Educational Webinar: Rapid Respiratory Testing and the Impact on Pediatric Care

Good afternoon. Thank you so much for joining us today. My name is Brandon Martin. I'm here with you from mckesson Medical Surgical and I'm very excited to welcome you to today's presentation regarding rapid respiratory testing in pediatric care. Before we get started, I would like to direct your attention to our disclaimer. And while you're reviewing that information, I will remind you that today's presentation is being recorded. And within a day or two, you can expect to receive a link to download a copy of the presentation. You can also download the slides by following the link under presentation materials to the left of your screen. And if you have a question, feel free to enter it into the Q and A panel at the bottom left corner of your webinar window at any time and we will do our best to answer at the end of the presentation. Today's program is entitled Rapid Respiratory Testing and the impact on pediatric care. We have two terrific speakers from the clinic setting and would like to first thank them for their presentation participation and commitment to this educational program. I'd also like to thank our co sponsor, Abbott for their extensive support and collaboration. Our first speaker today is Doctor Maurice Algier, pediatrician partner and president of All Star Pediatrics, a division of one pediatrics in Louisville, Kentucky. We have a lot of material to cover here today, so I don't want to take any more time. Doctor Algier. Thank you so much for your time. The floor is yours. All right. Thank you, Brandon. Uh We do have a lot to cover, but like Brandon said, these slides will all be available. So uh if I don't touch on everything on a slide, they'll be there for you all's review later. Uh But let's go ahead and dive in. So obviously, uh I am here uh on behalf of Abbott, I am receiving an honorarium, so I wanna disclose that for sure, but also s you know, make sure everyone realizes that this will not be an info commercial. This is uh gonna be based on what one pediatrics and all stars experience has been with testing technology. Uh Just a little bit about our uh clinics. We are six independent offices, uh private practices that came together to try and deliver a better quality uh uh care model uh in the Louisville metropolitan area, you know, we have seven divisions, 10 locations and 40 plus providers. So, uh so I can speak to, you know, a pretty wide breath as far as uh everything from, you know, solo practitioners to multi uh location offices, you know, with, you know, a dozen providers, uh today's learning objectives, what we're gonna hopefully come away with is knowing, you know, some different things about RSV and group based strip specifically. So we wanna be able to assess some recent trends and the current status of RSV and group uh a strep infections to, you know, inform some seasonal preparedness, which uh you know, we all should be thinking about. Now, we wanna be able to clarify the differences and the utility of some rapid testing technologies. We'd also like to be able to examine some testing guidelines and the impact of the test technology on, you know, patient care as well as staff workflows and then lastly describe some testing strategies to support diagnostic and antibiotic stewardship in urgent and primary care settings. Um And so with that, let's get right into it. We are gonna have some poll questions throughout the uh presentation. We have three of them planned. Uh And so this is our first one, you'll see a screen pop up where you can answer and then as soon as you answer that screen will disappear. But right now we want or for our first poll question, we want to know who is currently performing rapid testing for respiratory infectious diseases and in which areas, laboratory presurgical areas, clinics, as well as physician offices, urgent care, skilled nurse, and long term care pharmacy. Uh There's a blank there for other, you can fill in the blank and then you know, if it's not applicable to, you know, your setting, please let us know that. And then lastly if you just don't know, um that's ok too. So once you answer that, we'll come back to those uh questions here in a second and we'll see kind of where everyone's at with this. But let's dive in. We're, we're gonna talk about two specific respiratory infections like I stated earlier, RSV and some group a strap. So let's start with RSV. So respiratory sensual virus near and dear to every pediatrician's heart. Uh because as you can see here, almost every child will have this infection by the age of two. And we know that it is the most common form of bronchiolitis in infants and young Children. And it does account for up to 250 infant deaths annually. Uh just for, you know, that virus and we know the hospitalization burden is immense with uh with this virus that that comes in seasonally every year. So it is important for us to, you know, to focus on RSV and especially in certain pa patient populations, we know premature infants, especially those born before 29 weeks of gestation are at particular risk. Any child with chronic lung disease. If they have uh you know, a heart defect, especially if it's hemodynamically significant, that's important if their immune system um is deficient or if they have other kind of neuromuscular or neurologic conditions, you know, that can put them at, you know, risk of really severe disease. And then there's a host of other things you can see that we also consider, you know, some risk factors uh for RSV. But, but really, it's looking at that severe disease and, you know, and how are we gonna protect those, those uh most vulnerable? And so when we think about that, we have to look at, you know, how's it spread. And so we know that RSV uh can be spread by your self inoculation, right? So you're touching contaminated surfaces and exposing it to, you know, mucous membranes where it gets into the body, it's gonna incubate for roughly a week, you know, 4 to 6 days is typical. And then as you starting with your symptoms, we know that you're gonna shed that virus for another week, thereby causing spread to, you know, close contacts that we have or possibly people that maybe aren't as close, right? So, if I'm in a care setting, I know that this virus can live outside the body on hard surfaces for up to six hours. So maybe it's a child who was in that room who had RSV before you showed up there with your infant and you may be, you know, contaminating, uh you know, your own child, you know, inadvertently, not realizing that maybe there were some viral particles left uh behind. So it is important for us to think about, you know, RSV. And know that timing, uh, so that we can hopefully, you know, prevent some things, you know, and prevent that spread. Now, back to our first poll question. Uh, it is one of those things that, that, you know, we kind of like to know where everyone is at as far as where you're coming from and, and you can see the results on your screen that, you know, most of us are, you know, talking about, you know, we're using this testing and physician offices looks like 38% do that. Uh We've got a little bit of, you know, where it's, you know, sprinkled with urgent care and long term care center