Andrew M. Fine

Large-Scale Validation of the Centor and McIsaac Scores to Predict Group A Streptococcal Pharyngitis

BACKGROUND The Centor and McIsaac scores guide testing and treatment for group A streptococcal (GAS) pharyngitis in patients presenting with a sore throat, but they were derived on relatively small samples. We perform a national-scale validation of the prediction models on a large, geographically diverse population. METHODS We analyzed data collected from 206,870 patients 3 years or older who presented with a painful throat to a United States national retail health chain from September 1, 2006, to December 1, 2008. Main outcome measures were the proportions of patients testing positive for GAS pharyngitis according to the Centor and McIsaac scores (both scales, 0-4). RESULTS For patients 15 years or older, 23% (95% CI, 22%-23%) tested positive for GAS, including 7% (95% CI, 7%-8%) of those with a Centor score of 0; 12% (95% CI, 11%-12%) of those with a Centor score of 1; 21% (95% CI, 21%-22%) of those with a Centor score of 2; 38% (95% CI, 38%-39%) of those with a Centor score of 3; and 57% (95% CI, 56%-58%) of those with a Centor score of 4. For patients 3 years or older, 27% (95% CI, 27%-27%) tested positive for GAS, including 8% (95% CI, 8%-9%) of those testing positive with aMcIsaac score of 0; 14% (95% CI, 13%-14%) of those with a McIsaac score of 1; 23% (95% CI, 23%-23%) of those with a McIsaac score of 2; 37% (95% CI, 37%-37%) of those with a McIsaac score of 3; and 55% (95% CI, 55%-56%) of those with a McIsaac score of 4. The 95% CIs overlapped between our retail health chain–derived probabilities and the prior reports. CONCLUSION Our study validates the Centor and McIsaac scores and more precisely classifies risk of GAS infection among patients presenting with a painful throat to a retail health chain.

Clinical Predictors of Lyme Disease Among Children With a Peripheral Facial Palsy at an Emergency Department in a Lyme Disease–Endemic Area

INTRODUCTION. Although Lyme disease can cause peripheral facial palsy in Lyme disease–endemic areas, diagnostic predictors in children have not been described. OBJECTIVE. Our goal was to determine clinical predictors of Lyme disease as the etiology of peripheral facial palsy in children presenting to an emergency department in a Lyme disease–endemic area. METHODS. We reviewed all available electronic medical charts of children ≤20 years old with peripheral facial palsy who were evaluated in the emergency department of a tertiary care pediatric center from 1995 to 2007. We used the Centers for Disease Control Lyme disease definition: presence of erythema migrans lesion or serologic evidence of infection with Borrelia burgdorferi. We performed binary logistic regression with bootstrapping validation to determine independent clinical predictors of Lyme disease. RESULTS. We identified 313 patients with peripheral facial palsy evaluated for Lyme disease. The mean age was 10.7 years, and 52% were male. Of these, 106 (34%) had Lyme disease facial palsy. After adjusting for year of study, the following were independently associated with Lyme disease facial palsy: onset of symptoms during peak Lyme disease season (June to October), absence of previous herpetic lesions, presence of fever, and history of headache. In the subset of patients without meningitis, both onset of symptoms during Lyme disease season and presence of headache remained significant independent predictors. CONCLUSIONS. Lyme disease is a frequent cause of facial palsy in children living in an endemic region. Serologic testing and empiric antibiotics should be strongly considered, especially when children present during peak Lyme disease season or with a headache.

Validation of anaphylaxis in the Food and Drug Administration's Mini-Sentinel

We aim to develop and validate the positive predictive value (PPV) of an algorithm to identify anaphylaxis using health plan administrative and claims data. Previously published PPVs for anaphylaxis using International Classification of Diseases, ninth revision, Clinical Modification (ICD‐9‐CM) codes range from 52% to 57%.

Implementing a Guideline to Improve Management of Syncope in the Emergency Department

BACKGROUND AND OBJECTIVES: Thirty-five percent of children experience syncope at least once. Although the etiology of pediatric syncope is usually benign, many children undergo low-yield diagnostic testing. We conducted a quality improvement intervention to reduce the rates of low-yield diagnostic testing for children presenting to an emergency department (ED) with syncope or presyncope. METHODS: Children 8 to 22 years old presenting to a tertiary care pediatric ED with syncope or presyncope were included. We excluded children who were ill-appearing, had previously diagnosed cardiac or neurologic disease, ingestion, or trauma. We measured diagnostic testing rates among children presenting from July 2010 through October 2012, during which time we implemented a quality improvement intervention. Patient follow-up was performed 2 months after the ED visit to ascertain subsequent diagnostic testing and medical care. RESULTS: A total of 349 patients were included. We observed a reduction in the rates of low-yield diagnostic testing after our quality improvement intervention: complete blood count testing decreased from 36% (95% confidence interval 29% to 43%) to 16% (12% to 22%) and electrolyte testing from 29% (23% to 36%) to 12% (8% to 17%). Performance of recommended testing increased, such as electrocardiograms and pregnancy testing in postpubertal girls. Despite a reduction in diagnostic testing among children with syncope, patients were not more likely to undergo subsequent diagnostic testing or seek further medical care following their ED visit. CONCLUSIONS: Implementation of a quality improvement intervention for the ED evaluation of pediatric syncope was associated with reduced low-yield diagnostic testing, and was not associated with subsequent testing or medical care.

