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.