settings. Uh, you know, and then of course, you know, there's, there's a big chunk of, of other, uh out there as well. And so it is important for us, you know, to talk about, you know, how do we, you know, think about RSV when it comes to, you know, those particular settings. Well, one of the things we know about RSV is that it usually has a seasonality to it. Well, unfortunately COVID, you can see there in that 2020 blip, that was the last, uh, you know, uh year we had in RSV season right before the COVID um outbreak. And you can see what happened in 21 it disappeared and it had actually appeared in the summer. And so it was one of those things that we were scratching our head and you can see it here as well that, you know, we look at the summer of 21 and we were having a huge RSV outbreak. But that's not typical. You can see in 22 that we got back more into the typical season of it where it's really in the winter months, not in the summer months. And so we wonder what's coming for 23. Well, the best way to look for that, you know, we realize is to look at maybe some Australian data and see when did they have their um outbreaks this year? And you can see for this year, it is going back to a more typical presentation. Of course, remember I'll, you know, remind you that their seasons are opposite hours. So while we're having spring, they're having their winter and you, you can see that RSV did a nice rise in the 0 to 4 year old uh range and part of that being because during COVID, some of these kids weren't getting exposed to RSV. So we're seeing some catch up infections there and they're still seeing them in Australia. You can see this also, you know, when we look at comparing RSV to flu data that's coming in uh from Australia. And you can see that, you know, with, with RSV, as well as flu, that 0 to 4 year old population really gets hit hard, uh and flu, you know, starts to jump up and grab those teens and uh those school age Children as well. So, you know, we think about, you know, jumping back to the RSV discussion when we look at Australia's data and we see that they had that profound 2022 season, like we also shared last year. Uh We start to think, well, maybe we're gonna follow them, you know, in 23 as well. And so I direct your uh to that, you know, dark blue Arrow, uh where you can see that was the blip that we saw in 21 clearly. Um, um, you know, not, I'm sorry, the, the uh purple Arrow uh is, you know, the blip we saw there in 21 and with some peaks just kind of out of place. And so with 20 you know three, what we're hoping to see is that we're gonna get back into that normal timing, um, with the, um, with the RSV outbreak, you know, the, the kind of along the same lines of what we saw in 21 of course, that was during summer months, but we're hoping to see 23 come back in, you know, like it did in Australia in kind of its more typical seasonality pattern. Now, one thing also to note in Australia, which was interesting was that, remember I was saying that RSV on that earlier slide and you can see that, you know, 1 to 3% of our, you know, Children under one got admitted to the hospital. What was interesting was for this last year for RSV in Australia, nearly one half of all emergency room presentations for Children, 0 to 4 were bronchiolitis and they were admitted to the hospital. So it tells you that they were getting a little bit more severe disease. And so we will have to see and be ready for that here, uh, in the US in 23 to see. Are we gonna get that same um type of acuity? And so, you know, that's kind of, you know, very quickly going through, you know what we think about with RSV. But on the flip side of that, we also start talking about bacterial um upper respiratory and we think about group a streptococcal uh Ryti, which is, which is obviously another very important um infection in, in pediatrics. And we know that co it's most common during the winter and spring. Of course, no surprise there when the Children, you know, are in school, uh your incubation period, you know, again, 2 to 5 days, it can get anybody of any age. But it is most common in, in those uh school age Children cause obviously they're close contact uh with each other, you know, makes it uh uh you know, just a hotbed for, for spreading. But when we carry that into the adult population, we also have to think about those parents and those grandparents who are taking care of those school age Children. So certainly the at risk um as well. And you can see how profound it is the impact of, you know, 5.2 million outpatient visits, uh and 2.8 million antibiotic prescriptions annually for people in the US alone from zero to age 64. And so you can see this is a very, very important infection uh that we get a good handle on to make sure that we know who has it and hope hopefully stop that spread because we're not necessarily worrying about the pharyngitis per se. We're worried about some of those complications that can come with the group. A strep, you know, be those separative or non separative complications. Uh and we also worry about this, which is invasive group, a strep. And we've seen that on, you know, a gradual rise for, you know, more than five years. And, you know, while yes, you can see in the graph here that it may have come down just a little bit, um you know, immediately after COVID, we're starting to see it rise again and it's getting back, you know, higher than it was even at, you know, prepa levels. And so it is a big deal when you think about gosh, if we're dealing with evasive group based in Children as well as the elderly, and we're also thinking about a respiratory season with maybe increased flu and RSV activity and acuity, you can see where it becomes really important for us to be able to start distinguishing these uh infections and make sure we're treating the right people. And so with that in mind, you know, we look also at, you know, it's not just in the medical literature, I put this in here to remind us that even, you know, mainstream uh media has grabbed a hold of the fact that, you know, gosh invasive group, a strep is on the rise and we need to be aware of that. And you know, parents are, are, you know, they're, they're smart to this and so they see it. And so when they come to our offices, you know, they're gonna wanna know is that what my child has? And so where do we go from there? Well, we have to be able to diagnose all these upper respiratory infections. And we know as medical providers in medical school, we were taught that most of your diagnoses are gonna be made by a good history and physical and always throwing the caveat about what if, when they can't be right. So when we look here with, you know, and we're talking about RSV and strep, but you can also throw in COVID-19, you can throw in influenza A A and B that you can see huge amounts of overlap between symptomatology to also physical exam findings. And so at that point, you have to have some other way um to, you know, augment your decision making process and so to drive that point home, we go to our second poll question which is, look at these throats and you tell me which one, you know, has strep A versus just a virus. So, so which one of these has strep a throat, a throat, b, throat c or you know the answer or I'm sorry, c would