EvidenceAlerts

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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