Impact of a Point-of-care Respiratory PCR Panel in a Pediatric Clinic on Postvisit Communication and Follow-up Visits
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Abstract
While the FilmArray Respiratory Panel EZ has been proven to reduce inappropriate antibiotic use in the outpatient pediatric setting, it is unclear whether its implementation will also reduce downstream health costs such as provider visits and telephone calls. This analysis will help pediatricians make more informed decisions on the implementation and judicious use of the Respiratory Panel EZ in their clinical practice.
In 2016, the Food and Drug Administration approved the FilmArray Respiratory Panel EZ (Biofire Diagnostics, Salt Lake City, UT), a clinical laboratory improvement amendment-waived respiratory pathogen polymerase chain reaction (PCR) assay, which tests for 14 of the most common pathogens causing respiratory infections, including 11 viruses and 3 bacteria.1 It can be performed by most clinic staff including nurses and medical assistants if the clinic has a Certificate of Waiver, which is held by the majority of pediatric clinics.2 Implementation of rapid PCR panels has been shown to improve diagnostic efficiency in both the clinic and emergency department (ED) settings.3,4
The burden of cost and prevalence of children with upper respiratory infections (URI) presenting to outpatient pediatric clinics is high.5 One of the most common causes of pediatric URI is influenza, and rapid influenza testing has been proven to increase appropriate use of antivirals and decrease extraneous additional testing including blood tests, urinalysis and chest radiograph.6 It has also been shown to reduce downstream cost per patient including ED visits, primary care visits and false negatives resulting in future health complications.7
This is the second phase of an article recently published in The Pediatric Infectious Disease Journal, which showed that the FilmArray Respiratory Panel EZ (RPEZ) significantly impacted the appropriate use of antibiotics in the outpatient pediatric clinic setting.8 Because current literature on downstream costs that result from the implementation of the FilmArray RPEZ is lacking, this article aimed to determine if its use in an outpatient pediatric clinic led to fewer telephone calls, follow-up appointments, MyChart messages, emergency department visits and hospital admissions. In addition, we also aimed to determine if the RPEZ led to lower use of radiologic and laboratory tests.
METHODS
This quality improvement study occurred at University of Florida Health outpatient pediatric clinics. A total of 430 patients presenting to either of 2 clinics (“Clinic A” or “Clinic B”) with respiratory symptoms from January 31, 2018 to January 31, 2019 were included in this study. The FilmArray RPEZs performance characteristics have been previously described in Beal et al (2020).8 Two FilmArray 2.0 modules were installed in Clinic A, and samples were collected from pediatric clinic patients and run in real time. Results at Clinic A were released in the electronic medical record and communicated with the patient’s caregiver. At Clinic B, samples collected for influenza and respiratory syncytial virus (RSV) antigen (AG) tests were poured from the reagent buffer into universal transport media (Puritan UniTranz-RT Transport System) and frozen immediately. They were then transported on ice to the affiliated academic medical center where one FilmArray 2.0 module was installed in a research laboratory. Results of these tests from Clinic B patients were not released to patients or clinicians and not run in real time.
All follow-up data were collected from the electronic health record (Epic Systems Corporation, Verona, WI) including phone calls, digital provider messaging (MyChart), repeat clinic visits, Pediatrics After Hours visits and emergency room visits for 2 weeks following the initial clinic encounter.9,10 Laboratory and imaging studies from the initial or subsequent visits as well as relevant chronic illnesses were also recorded. Data were inputted into a REDCap (Research electronic data capture, funded by NCATS grant UL1 TR000064) secure data collection software. Follow-up encounters that occurred at outside institutions were not recorded or included. Also, follow-up encounters for well-child checkups that were scheduled by the parent or provider at a visit before the presentation of the acute respiratory symptoms that fell within the 2 weeks following were not included.
RESULTS
Values and statistical significance are listed for the following data in Table 1. Of 298 patients at Clinic A, 15.8% of them had at least 1 clinic or Pediatric After Hours visit, compared with 9.1% of 132 patients at Clinic B within 2 weeks following initial evaluation. Phone calls and e-messages were also higher at Clinic A.
In Clinic B, patients who were antigen negative but RPEZ positive more often had a repeat clinic or after-hours pediatric visit (13.2%) compared with those who were antigen negative and RPEZ negative (9.8%).
Of patients who returned for a follow-up visit at Clinic A, those who had tested positive on RPEZ (72.3%) composed a larger percentage of the group compared with those who were negative (27.7%).
At Clinic B, patients who had a negative antigen test but tested positive on RPEZ more often (13.2%) had a return clinic visit than those who were positive for both (2.7%).
For patients, who tested positive on RPEZ for adenovirus, those who were made aware of the specific diagnosis at Clinic A less often returned for a follow-up clinic visit (7.1%) compared with those at Clinic B (33.3%).
Of the patients who returned for a follow-up visit at Clinic B, 58.3% of them had a negative antigen tested but their frozen sample was positive for a least 1 organism on RPEZ.
Notably, RSV comprised only 3% of patients at Clinic B but 12.8% of patients at Clinic A. Of these 38 patients at Clinic A, 20 of them (52.6%) sought follow-up care, compared with only 1 of 4 patients at Clinic B, where this diagnosis remained unknown at the time.
The average age at Clinic A was 3.6 years, while at Clinic B it was 6.3 years. The percentage of patients under the age of 1 at Clinic A was 30.5% while at Clinic B the percentage was 11.4%. The percentage of patients returning for a follow-up clinic visit who were under the age of 1 compared with children older than 1 was higher at both clinics. (Clinic A 18.7% > 14.5%, Clinic B 13.3% > 8.5%).
CONCLUSIONS
We hypothesized that patients at Clinic A (who obtained results of the RPEZ immediately after their clinic visit) would have lower rates of phone calls, e-messages to providers and follow-up clinic visits compared with Clinic B, but this was not seen.
However, there were several indications that confirmation of diagnosis may have reduced the rate of follow-up visits. Patients in Clinic B who were unaware of a specific pathogen diagnosis because of a negative antigen test, but their frozen sample tested positive for a least 1 organism on RPEZ were more likely to return to the clinic for a follow-up visit; this indicates that knowledge of a specific viral illness pathogen may reduce the likelihood that a parent will return with their child to clinic.
Since recommendations for patients with RSV include close monitoring and follow-up care for infants, our results possibly represent improved use of resources and appropriate management of infants affected by RSV. We found that patients in Clinic B who did not receive a positive antigen test but tested positive on the RPEZ more often scheduled a follow-up visit. Additionally, age could have been a confounding factor as younger patients (which comprised more of the patients at Clinic A) more often require closer follow-up. In summary, while the FilmArray Respiratory Panel EZ has been proven to reduce inappropriate antibiotic use in the outpatient pediatric setting, it is unclear whether its implementation will also reduce use of downstream health resources. As new medical tests become available, physicians must evaluate their efficacy as well as the financial responsibility associated with their use for both the practice and each patient. This analysis provides more in-depth understanding of the downstream health costs associated with the use of the FilmArray RPEZ and will help pediatricians make more informed decisions on its implementation and judicious use in their clinical practice.
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