Economic and operational impact of an improved pathway using rapid molecular diagnostic testing for patients with influenza-like illness in a German emergency department

  • Matthias Brachmann
  • Katja Kikull
  • Clemens Kill
  • Susanne Betz
Original Research


To evaluate the economic and operational effects of implementing a shorted diagnostic pathway during influenza epidemics. This retrospective study used emergency department (ED) data from the 2014/2015 influenza season. Alere i influenza A & B rapid molecular diagnostic test (RDT) was compared with the polymerase chain reaction (PCR) pathway. Differences in room occupancy time in the ED and inpatient ward and cost differences were calculated for the 14-week influenza season. The process flow was more streamlined with the RDT pathway, and the necessary isolation time in the ED was 9 h lower than for PCR. The difference in the ED examination room occupancy time was 2.9 h per patient on a weekday and 4 h per patient on a weekend day, and the difference in the inpatient room occupancy time was 2 h per patient on a weekday and 3 h per patient on a weekend day. Extrapolated time differences across the influenza season were projected to be 2733 h in the ED examination room occupancy and 1440 h in inpatient room occupancy. In patients with a negative diagnosis, the RDT was also estimated to reduce the total diagnostic costs by 41.52 € per patient compared with PCR. The total cost difference was projected to be 31,892 € across a 14-week influenza season. The improved process and earlier diagnosis with the RDT pathway compared with conventional PCR resulted in considerable savings in ED, inpatient room occupancy time and cost across the influenza season.


Economic analysis Emergency department Influenza-like illness Molecular test Process optimization Rapid diagnostic test 



The economic evaluation was supported by a grant to bcmed, Düsseldorf, Germany, from Alere International, Bedford, UK. Susanne Betz and Clemens Kill did not receive any form of honoraria for their participation in this study. Medical writing, editorial, and other assistance: medical writing support was provided by Ross Jarratt of integrated medhealth communication, London, UK. Support for this assistance was funded by Alere International.

Compliance with ethical standards

Conflict of interest

Matthias Brachmann is majority owner of bcmed GmbH which received a grant for an economic evaluation from Alere International, Galway, Ireland. Katja Kikull was a project manager at bcmed GmbH at time of writing which received a grant for an economic evaluation from Alere International, Galway, Ireland. Clemens Kill received speaker fees and travel costs from Alere International, Galway, Ireland. Susanne Betz has no conflict of interest.

Research involving human participants and/or animals

This article does not involve any new studies of human or animal subjects performed by any of the authors.


