158 Correspondence / American Journal of Emergency Medicine 36 (2018) 134–168
29 June 2017 The dissemination of a questionnaire was addressed to the 110 par-
http://dx.doi.org/10.1016/j.ajem.2017.07.031
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Procalcitonin in the ED: A potential expensive
over-request that can be modulated through
institutional protocols
Procalcitonin (PCT) first appeared as a test to find out if bacterial in-
fection and to decrease the number and duration of treatments [1] as
well as the length of hospital stay [2]. Also benefits in duration in Emer-
gency Department (ED) were reported [3]. However further cost-effec-
tiveness studies for adults and children with suspected bacterial
infection presenting to the ED, resulted in only a small quality-adjusted
life years (QALYs) gain compared with standard clinical practice alone
[4]. Economic analysis was also not conclusive as the costs of unneces-
sary tests were not included in the study [4]. Moreover ED is a setting
with much more variation in clinical assessment and also in the decision
to give antibiotics when compared to intensive care unit [4,5].
Previous Redconlab studies have reported differences in laboratory
requesting patterns in ED [6]. The aim of the research was to study ED
PCT request, total expenses, effects of restricted criteria for its measure-
ment and potential economic savings.
ticipants of the previous REDCONLAB study [7], asking for the number of
PCT requested by ED clinicians and attended patients in ED for the year
2016. There were also asked for the price of a PCT test (reagent) and if
PCT demand was restricted.
PCT requested per 1000 ED admissions was calculated and com-
pared between laboratories with restricted and with free availability
for PCT demand. The average reagent price was calculated. We also cal-
culated how many PCT tests would have been not ordered if in labora-
tories where the request was not restricted would have had the same
figures as the ones where it was, and the potential economical savings
through the average price of the reagent.
All analyses were performed using SPSS Inc. for Windows, Version
21.0. (Chicago, SPSS Inc.). Descriptive statistics were generated for
test-utilization rates.
The difference between restricted-PCT group and free availability
PCT group was calculated by way of a U Mann-Whitney.
65 laboratories participated in the study. In 8 (12.3%) laboratories
PCT was not available for its request. PCT/1000 ED admissions in the re-
maining 57 laboratories was 21.89 (35.19). There was a dispersion of
the indicator results (Fig. 1).
32 (56.1%) laboratories conformed the free availability and 25
(43.9%) the restricted PCT availability group, showing lower request
(7.5; 11.0 vs 32.7; 36.4) (P b 0.05). Fig. 2 shows the demand for PCT in
both groups.
46 laboratories reported the price of the reagent. The average price
was 9.44$. Taking into account this reagent price 1,346,406$ were
spent in one year, to measure a total of 142,644 PCT requested from
ED that attended a total of 4,692,340 medical admissions in one year.
62,972 PCT tests could have been not measured if the demand in the
free availability group would have been the same as in the restricted-
availability counterpart, with potential savings of 594,390$.
The cost benefits for the PCT request are still uncertain, especially in
ED because there is much more variation in clinical evaluation and in
the decision to give antibiotics, as compared to the intensive care unit
[4]. Clinical assessment in patients with suspected bacterial infection
with low risk of sepsis may be variable, and therefore the clinical bene-
fits of adding PCT to standard clinical practice are uncertain and also un-
certainty remains around whether reductions in resource use [3,8]
would be applicable to generalized ED clinical practice [4]. In fact the
lack of consistent scientific evidence together with the relatively high
test costs do not allow for the addition for PCT testing to standard clin-
ical practice without a clear guidance or protocol on its use [5].
However our results show that there is a high PCT demand, high ex-
penses and variable demand. In fact, in 12% of laboratories, the test was
not available for its request, and the request ranged from 0.8 to 305.7
tests per 1000 ED admissions. Also the money spent was high on a
test whose benefit of its use in ED is still not clearly demonstrated.
