Published online March 1, 2006
PEDIATRICS Vol. 117 No. 3 March 2006, pp. 609-619 (doi:10.1542/peds.2005-0879)
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Group A Streptococcal Infections

Diagnosis and Management of Pharyngitis in a Pediatric Population Based on Cost-Effectiveness and Projected Health Outcomes

Robert S. Van Howe, MD, MS, FAAPa and Louis P. Kusnier, II, MDb

a Department of Pediatrics, Michigan State University College of Human Medicine, Marquette, Michigan
b Marquette Family Practice Residency Program, Marquette, Michigan

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.

Key Words: group A streptococcus • pharyngitis • cost-utility analysis • peritonsillar abscess • acute rheumatic fever

Abbreviations: GAS—group A hemolytic streptococcal • QALY—quality-adjusted life-year • QALD—quality-adjusted life-day • PTA—peritonsillar abscess • ARF—acute rheumatic fever • AAP—American Academy of Pediatrics • IDSA—Infectious Diseases Society of America • CI—confidence interval

Accepted Jul 12, 2006.




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