  1. 1.
    Kovács G, Kaló Z, Jahnz-Rozyk K, Kyncl J, Csohan A, Pistol A, et al. Medical and economic burden of influenza in the elderly population in central and eastern European countries. Hum Vaccin Immunother. 2014;10(2):428–40.CrossRefGoogle Scholar
  2. 2.
    World Health Organization. Fact sheet: Influenza (seasonal). 2016. Accessed 14 Nov 2017.
  3. 3.
    Thompson WW, Shay DK, Weintraub E, Brammer L, Bridges CB, Cox NJ, et al. Influenza-Associated Hospitalizations in the United States. JAMA. 2004;292:1333–40.CrossRefGoogle Scholar
  4. 4.
    Ginocchio CC, McAdam AJ. Current Best Practices for Respiratory Virus Testing. J Clin Microbiol. 2011;49(9 Suppl):44–8.CrossRefGoogle Scholar
  5. 5.
    Zheng W, Aitken R, Muscatello DJ, Churches T. Potential for early warning of viral influenza activity in the community by monitoring clinical diagnoses of influenza in hospital emergency departments. BMC Public Health. 2007;l7:250.CrossRefGoogle Scholar
  6. 6.
    Isaac-Renton JL, Chang Y, Prystajecky N, Petric M, Mak A, Abbott B, et al. Use of lean response to improve pandemic influenza surge in public health laboratories. Emerg Infect Dis. 2012;18(1):57–62.CrossRefGoogle Scholar
  7. 7.
    Leonardi GP, Mitrache I, Pigal A, Freedman L. Public hospital-based laboratory experience during an outbreak of pandemic influenza A (H1N1) virus infections. J Clin Microbiol. 2010;48(4):1189–94.CrossRefGoogle Scholar
  8. 8.
    Haber N, Khelili D, Martineau D, Dekimeche S, Szekely C, Lebon P, et al. Delay in diagnosis of influenza virus in an elderly hospitalized patient: a fatal outcome. Clin Med Insights Case Rep. 2012;5:5–8.CrossRefGoogle Scholar
  9. 9.
    Muller MP, Junaid S, Matukas LM. Reduction in total patient isolation days with a change in influenza testing methodology. Am J Infect Control. 2016;44(11):1346–9.CrossRefGoogle Scholar
  10. 10.
    Rorat M, Kurek T, Kuchar E, Szenborn L. The clinical couse of late diagnosed fatal cases of A (H1N1) influenza in Poland. Postepy Hig Med Dosw. 2013;67:595–600.CrossRefGoogle Scholar
  11. 11.
    Brendish NJ, Schiff HF, Clark TW. Point-of-care testing for respiratory viruses in adults: the current landscape and future potential. J Infect. 2015;71(5):501–10.CrossRefGoogle Scholar
  12. 12.
    Abraham MK, Perkins J, Vilke GM, Coyne CJ. Influenza in the emergency department: vaccination, diagnosis, and treatment: Clinical Practice Paper Approved by American Academy of Emergency Medicine Clinical Guidelines Committee. J Emerg Med. 2016;536–542.Google Scholar
  13. 13.
    Afilalo M, Stern E, Oughton M. Evaluation and management of seasonal influenza in the emergency department. Emerg Med Clin North Am. 2012;30(2):271–305.CrossRefGoogle Scholar
  14. 14.
    Fagbuyi DB, Brown KM, Mathison DJ, Kingsnorth J, Morrison S, Saidinejad M, et al. A rapid medical screening process improves emergency department patient flow during surge associated with novel H1N1 influenza virus. Ann Emerg Med. 2011;57(1):52–9.CrossRefGoogle Scholar
  15. 15.
    Soto M, Sampietro-Colom L, Vilella A, Pantoja E, Asenjo M, Arjona R, et al. Economic impact of a new rapid PCR assay for detecting influenza virus in an emergency department and hospitalized patients. PLoS ONE. 2016;11(1):e0146620.CrossRefGoogle Scholar
  16. 16.
    Jeong HW, Heo JY, Park JS, Kim WJ. Effect of the influenza virus antigen test on a physician’s decision to prescribe antibiotics and on patient length of stay in the emergency department. PLoS ONE. 2014;9(11):e110978.CrossRefGoogle Scholar
  17. 17.
    Bonner AB, Monroe KW, Talley LI, Klasner AE, Kimberlin DW. Impact of the rapid diagnosis of influenza on physician decision-making and patient management in the pediatric emergency department: results of a randomized, prospective, controlled trial. Pediatrics. 2003;112:363.CrossRefGoogle Scholar
  18. 18.
