Near-Patient Test for C-Reactive Protein in General Practice: Assessment of Clinical, Organizational, and Economic Outcomes

Abstract Background: The benefits of near-patient, point-of-care tests have not been fully examined. We have assessed the clinical, organizational, and economic outcomes of implementing a near-patient test for C-reactive protein (CRP) in general practice. Methods: In a randomized crossover trial during intervention periods, general practitioners (GPs) were allowed to measure CRP within 3 min, using NycoCard® CRP. During control periods, they had to mail blood samples for CRP measurements to the hospital laboratory and received test results 24–48 h later. Twenty-nine general practice clinics participated (64 GPs), and 1853 patients were included in the study. Results were evaluated at both the level of participating GPs and the level of included patients. Results: For participating GPs, the overall use of erythrocyte sedimentation rates (ESRs) decreased by 8% (95% confidence interval, 1–14%) during intervention periods, and the number of blood samples mailed to the hospital laboratory decreased by 6% (1–10%). No reduction in the prescription of antibiotics was seen. The proportion of study patients having a follow-up telephone consultation was reduced from 63% to 53% (P = 0.0001), and patients with CRP concentrations >50 mg/L had their antibiotic treatments started earlier when CRP was measured in general practices (P = 0.0161). Conclusion: The implementation of the near-patient CRP test was cost-effective mainly on the basis of a reduction in the use of services from the hospital laboratory by GPs. If the implementation is followed by education and clinical guidelines, opportunities exist for additional reduction in the use of ESR and for a more appropriate use of antibiotics.

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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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Evaluating a point-of-care C-reactive protein test to support antibiotic prescribing decisions in a general practice

Clinical Pharmacist ◽

10.1211/cp.2016.20201688 ◽

2016 ◽

Keyword(s):

General Practice ◽

Point Of Care ◽

Antibiotic Prescribing ◽

C Reactive Protein ◽

Reactive Protein

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Point-of-care C-reactive protein to assist in primary care management of children with suspected non-serious lower respiratory tract infection: a randomised controlled trial

BJGP Open ◽

10.3399/bjgpopen18x101600 ◽

2018 ◽

Vol 2 (3) ◽

pp. bjgpopen18X101600 ◽

Cited By ~ 4

Author(s):

Marjolein JC Schot ◽

Ann Van den Bruel ◽

Berna DL Broekhuizen ◽

Jochen WL Cals ◽

Eveline A Noteboom ◽

...

Keyword(s):

General Practice ◽

Randomised Controlled Trial ◽

Respiratory Tract ◽

Lower Respiratory Tract ◽

Antibiotic Prescription ◽

Point Of Care ◽

Controlled Trial ◽

C Reactive Protein ◽

Reactive Protein ◽

Randomised Controlled

BackgroundOverprescription of antibiotics for lower respiratory tract infections (LRTIs) in children is common, partly due to diagnostic uncertainty, in which case the addition of point-of-care (POC) C-reactive protein (CRP) testing can be of aid.AimTo assess whether use of POC CRP by the GP reduces antibiotic prescriptions in children with suspected non-serious LRTI.Design & settingAn open, pragmatic, randomised controlled trial in daytime general practice and out-of-hours services.MethodChildren between 3 months and 12 years of age with acute cough and fever were included and randomised to either use of POC CRP or usual care. Antibiotic prescription rates were measured and compared between groups using generalising estimating equations.ResultsThere was no statistically significant reduction in antibiotic prescriptions in the GP use of CRP group (30.9% versus 39.4%; odds ratio [OR] 0.6; 95% confidence interval [CI] = 0.29 to 1.23). Only the estimated severity of illness was related to antibiotic prescription. Forty-six per cent of children had POC CRP levels <10mg/L.ConclusionIt is still uncertain whether POC CRP measurement in children with non-serious respiratory tract infection presenting to general practice can reduce the prescription of antibiotics. Until new research provides further evidence, POC CRP measurement in these children is not recommended.

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Evaluating a point-of-care C-reactive protein test to support antibiotic prescribing decisions in a general practice

The Pharmaceutical Journal ◽

10.1211/pj.2016.20201688 ◽

2016 ◽

Keyword(s):

General Practice ◽

Point Of Care ◽

Antibiotic Prescribing ◽

C Reactive Protein ◽

Reactive Protein

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C-reactive protein point-of-care testing in children with cough: qualitative study of GPs' perceptions

BJGP Open ◽

10.3399/bjgpopen17x101193 ◽

2017 ◽

Vol 1 (4) ◽

pp. bjgpopen17X101193 ◽

Cited By ~ 1

Author(s):

Marjolein JC Schot ◽

Berna DL Broekhuizen ◽

Jochen WL Cals ◽

Esther Brussee ◽

Niek J de Wit ◽

...