be both or d you're just not able to distinguish and you need to test and so we'll see what everyone's responses are here in just a minute, but we'll keep moving. And so when we think about the testing, right, there's a couple of things. So one having the ability to test is one thing, but we also have to ask the more important questions of why are we testing? Is it for isolation reasons? Is it for treatment reasons which we're gonna dive into here in a second? And also even though I'm gonna be able to test, what am I gonna test for. So we have to be ready to know, you know, certain factors that will drive our, our testing panels. Are we gonna use the panel test? Are we, you know, gonna just use a single test? Do we have clinical suspicion? What's in the community? Um What am how most concerned about? And so you know uh what population am I dealing with? Right? Am I dealing with pedia pediatric patients? Am I dealing with nursing home patients? So it is important for you to look at the population, those risk factors to also drive home the point of what are we gonna do just because we have the ability to test, how are we gonna pick and choose. And so the A EP the American Academy of Pediatrics and our infectious disease uh Bible, we call it, the red book starts talking about strep throat specifically and it says the first thing is that you absolutely do not diagnose strep tose strep throat without having lab test confirmation. And they throw a few caveats in there saying, you know, there's a couple of populations, you don't necessarily have to test Children less than three because it's exceedingly rare for them to have group, a strep unless they have a known group, a strep contact and are showing symptoms. And those also they have more virally symptoms, right. So, cough Anora hoarseness, diarrhea, that's usually not a Hallmark of strep. And so those they say, well, maybe you don't have to test for strep, but maybe we have to look, you know, for something else, maybe we have to start looking for a viral infection there. And then also, you know, you can use multiple scores and criterias to look to say, you know, does this patient really have, you know, do we have a bona fide clinical suspicion of it? And if you really don't, don't do the test, um, you know, let's be steward of that. Uh, but the take home is, you know, you can't diagnose it without doing the test and certainly you cannot give an antibiotic or you should not give an antibiotic without some sort of lab confirmation. And so let's see, you know, kind of what the audience thought as far as what to do there. And, oh, you all are such a good audience. I love it. So the overwhelming majority, um you can see on the results here have said, you know, you just can't distinguish it and you have to test it. And so, you know, the, the the pictures I showed you, it was actually a trick question. Both of those are actually uh viral pharyngitis. And so you can see it's so extremely hard um to distinguish without a test. Now that's group a strep, but we're also talking about RSV. So let's think about that. So with RSV, the Academy says the exact opposite, it says go by history, go by physical, if you are super suspicious of them having bronchiolitis and they are in a risk factor. Um you know, category, you know, that may be a child that you're gonna admit to the hospital and observe. You don't even have to do the testing. You don't need radiographic evidence, you don't need lab confirmation, you just treat the patient. And I always think about well, COVID-19, you know, wasn't around. And so now that we have COVID-19, what do we do? We have other pathogens that are affecting the respiratory tract that I may need to know about. And so, you know, when I look at the last five RSV epidemics from, you know, uh you can see that, you know, we see our blip from, you know, the, the summer of 21. Uh but then we see a pretty good seasonality here pattern to it. But remember those words like trem that we worried about where we thought RSV and maybe flu and, you know, we were gonna have COVID all hitting simultaneously. Well, how do we distinguish those things? Well, we distinguish them through testing. And so, you know, that is one of the things that I that we start to talk about now more so is can we identify a virus, you know, that's causing, you know, the bronchioli or maybe just the underlying symptoms? We may think that it's a bronchialis, maybe it's not, we also can use our testing, you know, to maybe decrease, you know, our suspicion that maybe this isn't a bacterial infection we've seen in some studies that if we do test and we have confirmation, we can reduce the utilization of antibiotics kind of important. And so, so, you know, it's not just a test to say yes, this is RSV or not, but there are some really good benefits to it. We also know that it will help, you know, reduce healthcare transmission, right. So we know that if you test positive for RSV, we can reduce nosocomial infection by 39 to 50% in one particular study. Uh because we know, and we can cohort patients, we can do the same thing in daycares as well as, you know, elderly, um, you know, populations when it comes to, you know, assisted living communities, maybe when we have a good test that's reliable, we can help prevent some of that spread. The other thing, you know, again, I, I've told you my bias, I'm a pediatrician. One of the things I spend most of my day doing is educating people on all kinds of things. Isn't it nice to be able to educate them on RSV and all the effects that can come from that? And so we use that as an education piece so that the parent under stance, the shedding the risk to the, you know, to the other family members that may be coming from a seemingly simple innocent cold virus. And so this just kind of sums it up that, you know, everything we were talking about that there are some scenarios where we may wanna do some RSV testing. And so we know that what the illness is, we know that maybe we wanna diagnose it, but how do we do that? And this is where COVID made all of our patients experts on PC R, right? Every patient came in asking a parent requesting that PC R test they kept hearing about on the TV. And they really didn't know that they were asking for PC R. They were really asking for a molecular test. And why is that important? Because we know by this slide that, you know, in the old days an antigen test, you know, again, pediatrician, we may not get the perfect sample. And you can see if I can't amplify that sample and I stay under the limit of detection. I'm gonna have a false negative. But with molecular testing be that PC R or an isothermal reaction, any of the nucleic acid amplification test, I can come in with maybe a not optimal sample. I can amplify and now I can start grabbing those true pods. It is and more importantly, avoid those false negatives. And so that's when you have to start deciding what's gonna be best for my situation. Well, you have PC R where you can thermal cycle and if you have the time and you have the bench space uh for that great, you know, you can choose the PC R route. If you want something that's maybe a little more compact, you want something that you know, sits on the bench top that's maybe a little bit faster without