A new study that measured the effectiveness of a clinical education program for Valley fever shows improvement in the recognition and diagnosis of the illness and the need for more testing within the urgent care setting. The findings will be used to improve patient care at Banner Health Urgent Care Centers by identifying the illness closer to onset, preventing or decreasing the spread of infection, and reducing treatment cost.
The clinical education program for Valley fever was developed by Banner - University Medicine and the Valley Fever Center for Excellence at the University of Arizona College of Medicine – Tucson and implemented within Banner Urgent Care Centers. The study was conducted among urgent care patients 18 years old or older, who received care at Banner Urgent Care Services in Tucson and Phoenix metropolitan areas.
Researchers from Banner Urgent Care Services and the Valley Fever Center for Excellence measured the effectiveness of the new clinical education program and published their results in Open Forum Infectious Diseases, an online journal that focuses on biomedical science and clinical practice with an emphasis on knowledge that could improve patient care globally.
Found within parts of Arizona, California and the western hemisphere, coccidioidomycosis, a fungal infection commonly known as Valley fever, is significantly underreported due to lack of testing. Clinically diagnosed infections range from 9,400 to 22,600 cases per year, with estimates from the Centers for Disease Control and Prevention suggesting that the actual burden of the illness is 6 to 14 times higher than reported. Annually, the economic impact of the illness approaches $1.5 billion.
The study measured coccidioidal serologic testing results and their relation to medical diagnosis codes extracted from medical records after the introduction of the Valley fever educational program. The program was developed in 2018 and introduced in February 2020. Following implementation of the program, the overall number of coccidioidal tests ordered increased significantly, with roughly a three-fold increase in both testing as a proportion of overall visits and in patient diagnoses.
The percentage of clinics ordering more than 50 tests per year increased from 11% in 2018 to 78% in 2021. Similarly, the percentage of clinicians ordering more than two tests per year increased from 14.5% to 38.8%.
The study revealed that the diagnosis of community-acquired pneumonia and a distinctive type of skin rash, called “Erythema nodosum,” were diagnoses most associated with a Valley fever diagnosis. Medical diagnosis codes for pneumonia were the most frequently associated with positive tests, and other than cough, were associated with the greatest number of visits where coccidioidal tests were performed. Although E. nodosum was much less common than pneumonia, it had a much higher likelihood of the Valley fever test being positive.
Though there was a measured increase in testing pneumonia patients for Valley fever, over three-quarters of urgent care patients with community-acquired pneumonia were still not tested for Valley fever, despite the instituted educational program.
“Our findings show that patients presenting with either pneumonia or E. nodosum within highly endemic regions have a high likelihood of suffering from this disease and should be tested for this possibility. That only 7.2% to 22.0% of pneumonia patients were tested for coccidioidomycosis corroborates the preliminary CDC estimates of 6- to 14-fold underdiagnosis,” said John N. Galgiani, MD, director of the Valley Fever Center for Excellence and professor at the University of Arizona College of Medicine – Tucson.
The study took place from 2018 to 2021 and during that time, the Banner Urgent Care Centers in Phoenix and Tucson received 2.1 million visits from 1.5 million patients. The Banner coccidioidomycosis educational program is included during clinical orientation lectures for all newly hired clinicians. In July 2020, Banner Urgent Care Centers began presenting guidelines as part of quarterly refresher lectures for newly hired Banner Urgent Care clinicians without prior urgent care experience, and optionally for established urgent care clinicians. The training is also available to clinicians online.
Discussing why the education program was not more effective, the study listed several factors that might impede clinicians from ordering Valley fever tests. These include that prior medical training for many occurs in parts of the U.S. where Valley fever is not common, the delay between testing patients and receiving test results, and the concern that the cost of Valley fever testing might not be covered by insurance, although other studies by Valley Fever Center for Excellence researchers have shown that most insurances do cover testing costs.
“Further education, possibly with innovative methods, appears to be needed to make testing the norm in ambulatory clinics such as urgent care settings, as clinicians are often trained outside of areas where coccidioidomycosis is found and may not consider the diagnosis. For these clinicians, it is necessary to also educate them that community-acquired pneumonia is not solely a bacterial infection, and to include coccidioidomycosis testing and treatment to prevent inappropriate prescribing of antibiotics for non-bacterial respiratory infections in general,” said Devin Minior, MD, physician executive, Banner – Urgent Care.
Banner Urgent Care provides a close, convenient and affordable treatment option for patients with non-life-threatening illnesses and injuries such as cold and flu; ear, eye and throat infections; fevers; skin rashes; and sprains, strains and lacerations. Banner Urgent Care is open every day of the year and accepts most insurance plans. For more information, locations and hours of operation, please visit bannerhealth.com/urgentcare.
The Valley Fever Center for Excellence (VFCE) at the University of Arizona College of Medicine – Tucson was established in 1996 by the Arizona Board of Regents. The mission of the VFCE is to mobilize resources for the eradication of Valley Fever through the development of public awareness and education about Valley fever; the promotion of high-quality care for patients with Valley fever; the pursuit and encouragement of research into all aspects of the fungus Coccidioides, which causes the disease.
Rebecca Ruiz Hudman (McGill)