Referral Rates and Diagnostic Evaluation for Primary Ciliary Dyskinesia in Patients With Laterality Defects Who Meet Primary Ciliary Dyskinesia Evaluation Criteria.

Abstract

Objective: To determine if pediatric patients with laterality defects and meet the diagnostic criteria for primary ciliary dyskinesia (PCD) evaluation are being referred to and evaluated by pediatric pulmonologists. There are organ laterality defects in 50% of patients with PCD. Thus, patients with laterality defects are more likely to raise suspicion for PCD than those without laterality defects. We hypothesize that even in patients with laterality defects who meet PCD evaluation criteria, referral rates are low, leading to underdiagnosis (2).

Subjects and methods: A retrospective chart review of patients with laterality defects who met two or more of the PCD evaluation criteria was conducted at Dallas Children's Health using the electronic medical record. The four PCD evaluation criteria were laterality defect, chronic daily cough, nasal congestion starting in infancy, and NRDS of unclear etiology requiring oxygen or positive pressure for 24 h or longer. Referral rates to pediatric pulmonary medicine and genetics were determined. Completion of an evaluation by these services was analyzed.

Results: The electronic medical record search for laterality defects identified 433 patients. Of the 369 patients who met the inclusion and exclusion criteria for analysis, 189 (51%) met only one inclusion criterion for PCD evaluation (laterality defect), and 49% met 2 or more of the criteria. Of the 79 patients who met the bare minimum of two criteria for PCD evaluation, 41% were referred to pulmonary, 18% to genetics, and only 16% were evaluated for PCD. Of the 27 patients who met all 4 PCD criteria for evaluation, 96% were referred to pulmonary, 85% to genetics, and 93% were evaluated for PCD. Among the 369 patients studied, there were no significant differences in the referral rate associated with patient demographics, including sex, race, ethnicity, and insurance type. The frequency of referrals increased with the number of PCD criteria.

Conclusions: A substantial number of pediatric patients meeting two PCD referral criteria are not referred to pediatric pulmonologists, and a larger number are not being evaluated for PCD. As expected, patients with three or four PCD referral criteria have a higher rate of referral to pulmonary than those meeting the minimum two criteria. Many patients who meet all four criteria still need to be evaluated for PCD, even when referred to pulmonary or genetics. Most of the patients with laterality defects had congenital heart disease (CHD), and this was identified as the main etiology for respiratory symptoms for most of the patients who were not referred or evaluated. This highlights the importance of PCD education and awareness efforts for Pediatric specialists and subspecialists, including pediatric pulmonologists. It supports PCD being an underdiagnosed chronic condition and thus underscores the importance of acute clinical awareness and lower threshold to refer and evaluate patients for PCD, especially when other diagnoses, such as CHD are present.