sacrificing accuracy. Isothermal may be the way to go. And so there are multiple, multiple versions uh of both types of technology, but bottom line, they're all molecular tests and they are all highly, highly sensitive. So I'd like to show the group a, you know, strip uh example, when we look at throat culture, which we know is the gold standard. By the CDC. We can see that our sensitivity approach is 90 to 95% lateral flow, 85%. So not great, but that's OK. We're gonna back it up with a culture to get us back up to the 95%. But what was interesting was when we looked at in office culture in this one study uh by Cohen, um you could see that uh it was actually the sensitivity was down to 85%. And so, you know, maybe not the most pristine collection. And so, you know, you're not getting as good of a result. So when we get over to the NATS and we start looking at that, we start thinking about, wow, maybe we can really get our sensitivities up and that's exactly what it shows. So for our institution, we happen to, you know, choose uh the ID now because we like the timing of it with, without sacrificing sensitivity. So you can see I can get my negative result in as you know, quick as six minutes, which is the same timing as the old lateral flows we were used to. But I can get my positives as fast as two minutes and in pediatrics, that's key and again, speed does not lose my sensitivity. And so that's obviously critical for this and we can do the same exercise with RSV testing. We won't run through all the same things. But you can see even using a reader on a lateral flow, you know, your sensitivities are far inferior to any of the N A testing technology. And this 98.6 is uh based on, you know, the ID now, um uh literature and research. So, so again, net testing, you're gonna get, you know, a, a great result and you're gonna get it more expeditiously because why is that important? Because I have to be able to do something with this data, right? And so one thing that I think is interesting is, you know, I should have made this a poll question is what percent of providers actually spend more than 16 minutes with a patient? Well, you're gonna be, or be surprised to find out not many. So this is the reverse. So people in there less than 16 minutes, all clinicians are 56% look at pediatricians, 72%. And that's for multiple reasons. One, you know, we tend to have high volumes and, you know, um, you know, the, the winter months and also most parents don't want to sit there with a sick child, they want to get in, they wanna get their answer, they want to get back home, uh, where they can, you know, be more comfortable, you know, and make their child more comfortable. But it goes more than that, that rapid, you know, result also helps minimize, uh, you know, the hit to the economy. Right. So we know that if we can get a child with group, a strep treated by five o'clock and we can have them wake up fever free and feeling a little bit better the next day, they can go back to school and most people go. Ok. Well, big deal. It's one day. What does that really mean? Well, when you see at the bottom of this slide that the cost to the US economy for just group, a strep alone in those missed days is anywhere from 300 to $700 million. Depending on the study you look at, I'd say that's pretty significant. And so that's why having that rapid test result helps me. But it also helps me in another way because it keeps me from inappropriately prescribing antimicrobials. And so this slide makes everyone groan when they see it. And now this is old data. This is from 2018. But you can see from the urgent care to the emergency department even to the medical home, how many inappropriate uh, prescriptions we were doing back in 2018. Well, the good news is we've gotten a little bit better. So this study, um, is, uh, you know, uh, you know, kind of around the same uh, time frame looking at that prepa time period of, you know, 2017, 2018 and what we've been doing since and you can see we're better, but there's still so many inappropriate antibiotics going out and, you know, some people may say, well, you know, it's not really that big of a deal. Well, you know, it kinda is because group a strep, which is one of the easiest bacteria to kill. Um, you know, historically, in pediatrics, you can see these invasive group a isolates, you know, starting from 20 you know, 2006 to current, you're starting to see resistance and that was unheard of, you know, 40 years ago. And so it is a big deal. And so we do have to think about being a better steward of antimicrobials and that, you know, number one has added benefits, right. So we can hopefully reduce, you know, antibiotic resistance. We can get the kids back to school faster and the parents back to work faster. But we can also avoid some of those adverse drug reactions that we love getting those phone calls back about, you know, on a child who has an antibiotic, an antibiotic that they didn't even need in the first place. And so we think about that being stewards of care. And so, you know, it's not just stewards of antimicrobial care, but it's also diagnostic stewardship. And so I like to think about that when I'm ordering a test, right. Number one, am I gonna order the appropriate one? And is it really gonna alter my clinical decision making? Should there be a pathogen panel that I'm using that's gonna be very costly or should I do a more targeted test where it's really gonna, you know, tell me the answer that I want, I always tell, you know, my students who rotate with me that just because you have a test to do and a panel test specifically doesn't mean that's the right way to do medicine, you know. So we try to espouse the one test in one test out. Um, you know, philosophy here, not only for, you know, um you know, to be good stewards of uh of healthcare dollars, but also to be good stewards to our patients, right? I don't wanna be getting a false positives when I know that the population, you know, uh that I'm treating really doesn't have a high incidence of that. So, so we think about that for cost-effective care uh for the patient. And so it is important to, to think about what we're ordering. And so to bring all that into one synthesis. And I know I've covered a ton, we really start talking about impact of, of, you know, nats in our office and we drop it in three buckets. We talk about it in terms of the patients, the clinicians and in terms of operations. And so when for the patients, obviously huge win, right, their duration of their visits is shorter, we can get more patients in. So we're not putting people off to the next day, they're getting antimicrobials that are appropriate, they're getting back to school and work, um, satisfaction convenience. My goodness, it's through the roof for my clinicians. It's an easy sell, you know, they're getting objective versus just empiric diagnostic decisions. They're making sure that they're prescribing appropriately. They're also making sure that they're doing that in a timely fashion with a high degree of confidence. And so that makes my clinicians very, very satisfied. And when we think about operations, office managers love it too. Right. So we can get more patients through it improves our workflow, which Glenn's gonna go through in a little