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

BackgroundProcalcitonin (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.MethodsA 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.ResultsMean in-hospital costs were Euro46,081/patient in the PCT group compared with Euro46,146/patient with standard of care (i.e. -Euro65 (95% CI -Euro6314 to Euro6107); -0.1%). The duration of the first course of antibiotic treatment was lower in the PCT group with 6.9 vs. 8.2days (i.e. -1.2days (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 Euro73,665/patient in the PCT group compared with Euro70,961/patient with standard of care (i.e.+Euro2704 (95% CI -Euro4495 to Euro10,005), +3.8%), resulting in an incremental cost-effectiveness ratio of Euro57,402/QALY gained. Within this time frame, the probability of PCT guidance being cost-effective was 64% at a willingness-to-pay threshold of Euro80,000/QALY.ConclusionsAlthough 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.