    Özkaya E, Cambaz N, Çoskun Y, Mete F, Geyik M, Samanc N. The effect of rapid diagnostic testing for influenza on the reduction of antibiotic use in paediatric emergency department. Acta Paediatr. 2009;98(10):1589–92.CrossRefGoogle Scholar
  19. 19.
    Tillekeratne LG, Bodinayake CK, Nagahawatte A, Vidanagama D, Devasiri V, Arachchi WK, et al. Use of rapid influenza testing to reduce antibiotic prescriptions among outpatients with influenza-like illness in Southern Sri Lanka. Am J Trop Med Hyg. 2015;93(5):1031–7.CrossRefGoogle Scholar
  20. 20.
    Nguyen Van JC, Camelena F, Dahoun M, Pilmis P, Mizrahi A, Lourtet J, et al. Prospective evaluation of the Alere i Influenza nucleic acid amplification versus Xpert Flu/RSV. Diagn Microbiol Infect Dis. 2016;85(1):19–22.CrossRefGoogle Scholar
  21. 21.
  22. 22.
  23. 23.
    The National Association of Statutory Health Insurance Funds. Accessed 14 Nov 2017.
  24. 24.
    Bell J, Bonner A, Cohen DM, Birkhahn R, Yogev R, Triner W, et al. Multicenter clinical evaluation of the novel Alere™ i Influenza A&B isothermal nucleic acid amplification test. J Clin Virol. 2014;61(1):81–6.CrossRefGoogle Scholar
  25. 25.
    Federal Statistics Office (Destatis). Accessed 14 Nov 2017.
  26. 26.
    Li-Kim-Moy J, Dastouri F, Rashid H, Khandaker G, Kesson A, McCaskill M, et al. Utility of early influenza diagnosis through point-of-care testing in children presenting to an emergency department. J Paediatr Child Health. 2016;52(4):422–9.CrossRefGoogle Scholar
  27. 27.
    Salgada CD, Farr BM, Hall KK, Hayden FG. Influenza in the acute hospital setting. Lancet Infect Dis. 2002;2(3):145–55.CrossRefGoogle Scholar
  28. 28.
    Dugas A, Valsamakis A, Atreya MR, Thind K, Mancheqo A, Faisal A, et al. Clinical diagnosis of influenza in the ED. Am J Emerg Med. 2015;33(6):770–5.CrossRefGoogle Scholar
  29. 29.
    Parker BT, Marco MD. Emergency department length of stay: accuracy of patient estimates. West J Emerg Med. 2014;15(2):170–5.CrossRefGoogle Scholar
  30. 30.
    Bleustein C, Rothschild DB, Valen A, Valaitis E, Schweitzer L, Jones R. Wait times, patient satisfaction scores, and the perception of care. Am J Manag Care. 2014;20(5):393–400.Google Scholar
  31. 31.
    Tevis SE, Kennedy GD, Kent C. is there a relationship between patient satisfaction and favorable surgical outcomes? Adv Surg. 2015;49(1):221–33.CrossRefGoogle Scholar
  32. 32.
    Worthington K. Customer satisfaction in the emergency department. Emerg Med Clin North Am. 2004;22(1):87–102.CrossRefGoogle Scholar
  33. 33.
    Fusco F, Schilling S, De Iaco G, Brodt H, Brouqui P, Maltezou HC, et al. Infection control management of patients with suspected highly infectious diseases in emergency departments: data from a survey in 41 facilities in 14 European countries. BMC Infect Dis. 2012;12:27.CrossRefGoogle Scholar
  34. 34.
    Sugerman D, Nadeau KH, Lafond K, Cameron W, Soetebier K, Jhung M, et al. A survey of emergency department 2009 Pandemic Influenza A (H1N1) Surge Preparedness––Atlanta, Georgia, July–October 2009. Clin Infect Dis. 2011;52(Suppl1):177–82.CrossRefGoogle Scholar
  35. 35.
    Brachmann M. Prozessoptimierung durch Point-of-Care-Testung. In: von Eiff et al., editors. Management der Notaufnahme. 2nd ed. Berlin: Kohlhammer, 2016. pp. 321–6.Google Scholar
  36. 36.
    Sakaguchi H, Wada K, Kajioka J, Watanabe M, Nakano R, Hirose T, et al. Maintenance of influenza virus infectivity on the surfaces of personal protective equipment and clothing used in healthcare settings. Environ Health Prev Med. 2010;15:344–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  1. 1.bcmed GmbHUlmGermany
  2. 2.Witten/Herdecke UniversityWittenGermany
  3. 3.Ategris hospitalsMuelheimGermany
  4. 4.Center for Emergency MedicineEssen University HospitalEssenGermany
  5. 5.Department of Emergency MedicineUniversity Hospital MarburgMarburgGermany

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