title: The socio-economic value of diagnostic innovation - managing paediatric fever in the Emergency Department
Creators: name: Leigh, Simon
Publisher: name: University of Liverpool Repository
Year: 2023

description: Introduction: Ensuring the appropriate and most beneficial use of healthcare resources is a public health imperative. But so too is assuring that care quality is not measured solely by clinical or economic aspects of care but also by the entire patient experience. This thesis examines the economic and patient/parent-centric impact of managing a highly common condition, paediatric febrile illness, in Emergency Department (ED) settings. The chapters included explore the impact of paediatric febrile illness to patients, parents and health services alike, while also exploring the potential value of diagnostic and care-pathway innovations designed to reduce the incidence and impact of diagnostic uncertainty in the management of this highly common condition. Methods: Utilizing a series of rich cross-sectional, qualitative, and patient-centric datasets from the North West of England, I analyse, for the first time in this field, the combined economic, and patient/parent-centric impact of the ED management of paediatric febrile illness; using generalised linear, mixed logit and stochastic economic modelling techniques. All chapters adjust for both confirmed, and potentially clinically important covariates, including extensive analysis of uncertainty where possible. Following an introduction and an extensive literature review of studies examining the economic impact of paediatric febrile illness in ED-settings, Chapter 3 explores this subject, based on established care pathways. This study uses novel time-driven and activity-based micro-costing (TDABC) techniques to explore the impact of patient age, triage status, gender, clinical role and experience and other clinical parameters on healthcare utilisation. Chapter 4 explores and compares both parental and healthcare professional’s (HCPs) preferences for the management of paediatric febrile illness in ED-settings, using an economic mixed-methods approach. Following an iterative methodology of literature review, focus-group research, coin-ranking exercises and a discrete-choice experiment; this thesis performs an in-depth exploration of satisfaction with existing care pathways. In doing so, the findings quantify the potential value of diagnostic innovations, including point-of-care (POC) testing, accounting for differences in preferences among heterogeneous parental and health care professional (HCP)-groups. Chapter 5 employs a prospective cohort-control design to examine the potential role of GP-led management for non-urgent ED admissions including paediatric febrile illness, comparing key economic, operational (including waiting times), and clinical outcomes (including antimicrobial prescribing) versus existing care pathways. Finally, Chapter 6 utilises a decision tree approach to combine the findings of the previous chapters. It explores the potential economic and patient-centric value of a range of exploratory scenarios to improve the management of paediatric febrile illness in ED-settings, including POC-testing, GP-led management and both combined. The findings of this chapter highlight the factors most influential in determining the comparative cost-effectiveness of each strategy, providing recommendations for future implementations. Results: The findings of this thesis suggest that the management of paediatric febrile illness within EDs, imposes a substantial economic burden. Costs are driven predominantly by diagnostic uncertainty, which manifests itself as increases in observation time, clinically unnecessary antibiotic use, and prolonged inpatient admission. Children aged 0-6 months, those triaged as Manchester Triage System (MTS) yellow and above, and those managed by newly qualified doctors are the most likely to use additional resources in the ED. Ironically, the stepped-cautious approach often used when investigating paediatric febrile illness is also a key contributor to parental and HCP dissatisfaction with care. Prolonged waiting times induce significant concern, anxiety, and a fear of deterioration, while invasive investigations including venepuncture cause discomfort to children, which in turn affects parents. Receiving a faster diagnosis which improves confidence, and reduces uncertainty, is therefore a major benefit to both parents and HCPs, and this may be achieved via the use of novel, cutting edge rapid diagnostic technologies, such as host or pathogen molecular diagnostics, omics-driven approaches at the bedside, or POC-testing. Additionally, modifications to existing care pathways, such as GP-led management of non-urgent ED attendances may also be of significant benefit. While the latter is likely to improve operational and economic outcomes considerably, GP-led management may also inadvertently lead to increases in antimicrobial prescribing, if not accompanied by antimicrobial stewardship initiatives, which have proven highly successful in other settings. Given the importance of reducing clinically unnecessary antibiotic use, this may limit the utility of this strategy for the management of paediatric febrile illness in ED-settings; while factors including adherence to results, sensitivity and the cost of any POC-test, are also likely to limit the effectiveness of these diagnostic advances. Conclusions: Paediatric febrile illness, while common, is a clinical conundrum, and often necessitates a cautious approach, characterised by interventions which provide limited diagnostic value. Diagnostic uncertainty is a key orchestrator of febrile illness pathways, with certain populations, namely infants, and those triaged as MTS yellow or higher, most likely to receive potentially avoidable interventions, at the expense of reduced parental and HCP satisfaction with care. Policies to reduce the impact of diagnostic uncertainty, including GP-led management and POC-testing, are likely to improve economic, clinical, and patient-centric outcomes significantly, particularly if used in combination. Associated benefits are likely to be highest if such technologies and care pathways are tailored to those where the perceived risks of failing to identify potentially life-threatening bacterial infections are greatest.