A study today in JAMA Network Open suggests the COVID-19 pandemic was associated with increased respiratory pathogen testing rates at children's hospitals across the United States, a trend that has persisted and resulted in unnecessary costs. The authors say their findings support de-implementation efforts.
The study is based on information from the Pediatric Health Information System database, and it includes respiratory pathogen testing for more than 5 million encounters for respiratory illnesses at 39 children's hospitals before and during the COVID-19 pandemic, from 2016 through 2023. The vast majority of encounters (87.5%) occurred in emergency departments (EDs), with children being well enough to avoid hospital admission (ED-only).
Among all kids, 37% tested
Of the 5,090,923 encounters, 37.2% included respiratory pathogen testing. More than three fourths of tests (77.9%) involved children younger than 6 years, and 94.5% involved children without complex chronic conditions. Of the 5 million encounters, there were 634,303 hospitalizations, 22.1% of which required intensive care unit (ICU) treatment.
Hospitalizations with ICU visits had the highest percentage of respiratory testing (83.2% of encounters), followed by hospitalizations without ICU visits (60.6%), and ED-only encounters (33.2%).
According to the authors, increases in respiratory testing were seen at the onset of the COVID-19 pandemic in both ED-only encounters (level change, 33.78; 95% confidence interval [CI], 31.77 to 35.79]) and hospitalizations (level change, 30.97 [95% CI, 29.21 to 32.73]), associated initially with COVID-19–only testing.
Testing costs increased during pandemic
Testing rates after 2020 remained elevated, with the percentage of encounters with respiratory testing increasing from 13.6% (95% CI, 13.5% to 13.7%) in 2016 to a peak of 62.2% (95% CI, 62.1% to 62.3%) in 2022.
"While COVID-19–only testing decreased after 2020, other targeted testing and large-panel (>5 targets) testing increased," the authors wrote.
After adjusting for inflation, the authors said the costs of respiratory testing increased over time, from a low of $20.6 million in 2016 to a high of $111.0 million in 2022.
"The continued gradual increase of large-panel testing over the study period, in particular, may represent overuse of a costly, low-value intervention," the authors concluded. "Given the significant increase in the cost of testing per encounter over the study period (eg, from $34.2 in 2017 to $128.2 in 2022), large-panel testing presents an opportunity for targeted deimplementation efforts, especially in the ED, where testing results may not be available prior to patient disposition."
Knowing the virus often doesn't change management
Using respiratory viral panels to determine which pathogen was causing an illness was likely important in the early days of COVID-19 hospitalizations, when COVID patients were isolated. Likewise, testing can be helpful to identify patients that may benefit from oseltamivir (Tamiflu) if positive for influenza.
However, Todd Lyons MD, MPH, and Caroline Kahane, MD, both of Boston Children's Hospital and Harvard University, in a commentary on the study, said most pediatric respiratory illnesses require the same supportive care, and identifying the pathogen is not always necessary.
"For many children with respiratory illnesses, respiratory pathogen testing does not change clinical management," Lyons and Kahane wrote.
It may likely take years to return to a time when families are comfortable being told their child has just a virus without the need to know which.
"This is especially true for children and adolescents well enough to be discharged from the emergency department, which is the exact population for whom the authors observed the largest increase in testing. Clinicians should therefore consider for which patients viral pathogen testing would change management and add value and should avoid testing those for whom it will add cost without changing management or outcome."
Though the effort to reduce viral panel testing would be cost-saving, it would likely be met by resistance from parents, said Lyons and Kahane, who have now become accustomed to the practice.
"It may likely take years to return to a time when families are comfortable being told their child has just a virus without the need to know which," they said.
