The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department

Abstract

Background Paediatric fever is a common cause of emergency department (ED) attendance. A lack of prompt and definitive diagnostics makes it difficult to distinguish viral from potentially life-threatening bacterial causes, necessitating a cautious approach. This may result in extended periods of observation, additional radiography, and the precautionary use of antibiotics (ABs) prior to evidence of bacterial foci. This study examines resource use, service costs, and health outcomes. Methods We studied an all-year prospective, comprehensive, and representative cohort of 6518 febrile children (aged < 16 years), attending Alder Hey Children’s Hospital, an NHS-affiliated paediatric care provider in the North West of England, over a 1-year period. Performing a time-driven and activity-based micro-costing, we estimated the economic impact of managing paediatric febrile illness, with focus on nurse/clinician time, investigations, radiography, and inpatient stay. Using bootstrapped generalised linear modelling (GLM, gamma, log), we identified the patient and healthcare provider characteristics associated with increased resource use, applying retrospective case-note identification to determine rates of potentially avoidable AB prescribing. Results Infants aged less than 3 months incurred significantly higher resource use than any other age group, at £1000.28 [95% CI £82.39–£2993.37] per child, ( p < 0.001), while lesser experienced doctors exhibited 3.2-fold [95% CI 2.0–5.1-fold] higher resource use than consultants ( p < 0.001). Approximately 32.4% of febrile children received antibiotics, and 7.1% were diagnosed with bacterial infections. Children with viral illnesses for whom antibiotic prescription was potentially avoidable incurred 9.9-fold [95% CI 6.5–13.2-fold] cost increases compared to those not receiving antibiotics, equal to an additional £1352.10 per child, predominantly resulting from a 53.9-h increase in observation and inpatient stay (57.1 vs. 3.2 h). Bootstrapped GLM suggested that infants aged below 3 months and those prompting a respiratory rate ‘red flag’, treatment by lesser experienced doctors, and Manchester Triage System (MTS) yellow or higher were statistically significant predictors of higher resource use in 100% of bootstrap simulations. Conclusion The economic impact of diagnostic uncertainty when managing paediatric febrile illness is significant, and the precautionary use of antibiotics is strongly associated with increased costs. The use of ED resources is highest among infants (aged less than 3 months) and those infants managed by lesser experienced doctors, independent of clinical severity. Diagnostic advances which could increase confidence to withhold antibiotics may yield considerable efficiency gains in these groups, where the perceived risks of failing to identify potentially life-threatening bacterial infections are greatest. ...

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children

“…Robust QI balancing measures that should be assessed include clinician response, anchoring bias, increased and/or inappropriate antimicrobial prescriptions, fluid overload, increased PICU admissions and transfers to higher levels of care, and healthcare utilization costs [45]. Application of a screening tool requires ongoing optimization of sensitivity and specificity, continuous improvement efforts to maintain provider education and familiarity with the tool, and continual data acquisition to monitor implementation and increase utilization [42].…”

“…We suggest against using intravenous hydrocortisone to treat children with septic shock if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (weak recommendation, low quality of evidence). PICO 47 45. We suggest that either intravenous hydrocortisone or no hydrocortisone may be used if adequate fluid resuscitation and vasopressor therapy are not able to restore hemodynamic stability (weak recommendation, low quality of evidence).…”

What matters when managing childhood fever in the emergency department? A discrete-choice experiment comparing the preferences of parents and healthcare professionals in the UK

“…We identified a strong aversion to children experiencing pain from investigations. While observational data suggest the likelihood of venepuncture during the management of paediatric febrile illness is low, 17 pain from procedures including venepuncture is often the most traumatic experience when a child’s primary symptom is fever, impacting patient experience significantly. 23 24 Additionally, studies demonstrate that parents tend to overestimate pain experienced by their children, 25–27 and therefore our findings suggest that while pain from venepuncture may be expected to last a few minutes, pain from obtaining a single drop of blood from a finger prick for POC testing may be more favourable, thereby improving the experiences for both parents and children.…”

“…We followed methodological guidelines from the International Society for Pharmacoeconomics and Outcomes Research,16 identifying attributes of potential importance through a literature review, discussion with experts in paediatric infectious diseases, historical observational data17 and focus-groups.…”

“…This process is repeated with the values (levels) of the characteristics (attributes) changing each time. The attributes used for our DCE are listed in table 1, with levels determined from responses obtained during the focus-groups and previously published data from our hospital 17. The DCE was provided using paper forms and on a tablet-PC (the full survey is provided in online supplementary figure 1).…”