High-Value Care During the COVID-19 Pandemic: Lessons Learned and Future Opportunities

Fever is one of the most common chief complaints in children seeking care in the United States, representing up to one-third of all pediatric office visits and 20% of pediatric emergency department (ED) visits.^1,2  During the coronavirus disease 2019 (COVID-19) pandemic, a chief complaint of fever has adopted a new meaning because it may indicate either acute infection with COVID-19 or a diagnosis of multisystem inflammatory syndrome in children (MIS-C). Whereas the workup of fever may have previously consisted of a limited diagnostic evaluation, COVID-19 and MIS-C have complicated the traditional evaluation of fever in otherwise healthy children and challenged the practice of high-value care. In this article, we discuss the financial and social implications of evaluating a child for MIS-C, the importance of diagnostic stewardship in the setting of evolving disease entities and clinical uncertainty, and ways to improve the practice of high-value care during the COVID-19 pandemic.

MIS-C is defined by the Centers for Disease Control and Prevention as an illness involving an individual <21 years old with (1) laboratory evidence of inflammation, clinically severe illness requiring hospitalization, and multisystem (≥2) organ involvement, (2) no plausible alternative diagnosis, and (3) a positive test result for current or recent severe acute respiratory syndrome coronavirus 2 infection or exposure to COVID-19 within 4 weeks before the onset of symptoms.³  Because of the nonspecific nature of this definition, the evaluation of MIS-C complicates how health care providers practice high-value care in several ways. First, the evaluation of MIS-C is both extensive and expensive. Although diagnostic evaluations vary between hospitals, they generally include a combination of blood culture, respiratory viral panel, complete blood count, comprehensive metabolic panel, troponin, brain natriuretic peptide, creatine kinase-myocardial band, erythrocyte sedimentation rate, C-reactive protein, d-dimer, ferritin, procalcitonin, lactate dehydrogenase, coagulation panel with fibrinogen, interleukin-6, cytokine panel, urinalysis, chest radiograph, electrocardiogram, and echocardiogram.⁴  According to the chargemaster at a large children’s hospital in the northeastern United States, this can add up to >$8000 in laboratory testing and imaging per patient.⁵  Second, the components of the MIS-C workup are nonspecific for MIS-C and may add to diagnostic uncertainty rather than confirmation because many of these studies test for general inflammation. For example, C-reactive protein, erythrocyte sedimentation rate, and d-dimer can be elevated in many physiologic and pathologic states and are not specific to different infectious or inflammatory etiologies.^6,7  Finally, finding abnormal laboratories as part of the MIS-C evaluation often leads to additional unnecessary testing, cost, and stress for families.⁷  Some hospitals cannot perform echocardiograms in the ED, which means that patients who require echocardiograms must be admitted for imaging. According to the previously mentioned children’s hospital chargemaster,⁵  as well as a study of room charges by Synhorst et al,⁸  hospital admission can cost nearly $8000 per night on top of the existing $8000 MIS-C diagnostic evaluation, not including any additional testing that may have been ordered because of abnormal laboratories. Through this medical workup, families also incur nonmedical costs in the form of lost earnings due to missed work, transportation, childcare, or social and psychological stress.^9,10  Considering the downstream effects of diagnostic testing, the evaluation for MIS-C can have significant financial and emotional consequences for patients and their families.

In the face of an evolving pandemic in which new variants of COVID-19 continue to emerge, it can be difficult to practice high-value care. MIS-C is rare, with 7459 cases and 63 deaths nationally as of March 1, 2022.¹¹  However, its presentation is often variable and nonspecific, and its health outcomes are frequently serious and even fatal.^3,11  As MIS-C is a relatively new entity that is still being studied, the very uncertainty surrounding the diagnosis and optimal management of this disease makes it difficult to evaluate. Pediatric health care providers understand that testing all febrile children for MIS-C is low-value care; at the same time, MIS-C is a diagnosis we must at least consider in febrile children because its presentation may mimic other disease processes.^12,13  Now, in the third year of the pandemic, we can reflect on lessons learned in approaching pediatric patients with COVID-19 and MIS-C and we can apply these lessons to promote high-value care moving forward.

