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Cost-effectiveness of a faecal calprotectin-guided referral strategy for children with chronic abdominal symptoms: a
Sophie Martine Ansems1, Marjolein Berger1, Patrick van Rheenen2
1Department of Primary and Long-term Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
Insights
Fecal calprotectin (FCal) testing in children with chronic abdominal symptoms did not reduce specialist referrals in the intention-to-treat analysis. Improved adherence to FCal-guided strategies is needed for potential cost-effectiveness in primary care.
Area of Science:
- Pediatric Gastroenterology
- Health Services Research
- Clinical Trial Methodology
Background:
- Triage of children with chronic abdominal symptoms presents challenges for general practitioners (GPs).
- Identifying children who would benefit from pediatric specialist care requires effective diagnostic tools.
Purpose of the Study:
- To evaluate the cost-effectiveness of fecal calprotectin (FCal) testing.
- To guide referral decisions for children with chronic abdominal symptoms in primary care.
Main Methods:
- A pragmatic, cluster-randomized controlled trial involving 84 GP practices and 405 children (aged 4-18).
- Intervention group used an FCal-guided referral strategy; control group followed standard guidelines.
- Intention-to-treat (ITT) and per-protocol (PP) analyses were conducted, assessing specialist referrals and cost-effectiveness.
Main Results:
- Adherence to the FCal strategy was 59%.
- ITT analysis showed similar referral rates (22.8% vs 21.9%) and was not cost-effective (ICER €1534).
- PP analysis revealed fewer referrals in the intervention group (5.8% vs 20.3%) and demonstrated cost-effectiveness (ICER -€344).
Conclusions:
- Current results do not support recommending FCal testing in primary care without improved implementation.
- Further research should focus on enhancing adherence to FCal-guided referral strategies.
- Effective implementation is crucial for realizing the potential benefits of FCal testing in pediatric care.
Background:
Triaging children with chronic abdominal symptoms who might benefit from paediatric specialist care is challenging for GPs.
Aim:
To evaluate the (cost) effectiveness of faecal calprotectin (FCal) testing to guide referral to specialist care in children with chronic abdominal symptoms.
Design & Setting:
This pragmatic, cluster-randomised controlled trial with 1:1 randomisation of Dutch GP practices was conducted between October 2019 and July 2021. GPs in the intervention group followed an FCal-guided referral strategy and the control group adhered to Dutch GP guidelines, which do not recommend FCal testing. Eighty-four GP practices included 405 children aged 4-18 years with chronic abdominal pain and/or diarrhoea.
Method:
The primary outcome was specialist referral within 6 months after the baseline consultation. Incremental cost-effectiveness ratios (ICERs) were calculated from the societal perspective based on parental concern. Intention-to-treat (ITT) analyses and per-protocol (PP) analyses (strategy adherence in the intervention group and no FCal use in the control group) were conducted.
Results:
Adherence to the FCal strategy was 59%. Alarm symptoms for inflammatory bowel disease were more prevalent in the intervention group (26.6%) than the control group (8.9%). Referral rates were similar in the ITT analysis (22.8% versus 21.9%; adjusted odds ratio (AOR) = 0.94; 95% confidence interval [CI] = 0.57 to 1.54) and there were fewer referrals for the intervention group in the PP analysis (5.8% versus 20.3%; AOR = 0.21; 95% CI = 0.09 to 0.50). The intervention was not cost effective in the ITT analysis (ICER = €1534; 95% CI = -€9019 to €9579), but was cost effective in the PP analysis (ICER = -€344; 95% CI = -€4609 to €3096).
Conclusion:
The results do not justify recommending FCal testing in children in primary care without proper implementation. Additional research should focus on improving adherence to the FCal strategy.
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