more detail. The logistics in the lab are fantastic, you know, send outs, he's gonna focus on and tracking down orders. So the operation piece of it is also a win. Um And with that, I'm gonna, you know, let Brandon take it back over and we'll let Glenn take us through uh a little bit more detail, you know, especially on, you know, how we're, how we're looking at this and how we're preparing, you know, for the upcoming season. Thank you so much, Doctor Algier. Our second speaker today is a board certified family nurse practitioner, Glenn BS provider, practice Manager and partner at premier pediatrics in Norman, Oklahoma, Glenn. Thank you so much for joining us today. Thank you, Brandon. Thank you, Doctor Al Guy. That was an excellent review of molecular testing as well as the two respiratory infections that we were discussing today. Again. I um I tried to make my presentation more complimentary of what Doctor Algier was presenting. And I'm really gonna go over our experience with rapid respiratory testing and the impact of uh the care of our patients. When we made the transition to molecular testing versus lateral um flow antigen testing. Disclaimers similar as Doctor Algar. I am um speaking uh on, on an honorarium by Abbot Rapid Diagnostics uh test and I'm trying to keep this from being uh an infomercial as well. So I, I'm primary clinician. I see patients uh Monday through Friday, but I do have other practice roles that have been added over the last 8 to 10 years. Uh I began uh practicing or managing the practice probably seven or eight years ago and partnered um with two of the original physicians um probably around 2014, a little bit about our practice. We are located in Norman Oklahoma. Uh the, the uh side of the University of Oklahoma. We are just outside of Oklahoma City. We serve a very diverse population to include uh ethnically culturally uh as well as financially suburban cult um a and and rural patients. Uh We have Medicaid patients, private insurance patients, private pay patients and we have a fairly large practice. We have six pediatricians, uh eight nurse practitioners. And um we probably in a busy winter serve 350 patients uh a day. We are a stand-alone clinic. So these decisions were really made in-house by us. Uh When we decided to investigate molecular testing, uh A as an alternate to uh rapid lateral flow antigen testing. So I'm gonna start out with a poll question. This is primarily for, for those that work in a health care setting or a clinician setting. So the most used strategy for re infection testing in our institution, a clinician determined test ordered based on clinical assessment, suspicion or community epidemiology, standing orders as in test ordered based on defined presentations or a single respiratory test panel for all patients presenting with suspected respiratory infection. Or I don't know, as you guys are answering that question, I'm gonna keep moving and we will review these poll questions or answers in a moment. So we started investigating um the use of molecular testing or adding that to our testing protocol prior to maybe a year or two before uh COVID-19 pandemic. And we were primarily using rapid lateral flow testing in-house to include group A rep uh influenza A and B and RSV. And our experience really with rapid antigen testing proved to be uh fairly inconsistent. Um a lot of false negatives and we even use uh a variety of antigen testing to, to, to include those with analyzers. Uh but again, very inconsistent and probably resulted in more out of house testing uh for a definitive diagnosis to include respiratory infection panels or throat cultures and, and definitely an increased workload for our triage nurses since these patients were uh receiving these uh additional out of house testing uh in a local hospital or laboratory service required uh lots of follow up for our patients in order to provide the care that we needed to depending on the test results. So a few things we looked at when evaluating uh point of care, molecular testing for our practice um were some of the requirements of that we needed was something that was accurate and time sensitive uh was easily integrated, integrated into our practice model. Um And we wanted it to be patient centered. We really wanted to focus on effective patient care management allowed us to uh provide targeted disease state therapy and allow for care decisions in a time sensitive fashion. As Doctor Algier spoke to time is important for uh pediatricians. Uh parents really want to come in, they want a definitive diagnosis and they want treatment to be very time sensitive, wait times uh cause anxiety for parents. And we wanted to at least a net zero program cost and that really was not for our practice. We really wanted to make sure that whatever modality we brought in, we did not add additional cost to the patient on out of pocket COVID-19 hit. And it really expedited our change to more sensitive te uh testing platform. And after looking at uh the platforms that were available, we did settle on the ID now and a a big uh selling point on that was the fact that we could do rapid uh testing on multiple antigens to include COVID-19, which allowed us to provide the care we needed to, especially during that um uh difficult time. So again, our practice decision to to change was based on the increased sensitivity of the point of care uh tests that were available within a reasonable time frame. As doctor Al Guy has spoken to and a flexible menu that allowed us to test for influenza COVID-19 group based rep and RSV. We needed more reliable positive tests and negative tests which were very important for the clinicians that work here. And we wanted the ability to initiate treatment at an earlier time versus waiting for any outhouse test or non-defense. And we wanted proper stewardship, not only of testing um but antibiotic therapy. So as I've stated, I have three roles here. I'm a clinician. I'm the practice manager. I'm one of the partners and owners and really, I had to look at it as in three different avenues when we decided whether we were gonna bring molecular testing uh into, into our practice. And as a provider, I really wanted a reliable test. I wanted to decrease the number of false negatives and make sure that my positives that I could lay my hat on that and give a definitive diagnosis and treatment to my patients. We wanted to make sure that that improved care to our patients as a practice manager, customer service was the number one item that I looked at complaints. We try to limit as many as we can uh by giving excellent care, but it's gonna happen. And most often as a practice manager, the things that I hear is time, time to diagnose this time in the room, time to wait for the patient can't get a scheduled appointment with my provider. Those are things that we constantly strive to improve and those are things that are important to patients. And then as an owner, we really just wanted to make sure that we weren't adding any cost to the patient out of pocket expenses. So, back to our poll question here, the most due strategy for respiratory infection testing in our institution, it looks like the majority of the listeners uh picked a around 45% and 27% picked b we try and we encourage our uh providers uh to treat