Abstract
ObjectivesSepsis presents a major burden to the emergency department (ED). Because empiric inappropriate antimicrobial therapy (IAAT) is associated with increased mortality, rapid molecular assays may decrease IAAT and improve outcomes. We evaluated the cost-effectiveness of molecular testing as an adjunct to blood cultures in patients with severe sepsis or septic shock evaluated in the ED.MethodsWe developed a decision analysis model with primary outcome the incremental cost-effectiveness ratio expressed in terms of deaths averted. Costs were dependent on the assay price and the patients’ length of stay (LOS). Three base-case scenarios regarding the difference in LOS between patients receiving appropriate (AAT) and IAAT were described. Sensitivity analyses regarding the assay cost and sensitivity, and its ability to guide changes from IAAT to AAT were performed.ResultsUnder baseline assumptions, molecular testing was cost-saving when the LOS differed by 4 days between patients receiving IAAT and AAT (ICER -$7,302/death averted). Our results remained robust in sensitivity analyses for assay sensitivity≥52%, panel efficiency≥39%, and assay cost≤$270. In the extreme case that the LOS of patients receiving AAT and IAAT was the same, the ICER remained≤$20,000/death averted for every studied sensitivity (i.e. 0.5–0.95), panel efficiency≥34%, and assay cost≤$313. For 2 days difference in LOS, the bundle approach was dominant when the assay cost was≤$135 and the panel efficiency was≥77%.ConclusionsThe incorporation of molecular tests in the management of sepsis in the ED has the potential to improve outcomes and be cost-effective for a wide range of clinical scenarios.
Highlights
Sepsis presents a major burden to U.S emergency departments (ED), with up to 850,000 estimated visits annually between 2009–2011 [1]
Molecular testing was cost-saving when the length of stay (LOS) differed by 4 days between patients receiving inappropriate antimicrobial therapy (IAAT) and antimicrobial therapy (AAT) (ICER -$7,302/death averted)
In the extreme case that the LOS of patients receiving AAT and IAAT was the same, the incremental cost-effectiveness ratio (ICER) remained $20,000/death averted for every studied sensitivity (i.e. 0.5–0.95), panel efficiency 34%, and assay cost $313
Summary
Sepsis presents a major burden to U.S emergency departments (ED), with up to 850,000 estimated visits annually between 2009–2011 [1]. Treatment of septic patients places a significant financial burden on the U.S healthcare system with estimated $20.3 billion spent in 2011 [2], and the annual rate of increase of the average cost of hospital stay for sepsis is three-times the rate for hospital costs overall [3]. The management of sepsis relies on early initiation of appropriate antimicrobial therapy (AAT) [4], with a goal of administering AAT within 1 hour of recognition of severe sepsis or septic shock [5, 6]. While sepsis-related mortality rate can exceed 40% [7], empiric inappropriate antimicrobial therapy (IAAT) for severe infections has been shown to increase 30-day mortality by 71% and in-hospital mortality by 67% [8]. Rapid molecular diagnostic techniques for the identification of bloodstream pathogens directly from whole blood samples have been developed recently, with the potential of pathogen identification in 2–7 hours [12]
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