Abstract
BackgroundDue to the unpredictable burden of pandemic influenza, the best strategy to manage testing, such as rapid or polymerase chain reaction (PCR), and antiviral medications for patients who present with influenza-like illness (ILI) is unknown.Methodology/Principal FindingsWe developed a set of computer simulation models to evaluate the potential economic value of seven strategies under seasonal and pandemic influenza conditions: (1) using clinical judgment alone to guide antiviral use, (2) using PCR to determine whether to initiate antivirals, (3) using a rapid (point-of-care) test to determine antiviral use, (4) using a combination of a point-of-care test and clinical judgment, (5) using clinical judgment and confirming the diagnosis with PCR testing, (6) treating all with antivirals, and (7) not treating anyone with antivirals. For healthy younger adults (<65 years old) presenting with ILI in a seasonal influenza scenario, strategies were only cost-effective from the societal perspective. Clinical judgment, followed by PCR and point-of-care testing, was found to be cost-effective given a high influenza probability. Doubling hospitalization risk and mortality (representing either higher risk individuals or more virulent strains) made using clinical judgment to guide antiviral decision-making cost-effective, as well as PCR testing, point-of-care testing, and point-of-care testing used in conjunction with clinical judgment. For older adults (≥65 years old), in both seasonal and pandemic influenza scenarios, employing PCR was the most cost-effective option, with the closest competitor being clinical judgment (when judgment accuracy ≥50%). Point-of-care testing plus clinical judgment was cost-effective with higher probabilities of influenza. Treating all symptomatic ILI patients with antivirals was cost-effective only in older adults.Conclusions/SignificanceOur study delineated the conditions under which different testing and antiviral strategies may be cost-effective, showing the importance of accuracy, as seen with PCR or highly sensitive clinical judgment.
Highlights
Prompt antiviral treatment may be able to improve outcomes for adults infected by either seasonal or pandemic influenza viruses, antiviral treatment is costly, $77 to $121 per patient
Conclusions/Significance: Our study delineated the conditions under which different testing and antiviral strategies may be cost-effective, showing the importance of accuracy, as seen with polymerase chain reaction (PCR) or highly sensitive clinical judgment
Each simulation run for both the younger adults and older adults sent 5,000 simulated adults 5,000 times (i.e., 25,000,000 trials) through the model. These models represented an outpatient presenting to the clinic or emergency room with influenza-like illness (ILI) and a clinician’s choice among the following options: N Clinical judgment alone to distinguish influenza from ILI to guide antiviral use
Summary
Prompt antiviral treatment may be able to improve outcomes for adults infected by either seasonal or pandemic (such as novel H1N1) influenza viruses, antiviral treatment is costly, $77 to $121 per patient (due to repackaging differences). Testing for influenza, with either rapid influenza tests or polymerase chain reaction (PCR), may help better diagnose influenza and guide antiviral treatment [5]. These tests have associated costs and less than perfect sensitivity and specificity. In pandemic scenarios, some clinicians may be inclined to administer antivirals to everyone presenting with ILI if they believe that morbidity and mortality risk are elevated. Due to the unpredictable burden of pandemic influenza, the best strategy to manage testing, such as rapid or polymerase chain reaction (PCR), and antiviral medications for patients who present with influenza-like illness (ILI) is unknown
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