Outcomes, impact on management, and costs of fungal eye disease consults in a tertiary care setting.

OBJECTIVE: To determine the frequency of clinical management changes resulting from inpatient ophthalmic consultations for fungemia and the associated costs. DESIGN: Retrospective case series. PARTICIPANTS: Three hundred forty-eight inpatients at a tertiary care center between 2008 and 2012 with positive fungal blood culture results, 238 of whom underwent an ophthalmologic consultation. METHODS: Inpatient charts of all fungemic patients were reviewed. Costs were standardized to the year 2014. The Student t test was used for all continuous variables and the Pearson chi-square test was used for categorical variables. MAIN OUTCOME MEASURES: Prevalence of ocular involvement, rate of change in clinical management, mortality rate of fungemic patients, and costs of ophthalmic consultation. RESULTS: Twenty-two (9.2%) of 238 consulted patients with fungemia had ocular involvement. Twenty patients had chorioretinitis and 2 had endophthalmitis. Only 9 patients (3.7%) had a change in management because of the ophthalmic consultation. One patient underwent bilateral intravitreal injections. Thirty percent of consulted patients died before discharge or were discharged to hospice. The total cost of new consults was $36 927.54 ($204.19/initial level 5 visit and $138.63/initial level 4). The cost of follow-up visits was $13 655.44 ($104.24/visit). On average, 26.4 patients were evaluated to find 1 patient needing change in management, with an average cost of $5620.33 per change in 1 patient's management. CONCLUSIONS: Clinical management changes resulting from ophthalmic consultation in fungemic patients were uncommon. Associated costs were high for these consults in a patient population with a high mortality rate. Together, these data suggest that the usefulness of routine ophthalmic consultations for all fungemic patients is likely to be low.

The evaluation of new services: possibilities for preventing congenital toxoplasmosis.

We examine the resource implications of two potential health services aimed at preventing congenital toxoplasmosis: a screening service involving serological surveillance for toxoplasma infection in pregnant women and its prophylactic treatment; and a health education campaign to help pregnant women avoid acquiring toxoplasma infection, through advice about special precautions regarding hygiene. Measuring the costs and benefits of prevention is complicated by uncertainty of the incidence of congenital toxoplasmosis in the United Kingdom, the extent of its harmful manifestations--mental and visual handicap--and the effectiveness of preventive measures. Hence an important aspect of this study is that it exemplifies the use of 'sensitivity analysis' as an aid to evaluation in the absence of hard data. We find that a screening service would seem unlikely to save resources, but that a health education campaign would seem much more likely to do so and further assessment of its potential effectiveness would be valuable.