with autonomy, but we encourage them to uh order tests um efficiently and, and make sure that they're based on clinical evaluation, both history and physical exams. So we really want to make sure that we um have clinician determined testing. I will caveat that during uh COVID. Uh we were definitely overrun with the, the need for testing uh for COVID patients and the volume of patients that were testing positive. We did provide uh curbside testing and some curb curbside um evaluations and there were times that we had some standing orders and that was really customer based so that we could get them a diagnosis earlier and reduce uh the risk of s uh uh infection to others to include within the the facility and our health care providers. So, in summary, our decision to add molecular testing platform to our practice was based on the increased efficiency um uh of of the testing platform as well as the increased sensitivity. Uh we could rely on the positive tests and reduce the number of false negatives. It allowed us to test multiple antigens as group based rep influenza COVID-19 RSV and the increased efficiency of patient care workflow. A test that was received, a result was received in an earlier time frame allowed us to initiate treatment and or education in earlier time frame and limit the number of patients that required follow up after they left the office. So I've included a couple of case studies and really these are not to to trick anybody are relatively straightforward. And really the purpose of these was just to point out the effect the of molecular testing, positive effect of molecular testing on our real world patients in our practice to include time to test as well as customer service. So case study number one, it's a nine month old term infant with no chronic medical illnesses with two days of fever, a high 101 eating well and cough parents do report wheezing and the history of physical exam is consistent with bronchialis. Uh parents are healthy without any risk factors, but the child does attend daycare, uh community prevalence. It's in the fall with limited COVID-19 with, with flu cases uh in the community with the exam with what I would expect from a bronchitis alert, generally happy infant with clear Kriza. Um no signs of any secondary infection with mild uh wheezing and no retractions. So, clinical suspicion is RSV and a considered flu because it's in the community and those can overlap with symptoms. As Doctor Algier stated, the backbone of diagnosis for bronchioli is generally history and physical exam and you can make that diagnosis without additional testing. But the criteria for additional testing is really based off risk of complications, a premature infant, a child under the age of six months, any underlying cardiopulmonary or neuromuscular disorders, any immune compromise or co morbidity in 2021. The actual because of the number of COVID uh cases, cases and the multiple re infections that were in the community, they did encourage testing for um COVID um for comorbidity at that time. So the test, you could order influenza A and B and RSV. And the reason I mentioned those um is because uh influenza and RSV have symptoms that do overlap and the risk factor here is this child is in daycare and if possible that this child was positive for influenza A and B with under two days of febrile symptoms, they do meet the criteria for antiviral therapy. So our testing options are antigen testing and or molecular testing. And I wanted to point out the differences between the workflow between the two different types of testing platforms. So as a send out for RSV, if we had no in-house uh rapid testing, molecular antigen, the test, you know, the swab is collected, it's sent to the outpatient lab and results are gonna be available, it says 20 to 20 minutes to eight hours. In my experience, it's gonna take 3 to 4 hours at our local facility and that's three or four hours that a patient doesn't have a diagnosis. They've left the facility and I have to follow up with my lab and triage nurses for that result and any follow up therapy and a positive test obviously confirms the diagnosis, reassures us that we don't need to do antibiotic therapy. But a negative test, we may have to consider other ideologies and may require follow up testing. This adds time to the patient care and uh adds time to diagnosis, which is extremely important for parents. So treatment I won't go over this. Uh This is most clinicians know this but treatment of RSV is symptomatic treatment, treating the fever uh based off age depending on which uh age group you fit into dictates. Uh what is available for that child monitoring for any respiratory distress or secondary infection and then coordinate with the primary care provider. Again, treatment is symptomatic. The A AP did make a recommendation uh in 2000 thir 2013 against the use of albuterol steroids or epinephrine or antibiotic therapy for RSV. Uh Due to the fact that the effectiveness was not significantly proven through studies. However, this this uh exclusion um or does not include patients with any underlying conditions to include asthma, cystic fibrosis, neuromuscular conditions or cardiopulmonary compromise which um RSV could exacerbate those and would require maybe the use of the aforementioned uh medications, infection control measures. The biggest issue here is to limit exposure to others that might be high risk to include other infants in daycare, Children at home, elderly grandparents, those at risk for complications with RSV and the earlier to diagnosis, the earlier that we can control um uh infections and others around the child. So as comparison for workflow for a send out RSV or an on site rapid RSV test molecular as the bottom uh workflow illustrates a swab is collected in the clinic with a result less than 13 minutes. 13 minutes is extremely uh important to the parents because I can give them if it's positive, a definitive diagnosis. A treatment plan without the use of unnecessary additional testing and or antibiotic therapy. A negative test allows me to coordinate with the patient in the clinic and follow up should be shorter based on any additional testing that I may need to uh to uh obtain. Again. This is just an illustration of the time to diagnosis, the time to treatment, time to intervention, which again is a very, extremely important for parents, additional impact or the uh importance of impact of molecular testing. Uh stewardship of additional tests or uh unnecessary tests as well as antibiotic therapies. We did see a reduction of out of house testing to include the COVID-19 PC RS, uh throat cultures for group based rep respiratory infection panels, serum studies and ra radiologic studies uh for patients. And my hope at that point would be reduction of unnecessary urgent care emergency visits. Again, an infinitive diagnosis causes anxiety in patients and generally leads to either follow up visits here or follow up through an emergency room in urgent care for for uh additional work up if the ex the child does not improve. Um within the subsequent 2 to 3 days after visit as doctor alg spoken to. It's very important for antibiotic stewardship to treat patients when antibiotics are necessary and warranted and not treat patients when unnecessary. And