Our research also shows that vetting of restricted tests by applying gat-
ing policies works in the PCT test.
Our study results show that laboratory professional can promote and
preserve the cost-benefit in PCT testing [5]. The study has certain limita-
tions. We do not know if PCT is appropriately requested in every patient
because we have not reviewed every medical record to verify if clinical
suspicion supports the PCT request. The calculated economic savings
were on the basis of the reagent price without considering other costs
and may not apply to other settings, since our laboratories belong to
the Public Health Network.
In conclusion, there were high expenses and requests for PCT in ED.
The request was lower in such ED where the PCT request was restricted.
Significant economic savings could be achieved if the request in the lat-
ter would approximate to those with restricted criteria for PCT demand.
Competing interest
None declared.
 Correspondence / American Journal of Emergency Medicine 36 (2018) 134–168 159

Fig. 1. Dispersion of the ratio of PCT requests per 1000 ED admissions. Scattered plots showing the PCT/1000 ED admissions for each laboratory.

Source of funding Ethical approval

None declared. Not applicable.

Fig. 2. Comparison of PCT/1000 ED admissions indicator regarding order. Boxplot for PCT/1000 ED admissions depending on the existence of PCT restrictions to be ordered.
160 Correspondence / American Journal of Emergency Medicine 36 (2018) 134–168
Acknowledgements
Members of the REDCONLAB working group are the following:
Adolfo Garrido-Chércoles (Hospital Universitario de Donostia);
Aida Pérez-Fuertes (Complejo Hospitalario Universitario de Ferrol);
Amado Tapia (Hospital de Barbastro); Amparo Miralles (Hospital
de Sagunto); Ana Díaz (Hospital Universitario de La Princesa);
Ángeles Giménez-Marín (Hospital de Antequera); Antonio Menchen
(Complejo Hospitalario de Toledo); Arturo Carratalá (Hospital
Clínico Universitario de Valencia); Carmen Hernando de Larramendi
(Hospital Severo Ochoa de Leganés); Carmen Mar-Medina (Hospital
Galdakao-Usonsolo); Carolina Andrés-Fernández (Hospital General
de Villarobledo); Cesáreo Garcia (Hospital Universitario de Salaman-
ca); Consuelo Tormo (Hospital General de Elche); Cristina Santos
(Hospital Rio Tinto); Emilia Moreno-Noguero (Hospital Can Misses);
Enrique Prada de Medio (Hospital Virgen de la Luz de Cuenca); Félix
Gascón (Hospital Valle de los Pedroches, Pozoblanco); Fidel Velasco-
Peña (Hospital Virgen de Altagracia, Manzanares); Francisco
Miralles (Hospital Lluis Alcanyis, Xativa); J Carlos Garrido (Hospital
Universitario Marques de Valdecilla); Javier Aguayo-Gredilla (Hospi-
tal Universitario de Basurto); Jesús Domínguez (Hospital
Universitario de Guadalajara); Juan Jose Puente (Hospital Clínico
Universitario Zaragoza); Julián Díaz (Hospital Francesc de Borja,
Gandia); Laura Navarro (Complejo Hospitalario Universitario de Al-
bacete); Lola Máiz-Suarez (Hospital Lucus Augusti, Lugo); Luis
García-Menéndez (Hospital El Bierzo); M Carmen Plata (Hospital
Campo Arañuelo, Navalmoral de la Mata); M. Amalia Andrade-Olivie
(Hospital Xeral-Cies, CHU Vigo); M. Mercedes Herranz-Puebla (Hos-
pital General Universitario Gregorio Marañón); Mª Ángeles
Rodríguez-Rodríguez (Complejo Asistencial Universitario de Palen-
cia (Hospital Rio Carrión)); Mª Carmen Lorenzo-Lozano (Hospital
de Puertollano); Mª José Baz (Hospital de Llerena, Badajoz); Mabel
LLovet (Hospital Universitario Verge de la Cinta (Tortosa); Maria
