A5V4d

Health economics
symptom was noted. The rest (104) were all face-to-face consultations without telephone triage, and
in 18 consultations, ‘amber’ symptoms were recorded, with a diagnosis made in nine cases. Six of
these children were referred for a paediatric assessment unit for specialist advice, which represents
3.8% of children presenting with fever as their primary symptom. During the period of the survey,
there were no children who would have been classified as ‘red’ under the traffic light system.
Only 13 of those assessed remotely and 18 of those assessed face-to-face showed ‘amber’ features,
and thus potentially none of these children fell into the urgent referral group. The absence of either
‘red’ or ‘amber’ features would have allowed at least some of these children to be confidently
managed at home, and those with ‘amber’ features only could have been referred within a longer time
frame of safety netting, which could have been put into place following face-to-face assessment. The
data suggests that the proportion of children who require an urgent face-to-face referral following
remote assessment would potentially be reduced and is very small compared with the far greater
number of children who have either ‘amber’ symptoms and require assessment within a longer time
frame by a healthcare professional or have self-limiting illness (who can be confidently managed at
home).
Having reviewed the data and based on their own experience, the GDG consensus was that an
individual GP in a group practice such as the one surveyed would be unlikely to see more than one or
two cases of SBI a year, and for some of the more rare conditions would be unlikely to see one case
in their professional career. During the period of the survey there were no children who would have
been classified as ‘red’ under the traffic light system. This is because urgent referrals would only be
needed for children with ‘red’ features and a proportion of children with ‘amber’ features. This
assertion is supported by the data in the GP survey referred to above where no children were
classified as ‘red’ and 19% were ‘amber’.
Further evidence of the number of children likely to present to secondary care with ‘red’ symptoms
was considered. An American study of 6611 febrile children presenting to an emergency department
found that 3.3% of children had a Yale Observation Score greater than 10. 101 A YOS score of 10
means the child has symptoms that are ‘red’ signs and symptoms on the proposed traffic light system.
It is important to note that the 3.3% is a small fraction of the total number of children with fever but it
still may be an overestimate because the data do not indicate how many of the 3.3% of children with a
YOS score over 10 have other symptoms which are ‘red’ features in the traffic light system. Also, the
study was done in a hospital setting and it is based on the American healthcare system. Furthermore,
the GDG’s recommendation would only apply to children referred from remote assessment in this
context and not all children with ‘red’ symptoms, many of whom will present for a face-to-face clinical
assessment as their first point of healthcare contact.
Cost-effectiveness of a 2 hour referral for face-to-face assessment
The GDG did not identify any data on the likely cost or cost savings from recommending a 2 hour time
limit for an urgent face-to-face assessment or the likelihood of this leading to an increase in referrals
to specialist care. The issue was discussed in detail during a number of GDG meetings. The main
point that was agreed was that the GDG believes that the guideline’s recommendations will support
the identification of those children requiring urgent assessment, referral and initiation of management
which in some cases will be life-saving and certainly prevent unnecessary long-term morbidity. There
is a cost-effectiveness threshold under which any intervention that saves lives or prevents serious
morbidity is generally seen to be cost-effective. If we assume that a life-saving intervention that
prevents one death in a very young child is worth around 25 QALYs (75 years discounted at 3.5%),
then an intervention that costs £500,000 (25 × £20,000) and saves one life is within the threshold for
cost-effectiveness.
The GDG found it impossible to guess how many children with ‘red’ symptoms who were seen faceto-face
urgently from a remote assessment (within 2 hours) would be saved from death or serious
morbidity. The argument for cost-effectiveness is that £500,000 (to save one child’s life) could be
spent on additional face-to-face assessments for it to be cost-effective if it saved one life. The cost of
additional face-to-face assessment is hard to estimate if it is within surgery hours, but it costs around
£35–40 for an out-of-hours consultation *, 249 or £70 for a home visit. 250 Therefore if an additional 7,100
* Annual cost or provision of out-of-hours care in England was £316 million in 2004–05, and the number of people using the
service in England was 9 million.
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