A recently published review in JAMA Pediatrics considers historical reasons and present implications of testing for respiratory tract infections in children.
Respiratory tract infections (RTIs) in children are a major cost and burden to the healthcare system. These respiratory tract infections, like bronchiolitis, the common cold, and seasonal influenza, affect physician and nursing time, emergency department and clinical visits, and result in often unnecessary diagnostic tests and antibiotic prescriptions.
While there are certainly cases where diagnostic tests should be performed, a recently published review has found a wide variability in practice among clinicians, suggesting a possible lack of clarity on the value and role of respiratory viral testing.
The review, published by The Journal of the American Medical Association (JAMA) Pediatrics, suggests there may be less critical thought and discussion among frontline clinicians about the utility and indications for testing.
Observation: Testing Did Not Have Real Effect on Treatment
For example, the review reports that in 2014, more than 2000 children presenting with respiratory symptoms visited the emergency department of The Hospital for Sick Children in Toronto, Ontario. These 2000 children underwent tests before they were discharged. The results were available the next day after they were discharged. However, there was no actual process for a follow-up or communication of the results, illustrating that these tests did not have a real effect on the child’s treatment.
Determining Usefulness of Diagnostic Tests for Respiratory Tract Infections
The Choosing Wisely Campaign, an initiative of the American Board of Internal Medicine (ABIM) Foundation, has also questioned the usefulness of many commonly-used diagnostic tests in order to improve quality of care, reduce waste, and protect patients from potential harm.
So, if diagnostic testing for respiratory tract infections is often unnecessary, why are they ordered? And how useful are the results for clinical decision making in regards to the patient’s treatment?
To determine the utility, necessity, and implications of respiratory viral testing, the review considers the following questions:
- Why do we test for respiratory viruses?
- Why should we think twice before ordering the test?
- When is viral testing indicated?
Why Do We Test For Respiratory Viruses?
The main reasons for testing for respiratory viruses is to differentiate between viral and bacterial infections, to reduce additional investigations (for diagnostic certainty and to reduce clinical costs), and to reduce unnecessary antibiotic prescribing.
However, the review found that in some cases, testing actually resulted in more testing. The authors of the review presume this occurred when a test result was negative. They also found that in many cases, testing did not reduce unnecessary antibiotic prescribing.
Other reasons for testing for respiratory tract infections include:
- Reducing length of stay
- Help patients with similar viruses to manage resources if individual rooms aren’t available
- Provide prognosis on length of illness and severity
The authors state that previous clinical trials have failed to provide evidence of a reduction in length of stay. In regards to helping patients with similar viruses if rooms aren’t available, they state that this “may inadvertently transmit infections to other children who are already unwell, potentially leading to longer lengths of stay and further complications.”
Why Should We Think Twice Before Ordering Tests?
Clinicians now have many options for viral testing as the past decade has seen a growth in the availability and variety of diagnostic tests. However, these tests still have their benefits and limitations.
They may still produce false-positive results, and conventional point-of-care tests may still have high rates of false negatives. In fact, the Centers for Disease Control and Prevention recommend that clinicians ignore the results of a negative rapid influenza test if there is a high clinical suspicion. In these cases, they suggest continuing additional testing if the result is positive and if clinicians suspect a bacterial coinfection.
Testing also requires the correct technique for sample collection and materials are costly. Often, clinicians need to batch samples before they can analyze them, and this adds to the cost. With the wide variety of tests available, it’s also becoming more difficult for clinicians select the most appropriate test to use.
When is Viral Testing Indicated?
Viral testing does play a key role in many circumstances. For example, it is vital in pandemic circumstances, when a certain disease is prevalent throughout the country or world.
Testing can also help determine whether a patient in the emergency department will be discharged or admitted. In patients admitted to intensive care, testing can help physicians determine whether to take less common treatment options based on the cause of a disease.
Further, when confirming an influenza infection, testing may lead to a significant change in the patient’s management plan and could lead to a discontinuation of antibiotics.
Diagnostic Uncertainty Always Involved
It’s important to note that physicians need to be well-informed before making a proper diagnosis. A lack of confidence, diagnostic uncertainty, and concerns for litigation are some less-recognized reasons for unnecessary testing. The authors of the review state that since medicine “requires critical thinking and incorporating patient and family preferences into decision making in a judicious and responsible fashion”, some element of diagnostic uncertainty is always present.
The authors conclude that it is not a good enough reason to perform a test just because we can. They note that frontline clinicians should think twice before automatically requesting tests that are costly, uncomfortable for both the patient and healthcare professional, and contribute little to the patient’s treatment.
Written by Jessica Gelar, HBSc
Reference: Gill PJ, Richardson SE, Ostrow O, Friedman JN. Testing for Respiratory Viruses in Children. JAMA. 2017 July 10.