IMPORTANT FACTORS IN CLINICAL DECISION MAKING FOR RAPID STREPTOCOCCAL ANTIGEN TESTING: A SURVEY OF PEDIATRIC EMERGENCY DEPARTMENT (ED) PROVIDERS

Purpose: Although acute pharyngitis is a common complaint in pediatric EDs, group A streptococcus (GAS) accounts for only 30% of childhood pharyngitis and unnecessary testing is frequent and costly. Despite a campaign to decrease unnecessary rapid streptococcal antigen testing (RADT), including education and implementation of a decision-support tool, only modest results were appreciated (decrease from 67% to 59%).  We sought to determine factors important to ED providers when making a clinical decision to order an RADT.

                                                           

Method: An anonymous REDCap survey was sent to all nurses, advance practice nurses, and ED physicians (N=160). The survey asked 8 questions regarding what factors contribute to RADT: presence of GAS symptoms, risk of rheumatic fever (ARF) or tonsillar abscess, previous patient advocate complaint, parent request of an antibiotic or test, sibling with strep throat, and recurrent strep throat. Respondents used a 5-point Likert scale to indicate level of importance for each item. Medians and interquartile ranges were determined for each question. An additional question “Do you think antibiotic overprescribing for sore throat is a problem” was asked.

 

Result: A total of 118/160 (74%) responded to the survey. The most important factor in determining when to obtain a RADT was presence of GAS symptoms, followed by concerns of GAS complications (ARF or tonsillar abscess); while the least important factors were patient advocate complaint and parent request of an antibiotic (Figure 1). The majority of respondents (63%) felt that antibiotic overprescribing for sore throat is a problem.

Conclusion: Concerns for rare complications frequently drives RADT use decisions, despite most providers reporting antibiotic overprescribing as problematic. Understanding the factors for RADT clinical decision making will help our QI team develop targets to decrease unnecessary testing, which may include a component on improving clinician risk assessment and reducing cognitive bias (e.g. base rate neglect) when deciding to obtain an RADT.  Future engagement of providers on self-identified decision-drivers is critical for improving outpatient antimicrobial stewardship initiatives.