infections ◽

Point Of Care ◽

Narrative Review ◽

Economic Evaluations ◽

Point Of Care Testing ◽

C Reactive Protein ◽

Reactive Protein ◽

Tract Infections

Antimicrobial resistance (AMR) continues to be a global problem and continues to be addressed through national strategies to improve diagnostics, develop new antimicrobials and promote antimicrobial stewardship. Patients who attend general (ambulatory) practice with symptoms of respiratory tract infections (RTIs) are invariably assessed by some sort of clinical decision rule (CDR). However, CDRs rely on a cluster of non-specific clinical observations. A narrative review of the literature was undertaken to ascertain the value of C reactive protein (CRP) point-of-care testing (POCT) to guide antibacterial prescribing in adult patients presenting to general practitioner (GP) practices with symptoms of RTI. Studies that were included were Cochrane reviews, systematic reviews, randomised controlled trials, cluster randomised trials, controlled before and after studies, cohort studies and economic evaluations. An overwhelming number of studies demonstrated that the use of CRP tests in patients presenting with RTI symptoms reduces index antibacterial prescribing. GPs and patients report a good acceptability for a CRP POCT and economic evaluations show cost-effectiveness of CRP POCT over existing RTI management in primary care. POCTs increase diagnostic precision for GPs in the better management of patients with RTI. With the rapid development of artificial intelligence, patients will expect greater precision in diagnosing and managing their illnesses. Adopting systems that markedly reduce antibiotic consumption is a no-brainer for governments that are struggling to address the rise in AMR.

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