C-reactive protein (CRP)/ Viral Biomarker Testing to Improve Patient Care, Outcomes, Cost Avoidances and Antimicrobial Stewardship in a Community COPD Population.

Project overview, including who was involved in the project
Chronic obstructive pulmonary disease (COPD) exacerbation is a sustained worsening of symptoms resulting in the need for additional medication (usually steroids and antibiotics). Diagnosis can be inaccurate and management inappropriate, potentiated by prevalent population anxiety. This threatens individual and public health, increasing the risk of antimicrobial resistance (AMR) and has financial implications.

Guidelines encourage C-reactive protein (CRP) testing to facilitate prescribing decisions and support antimicrobial stewardship. The Bridgend COPD Team support older patients at home many of which cannot access CRP testing due to symptom severity and geographical challenges. Existing processes for CRP testing in the community are associated with increased travel time, costs, delayed treatment and are environmentally unsustainable.

Simultaneous measurement of myxovirus resistance protein A (MxA) and CRP in people with acute febrile respiratory infections is designed to help differentiate between viral and bacterial infections. FebriDx (Lumos Diagnostics) is a self-contained, portable, all-in-one test device with high sensitivity, specificity and negative predictive value for bacterial and viral infections and is supported for use by the National Institute for Health and Care Excellence (NICE) Medtech Innovation Briefing MIB224 (2020).

A prospective sample of patients meeting COPD Team inclusion criteria was included. FebriDx assessment occurred where there was diagnostic ambiguity or for reassurance to the patient that treatment was not clinically indicated. Patients self-referred or had been referred by primary care with acute exacerbation. Thirty-six participants were assessed at home over seven months. A data collection sheet was used to collate outcomes for each patient, including decision-making changes, prescribing, tolerance and communication. Data was retrospectively analysed at 3 and 7 months.

Who was involved in this work/project?
The Swansea Bay University Health Board Bridgend COPD Team comprises a multi-disciplinary team (MDT) of physiotherapists, nurses, occupational therapist, technician and dietitian providing community intervention for those with the highest disease severity and symptom burden. The service provides exacerbation support and self-management education with the aim of admission avoidance and early supported discharge.
Project outcomes/impact
42% of tests were positive for infection. Of these, 87% were positive for bacterial infection, 13% for viral. 58% of tests were negative when clinicians thought exacerbation was possible. Clinicians' decision-making and diagnosis was confirmed in 31% of cases. In 47% of cases, testing changed the clinician's mind, and a prescription was not made (or rescue pack not taken), amounting to 13 saved antibiotic and 4 steroid prescriptions. FebriDx demonstrated bacterial infection in 11% of cases undetected by clinical assessment alone. 8% of patients reporting exacerbation were dissuaded from rescue pack use. Staff valued the test as an excellent resource. 100% of tests were well-received by patients.
In a world approaching antimicrobial crisis, FebriDx delivered improved co-produced, effective care in the community COPD population. Patient safety increased by reducing inappropriate medication use, side effects and may also reduce harm from unrecognised pathology. FebriDx supports clinical reasoning in conjunction with clinical assessment in the case of diagnostic ambiguity. Patient education and reassurance improved. Joint decision-making was supported, especially with patients who frequently and inappropriately report exacerbation.

Cost avoidances were realised due to reduced admission/readmission, reduced travel costs for staff, reduced GP attendance, medication cost savings among other saved expenditures.

Ongoing funding for FebriDx has been achieved and device use is continuing to prove a valuable diagnostic tool for the Bridgend COPD Team.
If you were to run the project again, what would you do differently?
Device cost and limited availability meant that we were cautious with patient selection and only those patients with clinical diagnostic ambiguity were chosen or those that were clinically not exacerbating and the test was used for education purposes. This may have created some bias in the results obtained. Free use of the device for all patients with symptoms of exacerbation despite clinical assessment/diagnosis would provide a wider range of results which may be more valuable for interpretation. There were no clear inclusion/exclusion criteria for device use, it was based on subjective clinician decision. There was no clear question to answer, we just wanted to know if it would be a useful adjunct to clinical assessment. The data collection sheet was devised by the manufacturer and on using it for data analysis, it was difficult to interpret the data.
Advice you would have for others undertaking the same type of project.
Consider what question you would like to answer / problem you would like to address. Ascertain device availability as this will influence inclusion/exclusion criteria for device use. Ensure the data collection sheet gives you the information to answer your question/problem.