Keyword(s):

General Practice ◽

Qualitative Study ◽

Point Of Care ◽

Diagnostic Process ◽

Communication Tool ◽

C Reactive Protein ◽

Structured Interviews ◽

Acute Cough ◽

Reactive Protein ◽

The Impact

BackgroundPoint-of-care C-reactive protein (CRP) testing is widely accepted in Dutch general practice for adult patients with acute cough, but GPs’ perceptions of its use in children with suspected lower respiratory tract infection (LRTI) are unknown. Knowledge of these perceptions is important when considering broadening its indication to use in children.AimTo explore the perceptions of Dutch GPs of the addition of point-of-care CRP testing to the diagnostic evaluation of children, and compare these to their perceptions of use in adults.Design & settingA qualitative study in general practice in the Netherlands.MethodSemi-structured interviews were held with 11 GPs. Interviews were analysed using open coding and a thematic approach.ResultsGPs’ perceptions of the addition of point-of-care CRP testing to diagnostic process in children with suspected LRTI differ from their perceptions of this in adults. Five themes were identified: patient characteristics; vulnerability of the child; clinical presentation; availability of evidence; the impact of the procedure; and use of point-of-care CRP testing as a communication tool.ConclusionDifferences between the perceptions of using point-of-care CRP testing in children and adults need to be addressed when considering the possible implementation of this diagnostic instrument.

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Field-testing and validation in a primary care setting of a point-of-care test for C-reactive protein

Annals of Clinical Biochemistry International Journal of Laboratory Medicine ◽

10.1258/000456303763046139 ◽

2003 ◽

Vol 40 (2) ◽

pp. 178-180 ◽

Cited By ~ 26

Author(s):

David A. Seamark ◽

Susan N. Backhouse ◽

Roy Powell

Keyword(s):

Primary Care ◽

General Practice ◽

Point Of Care ◽

Laboratory Method ◽

Practice Setting ◽

Standard Laboratory ◽

C Reactive Protein ◽

General Practice Setting ◽

Reactive Protein ◽

Significant Difference

Background: Use of point-of-care testing (POCT) in primary care has increased. There is a need for high-quality field evaluation of POCT before deployment can be considered. Method: A POCT system for C-reactive protein was evaluated in a routine general practice setting. The standard laboratory method was a dry slide method based in a routine hospital laboratory. Results: Scatterplots for both venous and capillary blood POCT system results versus the standard laboratory assay produced correlation coefficients of greater than 0·96. Bland-Altman plots indicated that 95% of venous and capillary POCT results fell within ±10 mg/L of the mean value with no clinically significant difference from laboratory results. Conclusions: The POCT system performed reliably in a routine general practice setting with satisfactory performance against an accepted laboratory method.

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Qualitative study to explore the views of general practice staff on the use of point-of-care C reactive protein testing for the management of lower respiratory tract infections in routine general practice in England

BMJ Open ◽

10.1136/bmjopen-2018-023925 ◽

2018 ◽

Vol 8 (10) ◽

pp. e023925 ◽

Cited By ~ 4

Author(s):

Charlotte Victoria Eley ◽

Anita Sharma ◽

Donna Marie Lecky ◽

Hazel Lee ◽

Cliodna Ann Miriam McNulty

Keyword(s):

General Practice ◽

Focus Groups ◽

Point Of Care ◽

Easy Access ◽

Antibiotic Prescribing ◽

C Reactive Protein ◽

Acute Cough ◽

Practice Staff ◽

Reactive Protein ◽

Tract Infections

ObjectivesTo explore the knowledge, skills, attitudes and beliefs of general practice staff about C reactive protein (CRP) point-of-care tests (POCTs) in routine general practice and associated barriers and facilitators to implementing it to improve the management of acute cough.DesignA qualitative methodology including interviews and focus groups using the Com-B framework to understand individuals’ behaviour to implement CRP POCT in routine general practice. Data were analysed inductively and then aligned to the Com-B framework.SettingA service evaluation of CRP POCT over a 6-month period was previously conducted in randomly selected GP practices from a high prescribing National Health Service Clinicial Commissioning Groups in England. All 11 intervention practices (eight accepting CRPs; three declining CRPs) and the eight control practices, which were not offered CRP POCT, were also invited to interview. A further randomly selected practice not allocated to intervention or control was also invited to participate.ParticipantsSeven of eight accepting CRP, one of three declining CRP and four of nine control practices consented to participate. 12 practices and 26 general practice staff participated; 11 interviews, 3 focus groups and 1 hand-written response.ResultsParticipants reported that CRP POCT can increase diagnostic certainty for acute cough, inform appropriate management, manage patient expectations for antibiotics, support patient education and improve appropriate antibiotic prescribing. Reported barriers to implementing CRP POCT included: CRP cost, time, easy access to the POCT machine and effects on clinical workflow. Participants with greater CRP use usually had a dedicated staff member with the machine located in their consultation room.ConclusionsCRP POCT can help general practice staff improve patient care and education if incorporated into routine care, but this will need enthusiasts with dedicated POCT instruments or smaller, cheaper, more portable machines. In addition, funding will be needed to support test costs and staff time.

