Cost Savings from a Policy to Diagnose and Prevent Transmission of Adenoviral Conjunctivitis in Employees of a Large Academic Medical Center

From the 2021 HVPAA National Conference

Irene Kuo (Wilmer Eye Institute, Johns Hopkins University School of Medicine)

Background

Adenoviral conjunctivitis is highly contagious, can be associated with systemic infections, and can cause chronic visual impairment. It accounts for a large proportion of acute conjunctivitis. Outbreaks of epidemic keratoconjunctivitis (EKC) are costly in terms of productivity loss from work furloughs and spread to patients and have resulted in clinic and departmental closures.

Objective

To determine the institutional cost savings of a policy to triage, diagnose, and furlough medical center employees with adenoviral conjunctivitis to prevent adenoviral conjunctivitis outbreaks.

Methods

Economic evaluation of an ongoing quality improvement initiative at Johns Hopkins Medicine regarding employees with red eye triaged at the Occupational Health Clinic and diagnosed using polymerase chain reaction (PCR) validated for adenoviral conjunctivitis. The main outcomes and measures were total number of furloughs avoided and cost savings associated with reducing unnecessary furloughs.

Results

Of 2,142 employees with red eye, 1,520 (71.0%) were swabbed for PCR; 130 (8.6%) had positive adenoviral PCR, of whom 41 (31.5%) had EKC. Furloughing 130 PCR-positive employees vs. furloughing all 1,520 clinically suspicious employees represented an estimated savings of $442,073/year or $3,094,511 over seven years. The cost of performing PCR on employees suspicious for adenoviral conjunctivitis was 5.0% of the cost associated with furloughing all employees with red eye. No outbreak occurred.

Conclusions

This policy, notable for development and use of PCR for adenoviral conjunctivitis on a large-scale, resulted in substantial cost savings from fewer work furloughs compared to the number that would have been furloughed based on clinical diagnosis. These results may provide impetus for policy adoption by other institutions and for development of a rapid, sensitive, and specific diagnostic test for adenoviral conjunctivitis.

Clinical Implications

As part of an ongoing quality improvement initiative, the estimated cost savings from furloughing 130 employees instead of 1,520 was > $3 million over 7 years. Given the lack of proven therapy and the potential for rapid transmission and vision-threatening complications, medical centers should take triage, diagnosis, and containment of adenoviral conjunctivitis seriously. However, diagnosis is frequently difficult and inaccurate, leading to undesirable scenarios such as the unnecessary furlough of employees who are not contagious and inappropriate prescription of topical antibiotics, which can contribute to antibiotic resistance. Use of accurate diagnostic testing for adenoviral conjunctivitis (which currently does not exist on a commercial basis) resulted in cost savings from fewer employee furloughs compared with furloughs based on clinical diagnosis, the typical method of diagnosing conjunctivitis. No outbreak of adenoviral conjunctivitis occurred. EKC outbreaks have lasted 1.5 to 6 months at some medical centers, affecting more than 400 patients, staff, and doctors at one center over a 6-month period. As >80% of enrollees in a national managed care network received care for acute conjunctivitis from non-ophthalmologists, and the odds of non-ophthalmologists prescribing antibiotics for conjunctivitis can be as high as 3 times the odds of ophthalmologists doing so, the estimated costs savings above does not include downstream savings of antibiotic costs and costs of adenoviral infection or EKC outbreak that were prevented.

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