INTRODUCTION
Across numerous European nations, the integration of point-of-care testing (POCT) for C-reactive protein (CRP) has become standard practice in primary care settings. This widespread adoption is primarily aimed at guiding antibiotic therapy for patients presenting with acute respiratory infections. However, this beneficial approach has yet to be fully embraced in countries like the UK and Australia. Considering that general practice is the domain where the majority of antibiotic prescriptions originate, CRP testing offers a significant opportunity to refine antibiotic usage, reserving these medications for patients with more severe infections, particularly those of bacterial origin. The ongoing discourse has recently expanded to include the relevance of rapid CRP measurement in the context of COVID-19, further highlighting the test’s potential in managing respiratory illnesses.
The robust clinical evidence base supporting the use of CRP POCT to guide antibiotic therapy in adult populations has been rigorously examined by experts such as Cals and Ebell. Their findings underscore a growing body of evidence indicating that CRP testing can play a crucial role in safely decreasing antibiotic prescriptions in adult patients suffering from acute respiratory infections.1 Echoing these sentiments, a recent narrative review conducted by Cooke and colleagues questioned the reasons behind the underutilization of this valuable diagnostic tool in the UK.2
Given the substantial evidence advocating for CRP POCT, the key challenge now shifts to identifying and addressing the remaining obstacles hindering its widespread implementation, particularly in the context of diagnosing conditions like pneumonia in adults.
WHAT ARE THE BARRIERS TO IMPLEMENTATION OF CRP POCT?
One of the most frequently cited impediments to the broader adoption of point-of-care CRP testing is the complexity of funding and reimbursement mechanisms.3 The financial aspect is intrinsically linked to the perceived economic impact of implementing such testing. Economic evaluations, including a budget impact model comparing POCT to standard care4 and a decision-modeling study contrasting POCT alone and POCT combined with communication skills training against standard care5, have suggested that POCT exhibits only marginal cost-effectiveness. However, these analyses are often fraught with uncertainties and frequently overlook the long-term advantages of antibiotic stewardship—a factor admittedly challenging to quantify economically. Furthermore, the issue of silo budgeting complicates funding approvals, as the costs associated with implementing testing and the subsequent benefits realized downstream often fall under disparate healthcare budget allocations.
Beyond financial considerations, other barriers to CRP testing emerge from its integration into the consultation process. Concerns have been raised across multiple studies regarding the reliability of POCT results, the potential for overuse or over-reliance on testing, and the logistical challenges of seamlessly incorporating POCT workflows into existing practice operations.3,6 In the UK, regulatory bodies like the Medicines and Healthcare products Regulatory Agency (MHRA) stipulate that local laboratories should provide support for POCT conducted outside of hospital settings. Australia, however, faces a different set of challenges, including limited laboratory experience in supporting POCT beyond hospitals, although alternative POCT support frameworks are available.7
WHAT IS THE INTERNATIONAL EXPERIENCE OF CRP POCT?
Long-term experience of CRP POCT
While the body of research includes numerous trials assessing CRP POCT, there is a relative scarcity of data concerning the long-term effects of routine CRP testing on antibiotic prescribing patterns. The Netherlands offers a valuable case study, where CRP testing is implemented alongside established guidelines for interpreting test results and recommended clinical cut-offs. Data spanning the last decade from the Netherlands indicate that the proportion of patients exhibiting low CRP test results (≤20 mg/L, although the original article mentions 99mg/L which seems incorrect based on typical clinical cutoffs for low risk) remains consistent with findings from initial scientific studies that specifically included patients with lower respiratory tract infections. This consistency suggests that there has been no significant increase in overtesting over time.8 Conversely, in Sweden, where such stringent guidelines are not in place, reports of potential overtesting have surfaced.9 In Australia, a randomized controlled trial evaluating CRP testing as part of a multifaceted intervention strategy did not achieve widespread adoption, primarily due to insufficient support and encouragement for general practitioners to utilize the test effectively.10
CRP POCT during the COVID-19 pandemic
Hospital-based studies have highlighted the additional prognostic value of even moderately elevated CRP levels, among other biomarkers, in patients diagnosed with COVID-19 infections.11 However, the utility of CRP POCT in general practice settings during the pandemic remains less clear. During peak periods of the COVID-19 crisis, patient management strategies varied considerably both between and within different countries and regions. General practitioners in the Netherlands continued to employ CRP POCT, particularly in a subset of patients suspected of having COVID-19, to aid in crucial management decisions, primarily concerning hospital referrals and the diagnosis of (non-COVID-19) pneumonia. This sustained use underscores the adaptability and perceived value of CRP POCT even amidst a novel respiratory pandemic.
Support models for POCT
International experiences provide valuable insights into effective strategies for overcoming the documented barriers to POCT implementation. In the Netherlands, the infrastructure for CRP POCT is provided by the same organizations responsible for central laboratory testing services. This comprehensive model includes the provision of all necessary testing resources, coupled with thorough training programs for practice staff and ongoing quality management support. Notably, reimbursement for testing services is typically directed to the supporting laboratory rather than directly to the general practitioner, streamlining the financial and administrative processes.
