Cost and mortality prediction using polymerase chain reaction pathogen detection in sepsis: evidence from three observational trials
1 Department of Anesthesiology and Pain Therapy, University Hospital Bern, Inselspital, Freiburgstrasse, CH-3010 Bern, Switzerland
2 Department of Health Economics (VM), Roche Diagnostics Germany GmbH, Sandhofer Str., D-68305 Mannheim, Germany
3 Department of Pathology and Laboratory Medicine, University of California Davis Medical Center, 3453 Tupper Hall, Davis, CA 95616, USA
4 Department of Internal Medicine, Pulmonary and Critical Care, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO 63110, USA
Critical Care 2010, 14:R186 doi:10.1186/cc9294
See related commentary by Schrenzel, http://ccforum.com/content/15/1/111Published: 15 October 2010
Delays in adequate antimicrobial treatment contribute to high cost and mortality in sepsis. Polymerase chain reaction (PCR) assays are used alongside conventional cultures to accelerate the identification of microorganisms. We analyze the impact on medical outcomes and healthcare costs if improved adequacy of antimicrobial therapy is achieved by providing immediate coverage after positive PCR reports.
A mathematical prediction model describes the impact of PCR-based rapid adjustment of antimicrobial treatment. The model is applied to predict cost and medical outcomes for 221 sepsis episodes of 189 post-surgical and intensive care unit (ICU) sepsis patients with available PCR data from a prospective, observational trial of a multiplex PCR assay in five hospitals. While this trial demonstrated reduction of inadequate treatment days, data on outcomes associated with reduced inadequate initial antimicrobial treatment had to be obtained from two other, bigger, studies which involved 1,147 (thereof 316 inadequately treated) medical or surgical ICU patients. Our results are reported with the (5% to 95%) percentile ranges from Monte Carlo simulation in which the input parameters were randomly and independently varied according to their statistical characterization in the three underlying studies. The model allows predictions also for different patient groups or PCR assays.
A total of 13.1% of PCR tests enabled earlier adequate treatment. We predict that cost for PCR testing (300 €/test) can be fully recovered for patients above 717 € (605 € to 1,710 €) daily treatment cost. A 2.6% (2.0 to 3.2%) absolute reduction of mortality is expected. Cost per incremental survivor calculates to 11,477 € (9,321 € to 14,977 €) and incremental cost-effectiveness ratio to 3,107 € (2,523 € to 4,055 €) per quality-adjusted life-year. Generally, for ICU patients with >25% incidence of inadequate empiric antimicrobial treatment, and at least 15% with a positive blood culture, PCR represents a cost-neutral adjunct method.
Rapid PCR identification of microorganisms has the potential to become a cost-effective component for managing sepsis. The prediction model tested with data from three observational trials should be utilized as a framework to deepen insights when integrating more complementary data associated with utilization of molecular assays in the management of sepsis.