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Evaluation of heart murmurs in children: cost-effectiveness and practical implications
Michael S Yi1, Thomas R Kimball, Joel Tsevat
1Department of Internal Medicine and Institute for Health Policy and Health Services Research, University of Cincinnati Medical Center, Cincinnati, Ohio 45267-0535, USA.
Insights
The most cost-effective strategy for evaluating pediatric heart murmurs involves referring all patients for an echocardiogram (ECHO), though referral to a cardiologist may also be considered. Further analysis is needed to determine optimal resource allocation for diagnosing pathologic murmurs.
Area of Science:
- Pediatric Cardiology
- Health Economics
- Diagnostic Strategy Evaluation
Background:
- Pediatric heart murmurs are common, requiring effective diagnostic strategies.
- Evaluating murmurs involves balancing accuracy with healthcare costs.
Purpose of the Study:
- To assess the cost-effectiveness of six different strategies for evaluating pediatric heart murmurs.
- To identify the most efficient approach for diagnosing pathologic murmurs in children.
Main Methods:
- A decision-analytic model was developed to compare six diagnostic strategies.
- Strategies included varying combinations of pediatrician examination, cardiology referral, chest radiograph (CXR), electrocardiogram (ECG), and echocardiogram (ECHO).
Main Results:
- Strategy 6 (referring all patients for ECHO) was the most effective, detecting 100% of pathologic murmurs.
- Strategy 1 (referring suspected pathologic murmurs to a cardiologist) was least effective (82% detection) but cheapest ($72/patient).
- Strategies 2, 3, and 4 were not cost-effective; strategies 5 and 6 showed increasing costs with improved detection.
Conclusions:
- Adding CXR and ECG or selective ECHO referral increases costs with minimal accuracy gains.
- The optimal strategy (cardiologist referral vs. all-patient ECHO) depends on societal willingness to invest in diagnosing pathologic murmurs.
- Cost-effectiveness is sensitive to the prices of cardiology referrals and echocardiograms.
Objective:
To assess the cost-effectiveness of various strategies to evaluate heart murmurs in children.
Methods:
We modeled 6 strategies to follow the initial examination by the pediatrician: (1) refer suspected pathologic murmurs to a cardiologist, (2) obtain a chest radiograph (CXR) and electrocardiogram (ECG) and refer suspected pathologic murmurs to a cardiologist, (3) refer suspected pathologic murmurs for an echocardiogram (ECHO), (4) obtain a CXR and ECG and refer suspected pathologic murmurs for an ECHO, (5) refer all patients with murmurs to a cardiologist, or (6) refer all patients with murmurs for an ECHO.
Results:
The least effective was strategy 1, which detects 82% of pathologic murmurs at $72 per patient evaluated. Strategy 5 detects 95% of pathologic murmurs at $38,000 per additional case detected over strategy 1. The most effective, strategy 6, detects 100% of pathologic murmurs at $158,000 per additional case detected over strategy 5. Strategies 2, 3, and 4 were not cost-effective. The results were sensitive to the costs of cardiology referral and ECHO.
Conclusions:
Adding a CXR and ECG to the pediatrician's evaluation, or selectively referring directly to ECHO increases costs with little gain in accuracy. Given the current cost constraints present in health care, whether the optimal strategy involves referring to a cardiologist or obtaining an ECHO for all patients with murmurs depends on how much society should allocate to diagnose pathologic murmurs.