Diagnosis and management of

acute pharyngitis
in a paediatric population: a cost
effectiveness analysis
Carolina Giraldez-Garcia & Beltran Rubio &
Jose F Gallegos-Braun & Iaki Imaz &
Jesus Gonzalez-Enriquez & Antonio Sarria-
Santamera
Background
Acute pharyngitis is one of the most frequent causes of primary
care physician visits; however, there is no agreement about which is
the best strategy to diagnose and manage acute pharyngitis in
children. The aim of the current study was to evaluate the cost
effectiveness of the recommended strategies to diagnose and
manage acutepharyngitis in a paediatric population. A decision tree
. A nalysis was performed to compare the following six strategies:
treat all, clinical scoring, rapid test, culture, rapid test +
culture and clinical scoring + rapid test. The cost data came from
the Spanish National Health Service sources. Costeffectiveness was
calculatedfrom the payers perspective. Effectiveness was measured
as the proportion of patients cured without complications from the
disease and did not have any reaction to penicillin therapy; a
sensitivity analysis was performed. The findingsrevealed that the
clinical scoring + rapid test strategy is the most cost-effective,
with a costeffectiveness ratio of 50.72 .


Introduction
Acute pharyngitis (AP) is one of the most common causes for
primary care physician visits, accounting for 20% of the visits in
the paediatric population in Spain [5]. The majority of children
presenting with AP have symptoms attributable to a viral infection,
although many of them are infected with group A beta-haemolytic
streptococcus (GABHS), which is the most important bacterium
causing pharyngitis. Spanish studies of GABHS prevalence report a
range from 10% to 45% of AP cases

Although penicillin therapy is accepted as the first line in AP
treatment, it produces adverse reactions including anaphylaxis and
death [2, 15] and it also has the potential of contributing to the
emergence of drug-resistant bacterial strains [17]. Therefore,
penicillin should not be prescribed indiscriminately.


Decision analysis model
We constructed a decision model to estimate the short-term cost and cost
effectiveness associated with the following six strategies (Fig. 1):

1. Treat all. Treatment of all patients with antibiotics without testing.
2. Clinical scoring. Use of a clinical scoring system to triage the diagnosis and treat
those with a high score with antibiotics.
3. Rapid test. Test all patients with a rapid antigen test and treat those with positive
results with antibiotics.
4. Culture. Test all patients with a throat culture and treat those with positive
results with antibiotics.
5. Rapid test + culture. Test all patients with a rapid antigen test, treat those with
positive results, perform a culture for those with negative test results and treat those
with positive results with antibiotics.
6. Clinical scoring + rapid test. Use a clinical scoring system to triage the diagnosis,
ignore those with a low score, perform a rapid antigen test for those with a high
score and treat those with positive test results with antibiotics.
Perspective
We calculated costeffectiveness from the payers
perspective, considering the costs incurred by the
Spanish National Health Service in implementing each
of the strategies analysed.

Population
Patients between the ages of 2 and 14 years who
consult with a primary care physician due to AP
symptoms. We considered a hypothetical cohort of four
million children, based on estimates of the number of
paediatric consultationsfor sore throat that occur
annually in the Spanish primary care centers .
clinical scoring system
one point for each of the following five
criteria:
temperature >38C,
absence of cough,
swollen or tender anteriorcervical nodes,
tonsillar swelling or exudates
and an age range of 314 years.
We considered a score of 3 points as high
and <3 as low.

Rapid test throat culture
The rapid diagnostic tests considered were those
based on optical immunoassay techniques because of
their availability in Spanish healthcare centers.

Throat culture is considered the standard method for
establishing the diagnosis of paediatric GABHS
pharyngitis .Performing a throat culture for all
patients has the advantage of missing only a few
cases of GABHS pharyngitis, but delays the onset of
antibiotic treatment for at least 2 days.
Table 1 Probabilities variables used
in costeffectiveness analysis
Variable Probability
Prevalence of GABHS 0.25
Clinical scoring3 sensitivity 0.94
Clinical scoring3 specificity 0.11
Rapid test sensitivity 0.90
Rapid test specificity 0.78
Culture sensitivity 0.95
Culture specificity 0.99
Death from Penicillin allergy 0.00001
Severe allergic reaction to Penicillin 0.005
Mild allergic reaction to Penicillin
0.09499
Effective treatment 0.80
Suppurative complications 0.03
Rheumatic fever 0.0003
Table 2 Cost variables used in cost
effectiveness analysis
Variable Cost ()
Visit (general practitioner) 37.00
Phone call 2.70
Rapid test 2.67
Culture 5.43
Penicillin (oral) 6.22
Azitromicin 7.51
Severe allergic reaction 1,249.58
Mild allergic reaction 44.51
Suppurative complications 1,373.16
Rheumatic fever 2,468.41
Table 3 Cost, effectiveness and cost
effectiveness ratios of base case analysis
Results
The most cost-effective strategy was the
clinical scoring + rapid test, which
dominated to the other strategies except
culture
Moving from the clinical scoring + rapid test
strategy to the culture strategy would have
added an additional cost of 3,110 per patient
cured, without presenting complications from
GABHS or any adverse reaction to penicillin
(incremental costeffectiveness ratio).
In conclusion
using a clinical scoring system to triagen the diagnosis, ignoring those with
a low score, performing a rapid antigen test for those with a high score and
treating those with positive test results with antibiotics is the most cost-
effective strategy for the diagnosis and management ofn acute pharyngitis
in the paediatric population in Spain.

When the clinical scoring system has a low diagnostic accuracy, testing all
patients and treating those with positiveresults with antibiotics become the
most cost-effective strategy. These strategies could improve the
management of AP in primary healthcare because they allow the accurate
diagnosis and optimal treatment of GABHS, prevent a large number of
complications, minimize the unnecessary antibiotic prescription rate, and
reducing the potential adverse effects of inappropriate antimicrobial
therapy.

Thank u