a more sensitive test and more accurate test allows us to have this con uh conversation with confidence that antibiotic therapy is not necessary for respiratory infections and fewer demands by the patient to prescribe the antibiotic if the diagnosis is definitive and then case study number two to nine year old with sore throat, fever of 101 to 102 and headache for two days. Community prevalence its fall during the school year. The exam, mildly ill, ill appearing child with minimal erythema to the oropharynx, no partic lesions and no prominent tonsils. Again, this is not classic where I could diagnose this um with group A rep based solely on physical exam. And my clinical suspicion includes viral pharyngitis ideologies as well as group A rep and testing was warranted. The uniqueness of this test is that currently in Oklahoma uh Medicaid patients and this was a Medicaid patient uh with primary uh private insurance. Our Medicaid patients or Medicaid practices do not. Um the insurance does not cover molecular testing for based rep and we've tried to advocate for that. So in, in this instance, I initially started with an antigen test which was negative and I had two choices to send this child as recommendation for a throat culture and wait two days for a result or use the molecular test and get a result in less than 13 minutes. And I chose patient care and customer service over any reimbursement issues and the test was positive, which means I save this patient approximately 48 hours of time, waiting for a result to come back and then initiate treatment. And in fact, the follow up can be proven to be difficult. There has been a study done uh emergency room visits with Children with negative group, a strep with a positive or with a throat culture done. Uh 10% of those had a positive culture and it was um unable to reach them. So therapy was never started. So the importance of having a test that is uh increased sensitivity in the practice allows me to get a result in less than 13 minutes that I do not have to do a throat culture, improves patient care and customer service and allows me to give care in the practice and limit the time that my staff is trying to contact this patient for follow up care. So this is an example of a rapid strep antigen with a confirmation for send out if the in-house rapid strep is negative, as you can tell the time to result on a swab or uh procul after a negative antigen test can be anywhere from 18 to 36 hours. Although again, my experience here, it's 48 hours plus at our local facility, that's two days that I'm unable to treat if it's positive and or I have an infinitive diagnosis and the parent is waiting two days to find out what treatment will be prescribed as comparison on the bottom workflow, one single swab on a molecular test with a result in less than 2 to 6 minutes, which means I have a positive or negative, I can have the conversation of symptomatic treatment if the test is negative with no follow up for a culture, which means I can have that conversation prior to the patient leaving the room. And a positive test means I'm saving 48 hours I'm starting that patient on therapy markedly earlier than waiting for the thrill culture, which reduces the risk for infecting others. And I can have the conversation with confidence that a negative test does not need antibiotic therapy. So the patient impacts no culture required with the molecular test. You eliminate the 48 hour wait time, the ability to start antibiotic therapy immediately. Patients want a definitive diagnosis. They want treatment and they want imperative symptoms as quickly as possible. We, we allows my clinicians to have more efficient and effective care and eliminates or most eliminates any employee employee time spent communicating with the patient after the visit for throat cultures, which is not always one phone call. If that follow up is necessary. It generally takes more than one phone call to get the information to the patient and limits the possibility of infecting others. Again, the diagnosis during the office visit allows my clinicians to confidently prescribe antibiotics and it reduces again, reduces the spread to others outside of outside of the practice treatment of roof bra strap again, antibiotic therapy per current treatment guidelines. The takeaway from this is that with molecular testing, it shortens the length of symptoms because I'm starting therapy at an earlier time frame as well as allows for reduction of transmission other persons because I'm getting result prior to leaving the room and prevents hopefully prevents the development of complications due to earlier treatment. I'm speaking of accuracy and throughput for molecular testing and a point of care, outpatient uh testing platform, the amplification of molecular material increases the sensitivity and specificity of the test. This increase sensitivity and specificity allows for or allows for decrease in false negative results and increases true positive results. And again, as I've spoken before, antigen tests with less sensitivity can create very subjective results and generally requires for either additional testing or unnecessary tests and or unnecessary antibiotic therapy. As Doctor Alga or spoken to the stewardship of both testing and antibiotic therapy is very important, especially in a pediatric practice allows us to have the conversation of uh symptomatic supportive therapy, initiation of antiviral therapy, antibiotic therapy when appropriate at an earlier time and or the decision to transfer to a higher level of care, no confirmation of negative tests are required with th culture with molecular testing. And again, patient education allowing our patients to understand the decisions we make and, and have confidence uh in the follow up care and or uh the reduced need for testing and antibiotic therapy. Infection control measures. Earlier treatment allows us to uh uh limit the uh contagious of the patient uh anywhere from 12 to 24 hours after antibiotic therapy. Uh and education on how other ways they can reduce that by changing their toothbrush three or four days after therapy and or uh not sharing of any utensils, drinks, et cetera. Impact of molecular testing on transmission is really based on time, the time to test the time to result allows us to initiate infection control measures earlier to include quarantine recommendations. Infection control measures for group A strep RSV and influenza and reduction of unnecessary exposure to other persons to include those in the home daycare or outpatient lab or hospital services and in pre prep preparation for the next waiver season. As doctor Al Guy says we had the unexpected uh RSV outbreak in the summer uh during the COVID pandemic, we should stay prepared. We we uh initiated curbside testing uh during the height of the COVID or pandemic uh masking when appropriate based off CDC recommendations. And we had to keep in mind that RSV is not the only viral etiology that causes bronchitis and the seasonal patterns to each of these respiratory infections. One thing that we've had found valuable is that our local uh lab and hospital does keep track of the levels of viral illnesses within the community and allows us to heighten our awareness as well as information to the clinician to