Pediatric Respiratory Testing Rates, Costs Increased Post Pandemic

The COVID-19 pandemic has had numerous effects on medical practice, not limited to expanded telemedicine practices and accessible COVID-19 tests. A new study published in JAMA Network Open1 finds that pediatric respiratory testing increased at the start of the COVID-19 pandemic and has remained high through the years, with implications for how much this increase can cost.

Pediatric emergency department (ED) visits include those caused by respiratory tract infections. Respiratory pathogen testing can be used to determine the cause of the infection through testing for viruses, bacteria, and other organisms.2 A movement to decrease the use of the tests due to the cost and reduced clinical usefulness when it comes to making management decisions had been proposed prior to the pandemic. However, the COVID-19 pandemic prompted the use of these tests as a method of identifying the virus causing symptoms and observing viral patterns throughout the year. This study aimed to assess any changes in respiratory pathogen testing rates in children and adolescents from 2016 to 2023 in children who presented acute respiratory infections in pediatric hospitals in the US.

The Pediatric Health Information System was used to conduct a cross-sectional study. The database includes data on demographics, diagnosis, and billing data for all applicable patients. The study included data from 38 pediatric hospitals. Age, sex, race, ethnicity, primary payer, and Child Opportunity Index (COI) were all included in the demographic data. The index list of billing clinical transaction classification codes was used to identify the use of respiratory pathogen testing.

The rate and cost of respiratory pathogen tests increased from 2016 to 2022 | Image credit: Golib Tolibov - stock.adobe.com

Participants examined in the study needed to be younger than 18 years and have encounters and hospitalizations solely through the ED. Children were separated into 3 groups based on the severity of their encounter in order to evaluate any differences in testing rates based on encounters or setting: ED only, hospitalization without intensive care unit (ICU), and hospitalization with ICU. The percentage of encounters with respiratory pathogen testing was the primary outcome of the study.

There were 5,090,923 encounters from 2016 to 2023 included in the analysis, with the children and adolescents included having a mean (SD) age of 3.36 (4.06) years. A total of 87.5% of the encounters were ED only and 77.9% were in children younger than 6 years. A total of 22.1% of the hospitalizations resulted in a visit to the ICU.

Respiratory pathogen testing was given to 37.2% of encounters, with 83.2% of hospitalizations with ICU visits including a respiratory pathogen test. Encounters that had hospitalizations without ICU visits had respiratory pathogen testing in 60.6% of the cases and ED-only encounters had testing in 33.2% of cases. Children in the highest COI quintile, indicating neighborhood-level resource availability, had greater rates of testing (40.4%) compared with the lowest COI quintile (34.4%). Testing was also more likely in patients with more complex chronic conditions (CCCs) (77.7% for 2 or more CCCs vs 35.5% for 0 CCCs).

Rates of testing were highest from January to March each year, although these rates remained high throughout the year with decreased seasonal variation during the pandemic. The percentage of encounters that had respiratory testing increased from 13.6% (95% CI, 13.5%-13.7%) to 62.2% (95% CI, 62.1%-62.3%) from 2016 to 2022. Encounters that were only in the ED had the highest increase in testing from 8.8% to 59.3% from 2016 to 2022.

Inflation-adjusted standardized unit cost increased from 2016 to 2022 from $20.6 million to $111.0 million. Cost per encounter also increased from $34.2 (95% CI, $33.9-$34.6) to $128.2 (95% CI, $127.7-$128.6) from 2017 to 2022.

There were some limitations to the study. Other clinical factors that influenced testing could not be adequately accounted for in the database. Testing rates for other respiratory diagnoses, including asthma, were not examined. Testing patterns in patients who did not have a respiratory diagnosis during the pandemic were also not examined. The influence of other testing taken at home or another health care setting could not be assessed. The data were limited to 38 hospitals and may not be applicable to other health care settings. Ambulatory settings were also not included in the data. Relative cost contributions were not examined.

“These findings are likely to be interesting to clinicians and health policy professionals who could help drive future deimplementation efforts to make sure we approach testing through a lens of providing the most value to our patients and our health system,” Matthew Malloy, MD, MPH, lead author of the study, said in a statement.3

The researchers concluded that the rate of testing and the costs associated with that testing both increased over time, with pandemic levels of testing persisting for several years. They added that their study “support[s] a need for future value-oriented deimplementation efforts.”1

References

1. Molloy MJ, Hall M, Markham JL, et al. Trends in respiratory pathogen testing at US children’s hospitals. JAMA Netw Open. 2025;8(3):e250160. doi:10.1001/jamanetworkopen.2025.0160
2. Respiratory pathogens panel. MedlinePlus. Updated July 8, 2024. Accessed March 6, 2025. https://medlineplus.gov/lab-tests/respiratory-pathogens-panel/
3. Study identifies high costs of potentially unneeded respiratory testing in children. News release. March 6, 2025. Accessed March 6, 2025. https://scienceblog.cincinnatichildrens.org/study-identifies-high-costs-of-potentially-unneeded-respiratory-testing-in-children/