Improved Diagnostic Accuracy of Group A Streptococcal Pharyngitis With Use of Real-Time Biosurveillance

BACKGROUND Clinical prediction rules do not incorporate real-time incidence data to adjust estimates of disease risk in symptomatic patients. OBJECTIVE To measure the value of integrating local incidence data into a clinical decision rule for diagnosing group A streptococcal (GAS) pharyngitis in patients aged 15 years or older. DESIGN Retrospective analysis of clinical and biosurveillance predictors of GAS pharyngitis. SETTING Large U.S.-based retail health chain. PATIENTS 82 062 patient visits for pharyngitis. MEASUREMENTS Accuracy of the Centor score was compared with that of a biosurveillance-responsive score, which was essentially an adjusted Centor score based on real-time GAS pharyngitis information from the 14 days before a patients visit: the recent local proportion positive (RLPP). RESULTS Increased RLPP correlated with the likelihood of GAS pharyngitis (r(2) = 0.79; P < 0.001). Local incidence data enhanced diagnostic models. For example, when the RLPP was greater than 0.30, managing patients with Centor scores of 1 as if the scores were 2 would identify 62, 537 previously missed patients annually while misclassifying 18, 446 patients without GAS pharyngitis. Decreasing the score of patients with Centor values of 3 by 1 point for an RLPP less than 0.20 would spare unnecessary antibiotics for 166, 616 patients while missing 18, 812 true-positive cases. LIMITATIONS Analyses were conducted retrospectively. Real-time regional data on GAS pharyngitis are generally not yet available to clinicians. CONCLUSION Incorporating live biosurveillance data into clinical guidelines for GAS pharyngitis and other communicable diseases should be considered for reducing missed cases when the contemporaneous incidence is elevated and for sparing unnecessary antibiotics when the contemporaneous incidence is low. Delivering epidemiologic data to the point of care will enable the use of real-time pretest probabilities in medical decision making.

Trends in the Management of Viral Meningitis at United States Children’s Hospitals

OBJECTIVE: To determine trends in the diagnosis and management of children with viral meningitis at US children’s hospitals. METHODS: We performed a multicenter cross sectional study of children presenting to the emergency department (ED) across the 41 pediatric tertiary-care hospitals participating in the Pediatric Health Information System between January 1, 2005, and December 31, 2011. A case of viral meningitis was defined by International Classification of Diseases, Ninth Revision, discharge diagnosis, and required performance of a lumbar puncture. We examined trends in diagnosis, antibiotic use, and resource utilization for children with viral meningitis over the study period. RESULTS: We identified 7618 children with viral meningitis (0.05% of ED visits during the study period). Fifty-two percent of patients were <1 year of age, and 43% were female. The absolute number and the proportion of ED visits for children with viral meningitis declined from 0.98 cases per 1000 ED visits in 2005 to 0.25 cases in 2011 (P < .001). Most children with viral meningitis received a parenteral antibiotic (85%), and were hospitalized (91%). Overall costs for children for children with viral meningitis remain substantial (median cost per case

Integrating Spatial Epidemiology into a Decision Model for Evaluation of Facial Palsy in Children

5056, interquartile range

Use of population health data to refine diagnostic decision-making for pertussis.

3572–

Participatory Medicine: A Home Score for Streptococcal Pharyngitis Enabled by Real-Time Biosurveillance: A Cohort Study

7141). CONCLUSIONS: Between 2005 and 2011, viral meningitis diagnoses at US children’s hospitals declined. However, most of these children are hospitalized, and the cost for caring for these children remains considerable.

Incorporating vaccine-preventable disease surveillance into the National Health Information Network: leveraging children's hospitals.

OBJECTIVE To develop a novel diagnostic algorithm for Lyme disease among children with facial palsy by integrating public health surveillance data with traditional clinical predictors. DESIGN Retrospective cohort study. SETTING Childrens Hospital Boston emergency department, 1995-2007. PATIENTS Two hundred sixty-four children (aged <20 years) with peripheral facial palsy who were evaluated for Lyme disease. MAIN OUTCOME MEASURES Multivariate regression was used to identify independent clinical and epidemiologic predictors of Lyme disease facial palsy. RESULTS Lyme diagnosis was positive in 65% of children from high-risk counties in Massachusetts during Lyme disease season compared with 5% of those without both geographic and seasonal risk factors. Among patients with both seasonal and geographic risk factors, 80% with 1 clinical risk factor (fever or headache) and 100% with 2 clinical factors had Lyme disease. Factors independently associated with Lyme disease facial palsy were development from June to November (odds ratio, 25.4; 95% confidence interval, 8.3-113.4), residence in a county where the most recent 3-year average Lyme disease incidence exceeded 4 cases per 100,000 (18.4; 6.5-68.5), fever (3.9; 1.5-11.0), and headache (2.7; 1.3-5.8). Clinical experts correctly treated 68 of 94 patients (72%) with Lyme disease facial palsy, but a tool incorporating geographic and seasonal risk identified all 94 cases. CONCLUSIONS Most physicians intuitively integrate geographic information into Lyme disease management, but we demonstrate quantitatively how formal use of geographically based incidence in a clinical algorithm improves diagnostic accuracy. These findings demonstrate potential for improved outcomes from investments in health information technology that foster bidirectional communication between public health and clinical settings.