Diagnosis and management of pharyngitis in a pediatric population based on cost-effectiveness and projected health outcomes.

BACKGROUND: Pharyngitis is a common childhood complaint. Current management for children and adolescents includes 1 of 6 strategies, ie, (1) observe without testing or treatment, (2) treat all suspected cases with an antibiotic, (3) treat those with positive throat cultures, (4) treat those with positive rapid tests, (5) treat those with positive rapid tests and those with positive throat cultures after negative rapid tests, or (6) use a clinical scoring measure to determine the diagnosis/treatment strategy. The sequelae of untreated group A hemolytic streptococcal (GAS) pharyngitis are rare, whereas antibiotic treatment may result in side effects ranging from rash to death. The cost-utility of these strategies for children has not been reported previously. METHODS: A decision tree analysis incorporating the total cost and health impact of each management strategy was used to determine cost per quality-adjusted life-year ratios. Sensitivity analyses and Monte Carlo simulations assessed the accuracy of the estimates. RESULTS: From a societal perspective with current Medicaid reimbursements for testing, performing a throat culture for all patients had the best cost-utility. For private insurance reimbursements, rapid antigen testing had the best cost-utility. Observing without testing or treatment had the lowest morbidity rate and highest cost from a societal perspective but the lowest cost from a payer perspective. The model was most sensitive to the incidence of acute rheumatic fever and peritonsillar abscess after untreated GAS pharyngitis. Monte Carlo simulations demonstrated considerable overlap among all of the options except for treating all patients and observing all patients. CONCLUSIONS: Observing patients with pharyngitis had the lowest morbidity rate. The costs of this option were primarily from parental time lost from work. Before recommending observation rather than treatment of GAS pharyngitis, accurate estimates of the risk of developing acute rheumatic fever and peritonsillar abscess after GAS pharyngitis are needed.

Management of children with acute pharyngitis: a decision analysis.

BACKGROUND: Although the incidence of acute rheumatic fever has declined in the last decades, a few outbreaks have recently been reported. A rapid latex agglutination test for group A streptococci seems reasonably accurate, and early treatment of acute pharyngitis seems to influence the pharyngitis itself. These factors have promoted uncertainty concerning the current best management of patients with sore throat. METHODS: Clinical decision analysis is used to compare the risks and benefits of symptomatic treatment, and oral and intramuscular penicillin as therapeutic options, and the throat culture and the rapid latex agglutination test as diagnostic strategies. Best estimates of the risk of streptococcal pharyngitis, its complications, the carrier rate, the accuracy of diagnostic tests, the efficacy of antibiotic treatment, allergic reactions, medication compliance, and health outcomes are combined into a management advisory. All results are subjected to a sensitivity analysis in order to check their strength against plausible changes in assumptions. Quality adjusted life days (QALD) lost are used as an outcome measure. RESULTS: The agglutination test combined with oral penicillin yielded the lowest expected loss (.50) of QALD for a typical child with a risk of harboring streptococci of .60. The other strategies, however, yielded losses that were only several hundredths of QALD higher. CONCLUSIONS: For children with at least a 40% chance of harboring streptococci and a duration of complaints of less than 2 days before starting treatment, diagnostic testing and prescription of oral penicillin appear to be the best choice of initial management. The rapid latex agglutination test is more effective than the throat culture, because prompt penicillin treatment after a positive test result may shorten the duration of pharyngitis in infected children. High rates of acute rheumatic fever (over 5 X 10(-4] and low medication compliance change the best strategy to agglutination test with intramuscular administration of penicillin.

Streptococcal pharyngitis in the emergency department: analysis of therapeutic strategies.

Potential streptococcal pharyngitis represents a common presenting complaint of patients in emergency departments. Studies have shown that therapy within the first 48 hours of presentation hastens the resolution of the infection. A prior analysis of the cost of treatment for potential streptococcal pharyngitis in an outpatient practice suggested that when the likelihood of a positive throat culture is high, therapy is more cost effective without a throat culture. The current analysis evaluates the effects of emergency department charges, incomplete follow-up, and several common screening tests (Gram stain, clinical scoring) upon the cost of treatment and the risk for rheumatic fever. The results of the current analysis support the use of common screening tests to permit immediate oral or parenteral penicillin treatment of selected patients without a throat culture and the use of a throat culture to detect false-negative screen results.

Selective utilization of clinical diagnosis in treatment of pharyngitis.

Exudate, adenopathy, and fever were used to predict clinically whether pharyngitis was streptococcal, nonstreptococcal, or questionable in 466 adults and 234 children. Clinical accuracy was: nonstreptococcal - adults 94.6 percent, children 86.9 percent; streptococcal - adults 44.2 percent, children 53.5 percent. Significance of results was determined by calculating the cost of routine cultures compared to risk of rheumatic fever. The economic justification of cultures was lowest in nonstreptococcal adults, streptococcal adults, and streptococcal children. Therapy of streptococcal patients presented an additional risk: anaphylaxis. The fatality risk after penicillin injection compared to the increased risk of rheumatic fever after oral penicillin is: adults 7.5 percent (clinical diagnosis), 3.3 percent (laboratory diagnosis); children 1.8 percent and 0.8 percent respectively. It is recommended that throat culture be obtained for all questionable patients and clinically nonstreptococcal children. Penicillin should be administered orally in the majority of adults.