Alt text: A medical professional conducts a point-of-care CRP test, utilizing a handheld device on a patient in a clinic setting, emphasizing rapid diagnostics for informed healthcare decisions.
The Norwegian organization Noklus, funded by the central government, provides POCT support to a vast network of general practitioners across Norway and neighboring countries. Regular reports and publications from Noklus consistently demonstrate the high standards of POCT performance achieved within this supported framework.12 However, it is worth noting that Noklus’s monitoring activities do not extend to clinical and process outcomes, which are crucial components of an optimal POCT implementation model.
While direct reimbursement for POCT is not generally available for general practices in Australia, many GPs routinely perform POCT for international normalized ratio (INR) monitoring. Furthermore, GPs in rural and remote areas of Australia often utilize a broader range of POCT services, supported by virtual POCT organizations that provide remote guidance and quality assurance.7 Collectively, the accumulated experience with POCT in both Australia and the Netherlands highlights a significant trend: once general practitioners and their practice staff become proficient in using POCT, they effectively integrate it into their daily practice workflows. Contrary to initial concerns about disruption, many practitioners report that POCT actually enhances practice efficiency and streamlines patient care.
NEXT STEPS
The logical next step involves conducting a large-scale implementation trial to rigorously evaluate the impact of CRP POCT in general practice settings. This trial should comprehensively measure both clinical and economic outcomes, with a particular focus on reductions in antibiotic prescriptions. However, a more pragmatic and immediately achievable approach may be to prioritize the implementation of CRP POCT with the more focused objective of refining the diagnostic process itself. The primary improvement sought would be a shift in antibiotic prescribing patterns, ensuring that patients with genuine pneumonia receive necessary antibiotic treatment while minimizing unnecessary prescriptions for those with minor, often viral, illnesses. The experiences in the Netherlands suggest that this more judicious approach to prescribing not only improves patient care but also enhances satisfaction for both patients and general practitioners, representing a valuable and readily appreciated outcome.13
A crucial second step is the recognition and acceptance that robust support models are indispensable for enabling general practitioners to effectively conduct POCT as intended. Such support structures are essential for addressing quality assurance issues and can significantly aid in the seamless integration of POCT into existing practice workflows. The specific form of these support models may need to be tailored to the unique context of each country. However, in Australia, successful organizations dedicated to POCT support already exist and demonstrate the viability of this approach. While there are associated costs with establishing and maintaining such support systems, the required investment can be strategically distributed across multiple types of point-of-care tests as POCT adoption expands—a likely trajectory based on international experiences.
A third, and potentially more contentious, step involves establishing effective mechanisms for monitoring the implementation of CRP POCT. Unlike pharmaceuticals, point-of-care tests typically do not undergo rigorous post-market surveillance, despite widespread evidence of both over- and undertesting in clinical practice. Thornton and colleagues have explored these critical issues in the specific context of CRP POCT.14 Furthermore, broader evidence indicates suboptimal implementation of numerous healthcare interventions across the board, underscoring the need for improved implementation practices.15 The counterarguments to stringent monitoring often cite concerns about creating undue burden on general practitioners and raising potential issues related to data privacy and patient confidentiality. Therefore, a balanced approach is needed, potentially involving periodic audits of relevant outcomes that are designed to be easily implemented and funded as part of a quality improvement initiative. In Australia, the Practice Incentives Program could potentially serve as a framework for such audits, integrated within the POCT support model.
Finally, the funding and reimbursement of CRP POCT should be strategically viewed as a broader healthcare investment with a holistic, system-wide perspective. It should be recognized as an integral component of a multi-faceted strategy aimed at combating the escalating threat of antibiotic resistance. Avent and colleagues emphasize that isolated interventions are unlikely to yield sustainable reductions in antibiotic prescribing. Instead, effective antibiotic stewardship necessitates a combination of behavioral and regulatory strategies, such as incorporating accreditation standards, to achieve lasting impact.16
Considering the enduring presence of COVID-19 as a significant cause of acute respiratory infections, future POCT strategies should also encompass testing capabilities for COVID-19, alongside influenza and other relevant microbiological agents. The technological landscape is rapidly evolving, and it is anticipated that a range of multiplex devices capable of simultaneously measuring CRP, COVID-19 markers, influenza viruses, and other pathogens will soon become available, further enhancing the diagnostic utility of point-of-care testing in primary care.
CONCLUSION
Strategic investment is essential to establish robust, high-quality, and patient-safe point-of-care CRP testing infrastructure within general practice settings. This investment should empower healthcare providers to effectively utilize CRP testing for the differential diagnosis of acute respiratory infections, particularly pneumonia in adults. Such implementation should be considered a key element within a broader, multi-pronged strategy dedicated to reducing inappropriate antibiotic usage and combating antimicrobial resistance. Crucially, this investment must encompass dedicated funding for comprehensive POCT support systems and ongoing implementation monitoring. Long-term monitoring of patient and healthcare professional experiences, along with relevant clinical outcomes, is imperative to rigorously assess whether CRP POCT demonstrably enhances the quality of patient care, including promoting responsible antibiotic stewardship practices in the diagnosis and management of conditions like pneumonia in adults.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
