Article: Cotter JM, Thomas J, Birkholz M, et al. Clinical Impact of a Diagnostic Gastrointestinal Panel in Children. Pediatrics. 2021;147(5):e2020036954.
Fellow: Brittany Casey, MD; Johns Hopkins All Children’s Hospital, Saint Petersburg, FL
Summary: Diarrhea and gastroenteritis are common causes of dehydration and need to seek medical care in the United States. Many hospitals have transitioned from conventional stool studies, such as culture, serology, and assays to nucleic acid amplification multiplex diagnostic panels, such as the BioFire FilmArray Gastrointestinal Panel (GIP). To date, there have been no large pediatric population studies to evaluate the clinical utility of the GIP. This cross sectional cohort study of children l8 and younger sought to compare stool test use, pathogen detection, and time to result in addition to evaluating the clinical impact of GIP on patient outcomes, including length of stay and resource use between GIP and conventional diagnostic testing in the ambulatory, emergency/urgent care, and inpatient setting.
Bivariate analysis was used to compare outcome variable between the 2 eras, conventional testing versus GIP, using Pearson’s χ2 test for categorical values and Wilcoxon rank test for medians.
In the study, 12,222 stool tests were performed in 8720 patient encounters among 6,733 unique patients. The proportion of children who underwent stool testing in the GIP era in comparison to conventional stool testing increased by 21%, along with decreased time to result (4hrs versus 31hrs; P<.001), higher percentage of positive results (40% vs 11%; P<.001), and decreased time to treatment with antibiotics/antiparasitics (11hrs versus 36hrs; P<.001). In the patient population requiring treatment for a parasitic or bacterial pathogen, length of stay was decreased by approximately 2 days in the GIP era cohort compared to the conventional testing cohort (3.1 days versus 5.1 days; P<.001) although this only accounted for 3% of the patient population. When analyzing all patients, there were no differences noted in ancillary testing, imaging studies, length of stay, or total charges between the GIP and conventional testing cohorts.
Strengths: This cross sectional cohort study is the first to analyze clinical impact of the BioFire FilmArray Gastrointestinal Panel (GIP). This study had a large sample size and included multiple clinical settings ranging from ambulatory to ED/Urgent care, and inpatient. Given that this laboratory test is increasing in use, this study provides clinical relevance and baseline data for proposed clinical outcomes.
Limitations: First, this study was performed at a single center, quaternary care, urban academic children’s hospital. Although 4 community based hospital affiliates were included, this does limit the generalizability of the results found. In addition, as this was a retrospective study, it is unclear as to institutional changes that may have occurred that potentially affected the use of conventional testing versus GIP testing, such as limitations that may have been placed on the ability to order conventional studies prior to GIP once the GIP was available.
Major Takeaway: The use of nucleic acid amplification multiplex diagnostic panels, such as the BioFire FilmArray Gastrointestinal Panel (GIP) increased the number of children who underwent stool testing for gastroenteritis symptoms and allowed for a decreased time to result, a decreased time to initiate antibacterial or antiparasitic therapy, and did decrease length of stay and overall hospital cost for those patients requiring therapy. However, for the overall population, the improved detection and quick resulting time did not impact outcomes, which calls into question the diagnostic utility and stewardship of this test from the perspective of high value care.
How this article should impact our practice: While this test in certain patient populations may have utility, mainly those with suspected bacterial or parasitic infections based on history and physical exam findings, overall, this test does not change clinical outcomes for the vast majority of patients presenting with acute gastroenteritis. Therefore, until further studies provide more evidence for utility and guidelines are created for ordering practices, this study should be ordered with consideration of its limited use in guiding management.
Fellow: Brittany Casey, MD; Johns Hopkins All Children’s Hospital, Saint Petersburg, FL
Summary: Diarrhea and gastroenteritis are common causes of dehydration and need to seek medical care in the United States. Many hospitals have transitioned from conventional stool studies, such as culture, serology, and assays to nucleic acid amplification multiplex diagnostic panels, such as the BioFire FilmArray Gastrointestinal Panel (GIP). To date, there have been no large pediatric population studies to evaluate the clinical utility of the GIP. This cross sectional cohort study of children l8 and younger sought to compare stool test use, pathogen detection, and time to result in addition to evaluating the clinical impact of GIP on patient outcomes, including length of stay and resource use between GIP and conventional diagnostic testing in the ambulatory, emergency/urgent care, and inpatient setting.
Bivariate analysis was used to compare outcome variable between the 2 eras, conventional testing versus GIP, using Pearson’s χ2 test for categorical values and Wilcoxon rank test for medians.
In the study, 12,222 stool tests were performed in 8720 patient encounters among 6,733 unique patients. The proportion of children who underwent stool testing in the GIP era in comparison to conventional stool testing increased by 21%, along with decreased time to result (4hrs versus 31hrs; P<.001), higher percentage of positive results (40% vs 11%; P<.001), and decreased time to treatment with antibiotics/antiparasitics (11hrs versus 36hrs; P<.001). In the patient population requiring treatment for a parasitic or bacterial pathogen, length of stay was decreased by approximately 2 days in the GIP era cohort compared to the conventional testing cohort (3.1 days versus 5.1 days; P<.001) although this only accounted for 3% of the patient population. When analyzing all patients, there were no differences noted in ancillary testing, imaging studies, length of stay, or total charges between the GIP and conventional testing cohorts.
Strengths: This cross sectional cohort study is the first to analyze clinical impact of the BioFire FilmArray Gastrointestinal Panel (GIP). This study had a large sample size and included multiple clinical settings ranging from ambulatory to ED/Urgent care, and inpatient. Given that this laboratory test is increasing in use, this study provides clinical relevance and baseline data for proposed clinical outcomes.
Limitations: First, this study was performed at a single center, quaternary care, urban academic children’s hospital. Although 4 community based hospital affiliates were included, this does limit the generalizability of the results found. In addition, as this was a retrospective study, it is unclear as to institutional changes that may have occurred that potentially affected the use of conventional testing versus GIP testing, such as limitations that may have been placed on the ability to order conventional studies prior to GIP once the GIP was available.
Major Takeaway: The use of nucleic acid amplification multiplex diagnostic panels, such as the BioFire FilmArray Gastrointestinal Panel (GIP) increased the number of children who underwent stool testing for gastroenteritis symptoms and allowed for a decreased time to result, a decreased time to initiate antibacterial or antiparasitic therapy, and did decrease length of stay and overall hospital cost for those patients requiring therapy. However, for the overall population, the improved detection and quick resulting time did not impact outcomes, which calls into question the diagnostic utility and stewardship of this test from the perspective of high value care.
How this article should impact our practice: While this test in certain patient populations may have utility, mainly those with suspected bacterial or parasitic infections based on history and physical exam findings, overall, this test does not change clinical outcomes for the vast majority of patients presenting with acute gastroenteritis. Therefore, until further studies provide more evidence for utility and guidelines are created for ordering practices, this study should be ordered with consideration of its limited use in guiding management.