Format

Send to

Choose Destination
BMC Med. 2019 Mar 6;17(1):48. doi: 10.1186/s12916-019-1275-z.

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

Author information

1
Institute of Infection and Global Health, University of Liverpool, 8 West Derby St, Liverpool, L69 7BE, UK. Simon.leigh@liverpool.ac.uk.
2
Infectious Diseases Department, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK. Simon.leigh@liverpool.ac.uk.
3
Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK.
4
The Royal Liverpool University Hospital, Prescot St, Liverpool, L7 8XP, UK.
5
Medical Statistics Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
6
Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK.
7
Royal Bolton Hospital, Minerva Road, Farnworth, BL4 0JR, UK.
8
School of Medicine, University of Liverpool, Cedar House, Liverpool, L69 3GE, UK.
9
Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, B15 2TH, UK.
10
Pinderfields District General Hospital, Aberford Road, Wakefield, WF1 4DG, UK.
11
Wirral University Teaching Hospital, Arrowe Park Road, Wirral, CH49 5PE, UK.
12
Information Department, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK.
13
Finance Department, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK.
14
Emergency Department, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK.
15
Department of Clinical Research, MARCH Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
16
Department of Computer Science, University of Liverpool, Ashton Building, Ashton Street, Liverpool, L693BX, UK.
17
Department of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine and University of Liverpool, Liverpool, UK.
18
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA.
19
Institute of Infection and Global Health, University of Liverpool, 8 West Derby St, Liverpool, L69 7BE, UK.
20
Infectious Diseases Department, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK.

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.

KEYWORDS:

Antibiotics; Children; Cost of illness; Febrile; Fever; Health economics; Pyrexia; United Kingdom

PMID:
30836976
DOI:
10.1186/s12916-019-1275-z
Free PMC Article

Supplemental Content

Full text links

Icon for BioMed Central Icon for PubMed Central
Loading ...
Support Center