Question

• A patient presented to the ER with headache, fever, neck pain, vomiting, and was non-toxic appearing. Aseptic meningitis was suspected, but when an enterovirus PCR was ordered, you find out the UMHS does not run the test for enterovirus PCR. Given the UMHS is a cost-effective institution, would the enterovirus PCR provide the UMHS with a diagnostic tool that could provide significant cost savings/increased revenue while maintaining high quality patient care?

Clinical Bottom Lines

1. Enterovirus PCR (EV-PCR) has been shown to be a very sensitive and specific test to diagnose enterovirus meningitis.^1,2,4
   
2. This article and others implicate a significant cost savings.^1-4
   
3. EV-PCR can affect clinical decision making by allowing for earlier discharge of patients, less use of unnecessary ancillary tests, and therapeutic interventions (such as IV antibiotics).^1,4
   
4. Its economic utility may be increased especially if it is utilized during the peak enterovirus meningitis seasons, and if the CSF analysis aids as a pre-determinant to order an EV-PCR.^1,2
   
5. The economic benefit obtained may be applicable from multiple perspectives in an economic analysis (i.e. to the society as a whole, health care payer perspective, to the medical institution, and to the patient/family in QALY).¹

Summary of Key Evidence

1. Retrospective review of electronic medical records of 280 pediatric patients that had EV-PCR ordered at UCSD medical center during one calender year.¹
   
2. When patients had a positive EV-PCR test result available before discharge vs. patients who had a negative EV-PCR test result, those who tested positive had shorter hospital stays, fewer ancillary tests performed, received IV antibiotics for less time, and were discharged sooner (as soon as the result was available).
   
3. Only 2/137 patients (1.5%) with a positive PCR test were re-hospitalized within 14 days of discharge; while 11/139 (8%) with a negative PCR test were re-hospitalized within 14 days of discharge. Therefore an uncomplicated recovery can be expected with a positive PCR result.
   
4. In the subset of patients with a discharge diagnosis of viral meningitis, the patients who had positive results available had a statistically significant shorter length of stay, time from results of PCR to discharge time, number of ancillary tests performed, and IV antibiotics given.
   
5. There were a subgroup of patients discharged before the results of the PCR became available, indicating that the PCR test may have been unwarranted. These patients tended to be older (median age 1.9 years). Physicians were likely to be more comfortable with earlier discharge of older children than of neonates/infants.

Additional Comments

• Strengths of this paper lies in the analyses that can be done (i.e. it can be assessed) from multiple points of view (i.e. length of hospital stay, utilization of ancillary tests, use of IV antibiotics), and its use of the test year round.
  
• Weaknesses of this study include not performing a detailed economic analysis (i.e. it only states that economic benefits can be inferred from the results), and that it does not separate the impact of the PCR from that of the clinical presentation on the medical decision making.
  
• This article suggests that there may be savings by using EV-PCR as a diagnostic test.
  
• Numerous variables will affect actual cost savings for my institution that begins to use EV-PCR. A clinical decision algorithm and a prospective study may be useful to confirm its effect here.
  

Citation

1. Ramers C, Billman G, Hartin M, Ho S, Sawyer MH. Impact of a diagnostic cerebrospinal fluid enterovirus polymerase chain reaction test on patient management. JAMA 2000; 283(20):2680-5.
   
2. Hamilton MS, Jackson MA, Abel D. Clinical utility of polymerase chain reaction testing for enteroviral meningitis. Pediatr Infect Dis J 1999; 18(6):533-7.
   
3. Rice SK, Heinl RE, Thornton LL, Opal SM. Clinical characteristics, management strategies, and cost implications of a statewide outbreak of enterovirus meningitis. Clin Infect Dis 1995; 20:931-7.
   
4. Marshall GS, Hauck MA, Buck G, Rabalais GP. Potential cost savings through rapid diagnosis of enteroviral meningitis. Pediatr Infect Dis J 1997; 16:1086-7.
   

CAT Author: Christopher Kim, MD

CAT Appraisers: Jonathan Fliegel, MD

Date appraised: December 10, 2001