The first lesson is that, when evaluating a child with fever, we must maintain a broad differential diagnosis and be cognizant of our own biases. MIS-C can present similarly to other pediatric illnesses, including viral syndromes, urinary tract infections, or appendicitis.^12,13  Anchoring to MIS-C without considering other more common illnesses may delay diagnosis and lead to a more complicated clinical course.¹³  We need to assess the pretest probability of MIS-C by understanding local epidemiology and asking about COVID-19 exposure and vaccination status. For example, the Pfizer vaccine is 91% effective in preventing MIS-C in children ages 12 to 18,¹⁴  so evaluation of a febrile child in this age category will differ on the basis of vaccination status given the differential risk of MIS-C. Additionally, we need to be mindful of the multisystem nature of MIS-C. A physical examination is critical, as patients with MIS-C may have evidence of respiratory, gastrointestinal, skin, neurologic, cardiac, or other organ distress.¹⁵  A febrile child with normal vital signs and a normal physical examination would yield a lower pretest probability for MIS-C than an ill-appearing child with hemodynamic instability or respiratory distress. Finally, when pursuing laboratory evaluation for MIS-C, we must still consider that elevated inflammatory markers are nonspecific for MIS-C and could be seen in a variety of other illnesses.^6,7 

The second lesson is the importance of establishing clinical pathways when faced with new disease entities. A clinical pathway is an evidence-based protocol used to standardize care for a specific clinical problem in a specific population.¹⁶  Clinical pathways have been shown to improve patient safety and quality of care, increase efficiency, and reduce health care costs.¹⁶  Although the development of MIS-C pathways was initially challenging because of limited evidence, pathways now exist in many centers. The American Academy of Pediatrics also released a guidance statement on MIS-C, which has helped standardize the evaluation of MIS-C on a national level.¹⁵  For hospitals that do not yet have a clinical pathway, we would recommend formulating one to identify clear indications for MIS-C evaluation.

Finally, the third lesson is the need for health care professionals to stay informed of new studies and clinical recommendations as we learn more about COVID-19 and MIS-C. Incorporating emerging evidence into practice can improve the quality and value of patient care delivered. For example, referencing the American Academy of Pediatrics’ interim guidance on MIS-C can help us triage which patients should be sent to the ED for MIS-C evaluation versus outpatient management.¹⁵  Implementing current MIS-C management guidelines from the American College of Rheumatology to treat patients with MIS-C may reduce morbidity and mortality in those patients.¹⁷  In addition, staying up to date with studies on COVID-19 vaccine safety can help us better educate families and advocate for COVID-19 vaccination in children. As of February 23, 2022, only 32% of 5- to 11-year-old children and 66% of 12- to 17-year-old children in the United States have received at least 1 dose of a COVID-19 vaccine.¹⁸  Meanwhile, COVID-19 infection rates in this group are growing; from February 17, 2022 to February 24, 2022, children represented 26.2% of the weekly reported cases.¹⁹  COVID-19 vaccines are safe, protect against COVID-19 infection, prevent serious illness, hospitalization, and death, and reduce the risk of subsequent development of MIS-C in children.^14,20  As pediatric providers, we are obligated to advocate for the health and well-being of children, especially when it comes to preventive care.

Health care providers have faced many novel challenges during the COVID-19 pandemic but have also learned how to rapidly adapt to new illnesses and changing management guidelines. Although COVID-19 is still an evolving entity, we need to recognize that overtesting for MIS-C in well-appearing febrile children does not provide high-value, patient-centered care. Everything in health care comes at a cost; patients and their families bear not only the financial cost of hospitalization but also the psychological burden of undergoing unnecessary testing, receiving equivocal test results, and enduring prolonged hospital stays.^9,10  Although it is our duty as health care providers to not miss a diagnosis, it is just as much our duty to minimize costs, reduce unnecessary health care utilization, and avoid harmful interventions to deliver high-value care to our patients.