include in their differential diagnosis and some tracking mechanisms in house allows us to order in stock and we track that and we provide that information to providers allows them to know what other providers are seeing within the practice. Uh Generally that allows me to include that in my differential app. I've seen a heightened increase in the number of positive tests based off the antigen and then monitoring insurance coverage changes. Again, I've uh after, as I've said, uh our, our Medicaid has decided to and limit the use of molecular testing for group A rep. Um and allows us to advocate with our rep for a more sensitive and accurate test. Our end goal at this point is to uh improve our patient care and give excellent care. And one of those things is advocacy for the patient. So in summary, it is very important for stewardship of both antibiotic and unnecessary testing, especially in an outpatient care clinic or pediatric clinic. There are marked differences, the antigen and molecular testing in regards to sensitivity and reliability, which were definitely key influences of our change or adding molecular testing to our practice and huge differences in time and workflow between antigen and molecular diagnostic tests, particularly for group A rep but other antigens as well allowed the change to elective testing, facilitate, facilitated our our process and favorably impacted our workflow for both providers, staff and patients. And hopefully, the case studies demonstrated the prudent use of diagnostic tests and, and the impact on patient care and ins and lastly, molecular testing had a positive impact on our workflow, patient care models and customer service. Thank you. Thank you so much Glenn uh and Doctor Algar as well. I thank you both for your time today. Um We've got just a couple of minutes left. I think we may be able to get in just a couple of questions. Um I will read these aloud and just give you both uh um a moment to answer. Um starting with the first one that came in. What unplanned changes did you find as a result of implementing rapid testing? How did you address Glenn? Do you want to take that or do you want me to, to jump in uh changes to molecular testing? Um Yeah, one of, one of our concerns when we changed over really was really out of pocket expense for patients. Um What we did is worked with our patients and, and test case this through several various insurance and then let the patient know that we would write off any additional suspense on the on on the back end, it allowed us to gain information about what the coverage was in the community. Um without adding additional cost um to the patient, really the the training for the for the ID now or the platform that we use was very straightforward. So our nurses were a little anxious to begin with but are very comfortable with that. Now. Um So those really the, the, the the monetary component was the biggest issue and how that would affect our patients on the back end. Yeah, and I'd, I'd echo that. I, I think that that was uh an important piece for us and then also, you know, the unexpected consequence of a dual ordering. So now we were, you know, not just ordering one test. Uh for group a specifically uh you know, we were having to, you know, because of insurance concerns, keep, you know, kind of that management of, you know, uh OK, who can get lateral flow and in house throat culture, which we do versus being able to do the, the uh rapid molecular. So, so that was probably the, the biggest thing for us was trying kind of, you know, figure that dance out of um of keeping the right stock. Uh So we wouldn't run out of, of either of either platform for the other uh things RSV uh Flu COVID. Uh We used ID now exclusively um after testing some other platforms. So, so that wasn't quite as big of a, a big big of an issue for, for the ordering piece. Excellent. Thank you both so much. Um Let's go ahead and try to get one more question in uh this one was uh how do you choose between using a panel versus individual tests? How does that choice impact the patient encounter and their satisfaction? So, with our practice, uh you know, I kind of spoke a little bit to it that we like the one in one out philosophy. Um So we will try and look because we're, you know, set in a, in a community, you know, we look at our individual location. So we're, we're drawn from, you know, similar schools, similar daycares. So we can look at what's, what's in the community and then we make our, our decisions based on that. Uh you know, I may start with, you know, a flu test for instance, like, uh you know, Glenn was talking about in his example and, you know, and if I get a positive there, I may stop. Uh if not, I may go that next step to uh to look for, to look for an RSV. If I, if I have a deep suspicion of that or maybe even a group, a strep. But um but I try to kind of look at what's in the community. Uh and then order, order from there, I will tell you that, you know, from our parent perspective, we have not had any complaints come back. Uh We have had a few angry parents that uh went to some of the local urgent cares and uh er s that ran, you know, large viral respiratory panels and, you know, received uh you know, extremely large bills for that. Uh and called us to ask, you know, well, why did they run that? And, you know, we, we had to, you know, do our best to try and answer it. But uh but no, and also letting them know that no, we don't utilize that here in our office. So, so they could feel more confident that if they were coming here, they weren't gonna get, you know, hit with a uh uh you know, a viral respiratory panel uh bill which can you know, can be substantial. So, so that, that's kinda, that's kinda how, how we approach that. Yeah. And I think similarly we do the same, our clinicians really base the tests that they order of what's, what's prevalent in the community. How is the child presenting, what is the history of the illness and the and the physical exam? And we really try and limit any unnecessary test. So we really do one test at a time. Personally, I do one test at a time that may take me a little more time with that patient. But I really am trying to limit any unnecessary tests or any expense to the patient. Um You know, because I have dual roles here. Um Customer service is extremely important. It's always on my mind. So I'm thinking as a clinician and, and as the practice manager and I really encouraged our uh clinicians to do the same. Excellent. Well said uh Glenn, Doctor Olga. Thank you both so much for your time. We have uh reached the end of our presentation today. I want to thank all of you in the audience for joining us. Uh I'll give you just another second to read through our disclaimer one more time and there's a contact number there for our um for our clinical team. Uh Thank you all again so much for joining us today. I really enjoyed the presentation. Uh I do want to invite you all to visit M ms.mckesson.com/educational dash webinars for a full list of upcoming events uh register, share with your colleagues or sign up to receive additional webinar schedule updates. Uh Thank you all so much, gentlemen. It's, it's, it's really been a pleasure. I I appreciate the time today. Thank you. Thank you. Have a great day, everyone.