Dolores Albaladejo (Hospital Santa Lucia, Cartagena); Maria Esther
Sole-LLop (Hospital de Alcañiz); M Luisa Lopez-Yepes (Hospital
Virgen del Castillo de Yecla); Marta Garcia-Collia (Hospital Ramon
y Cajal, Madrid); Martin Yago (Hospital de Requena); MC Martin-
Fernández de Basoa (Hospital Nuestra Señora de la Candelaria, Tene-
rife); Milagrosa Macías-Sánchez (Area de Salud de Caceres
(Complejo Hospitalario San Pedro de Alcantara); Nuria Fernández-
García (Hospital Universitario Rio Hortega-Valladolid); Oscar
Herráez-Carrera (Hospital C.H. La Mancha Centro); Pastora
Rodríguez (Hospital Universitario de A Coruña); Patricia Esteve
(Hospital Ernest Lluch); Pilar García-Chico (Hospital General
Universitario de Ciudad Real); Raquel Blázquez-Sánchez (Hospital
de Móstoles); Ricardo Molina (Hospital Virgen de los Lirios, Alcoy);
Santiago Prieto-Menchero (Hospital Universitario de Fuenlabrada);
Silvia Pesudo (Hospital La Plana); Tomas Pascual (Hospital
Universitario de Getafe); Vicente Villamandos (Hospital Santos
Reyes, Aranda del Duero); Vidal Perez Valero (Hospital Regional
Universitario de Malaga, Hospital Universitario Virgen de la
Victoria).
Maria Salinas
Clinical Laboratory, Hospital Universitario de San Juan, San Juan de
Alicante, Spain
Department of Biochemistry and Molecular Pathology, Universidad
Miguel Hernández, Elche, Spain
Corresponding author at: Clinical Laboratory, Hospital Universitario de
San Juan, Carretera Alicante-Valencia, s/n, 03550 San Juan de Alicante,
Alicante, Spain.
E-mail address: salinas_mar@gva.es
Maite López-Garrigós
Clinical Laboratory, Hospital Universitario de San Juan, San Juan de
Alicante, Spain
Emilio Flores
Clinical Laboratory, Hospital Universitario de San Juan, San Juan de
Alicante, Spain
Department of Clinical Medicine, Universidad Miguel Hernández,
Elche, Spain
Joaquín Uris
Department of Public Health, Universidad de Alicante, Alicante, Spain
Carlos Leiva-Salinas
Department of Radiology, University of Virginia, Charlottesville, VA, USA
On behalf of the Pilot Group of the Appropriate Utilization of Laboratory
Tests (REDCONLAB) working group
16 June 2017
http://dx.doi.org/10.1016/j.ajem.2017.07.033
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Clustering-making model for diagnosis of
acute coronary syndrome using PCA based on
K-MICA algorithms
Acute coronary syndrome (ACS) includes a variety of clinical condi-
tions ranging from unstable angina and non-ST segment elevation
MI(NSTEMI) to ST segment elevation MI(STEMI). All patients diagnosed
with STEMI or NSTE-ACS, where the latter encompasses UA and
NSTEMI, were identified [1,2].
Harrison et al. [3] presented multilayer perceptron to differentiate
UA from MI. They have achieved a good predictive performance by
using ECG findings while excluding Troponin level. Green et al. [4]
only investigated the ECG information for classifying ACS patients. The
performance of the artificial neural network (ANN) and logistic regres-
sion was compared to decisions taken by physicians. The results show a
relatively higher efficacy of logistic regression compared to the ANN.
The collected data comprises the medical record of all patients who
went to the emergency medical center of the Shahid Modarres Hospital.
This record includes 99 patients having all 14 factors included in this
study (Table 1).
This study aims to diagnose the ACS disease using a hybrid intelli-
gent system. System diagnosis used here consists of two phases: feature
selection and clustering methods. The feature selection phase is