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Economic considerations support C-reactive protein testing alongside malaria rapid diagnostic tests to guide antimicrobial therapy for patients with febrile illness in settings with low malaria endemicity

Malaria Journal ◽

10.1186/s12936-019-3059-5 ◽

2019 ◽

Vol 18 (1) ◽

Author(s):

Yoel Lubell ◽

Arjun Chandna ◽

Frank Smithuis ◽

Lisa White ◽

Heiman F. L. Wertheim ◽

...

Keyword(s):

Antimicrobial Resistance ◽

Antimicrobial Therapy ◽

Diagnostic Tests ◽

Distribution Systems ◽

Point Of Care ◽

Febrile Illness ◽

Cost Effective ◽

Rapid Diagnostic Tests ◽

C Reactive Protein ◽

Reactive Protein

AbstractMalaria is no longer a common cause of febrile illness in many regions of the tropics. In part, this success is a result of improved access to accurate diagnosis and effective anti-malarial treatment, including in many hard-to-reach rural areas. However, in these settings, management of other causes of febrile illness remains challenging. Health systems are often weak and other than malaria rapid tests no other diagnostics are available. With millions of deaths occurring annually due to treatable bacterial infections and the ever increasing spread of antimicrobial resistance, improvement in the management of febrile illness is a global public health priority. Whilst numerous promising point-of-care diagnostics are in the pipeline, substantial progress can be made in the interim with existing tools: C-reactive protein (CRP) is a highly sensitive and moderately specific biomarker of bacterial infection and has been in clinical use for these purposes for decades, with dozens of low-cost devices commercially available. This paper takes a health-economics approach to consider the possible advantages of CRP point-of-care tests alongside rapid diagnostic tests for malaria, potentially in a single multiplex device, to guide antimicrobial therapy for patients with febrile illness. Three rudimentary assessments of the costs and benefits of this approach all indicate that this is likely to be cost-effective when considering the incremental costs of the CRP tests as compared with either (i) the improved health outcomes for patients with bacterial illnesses; (ii) the costs of antimicrobial resistance averted; or (iii) the economic benefits of better management of remaining malaria cases and shorter malaria elimination campaigns in areas of low transmission. While CRP-guided antibiotic therapy alone cannot resolve all challenges associated with management of febrile illness in remote tropical settings, in the short-term a multiplexed CRP and malaria RDT could be highly cost-effective and utilize the well-established funding and distribution systems already in place for malaria RDTs. These findings should spark further interest amongst industry, academics and policy-makers in the development and deployment of such diagnostics, and discussion on their geographically appropriate use.

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C-reactive protein cut-offs used for acute respiratory infections in Danish general practice

BJGP Open ◽

10.3399/bjgpopen20x101136 ◽

2020 ◽

pp. bjgpopen20X101136

Author(s):

Jesper Lykkegaard ◽

Jonas Kanstrup Olsen ◽

Rikke Vognbjerg Sydenham ◽

Malene Hansen

Keyword(s):

General Practice ◽

Respiratory Infections ◽

Point Of Care ◽

Signs And Symptoms ◽

Antibiotic Prescribing ◽

C Reactive Protein ◽

Cross Sectional ◽

Duration Of Symptoms ◽

Reactive Protein ◽

Tract Infections

Background: General practitioners (GPs) can use C-reactive protein (CRP) point-of-care test to assist when deciding whether to prescribe antibiotics for patients with acute respiratory tract infections (RTIs). Aim: To estimate which CRP cut-off levels Danish GPs use to guide antibiotic prescribing for patients presenting with different signs and symptoms of RTIs. Design and setting: Cross-sectional study. General practice in Denmark. Methods: During winter 2017 and 2018, 143 GPs and their staff registered consecutive patients with symptoms of an RTI according to the Audit Project Odense method. CRP cut-offs were estimated as the lowest level at which half of the patients were prescribed an antibiotic. Results: In total, 7,813 patients were diagnosed with an RTI of whom 4,617 (59%) had a CRP test performed. At least 25% of the patients were prescribed an antibiotic when the CRP level was above 20 mg/L, at least 50% when CRP was above 40 mg/L, and at least 75% when CRP was above 50 mg/L. Lower thresholds were identified for patients aged 65 years and those presenting with a fever, poor general appearance, dyspnoea, abnormal lung auscultation or ear/facial pain - and if the duration of symptoms was either short (≤1 day) or long (>14 days). Conclusion: More than half of patients presenting to Danish general practice with symptoms of an RTI have a CRP test performed. At CRP-levels above 40 mg/L the majority of patients have an antibiotic prescribed.

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