Question

• What is the most cost effective way to screen children diagnosed by their pediatrician with a heart murmur?

Clinical Bottom Lines

1. EKG and CXR are not cost effective screening tools.
2. Referral of all patients to cardiology would cost $38,000/ pathologic murmur identified over selective referral.
3. Referral of all patients to ECHO would cost $158,000/ pathologic murmur identified over selective referral.

Summary of Key Evidence

Strategy	Cost of study	% Lesions Detected	Incremental C-E ratio
Selective to Cards	$72	82%	---
Selective to ECHO	$133	86%	extended dominance
ECG/CXR/sel to Cards	$137	83%	dominated
All to Cards	$174	95%	$38,000/ case
ECG/CXR/sel to ECHO	$200	88%	dominated
All to ECHO	$332	100%	$158,000/ case

Additional Comments

• This study did not model a strategy of observation only.
• If pediatrician auscultatory skills improve to 91% sensitivity (from 86%), selective referral to ECHO would cost $66,000/case identified and detect almost all of the pathologic lesions.
• No distinction was made between the various underlying lesions.
• This study did not model health care costs of treating the carious lesions.
• If prevalence increases to 14%, referral of all murmurs to ECHO would cost $18,000/case. This may be a reasonable strategy in special populations.
  

Citation

1. Yi MS, Kimball TR, Tsevat J, Mrus JM, and Kotagal UR. Evaluation of heart murmurs in children: Cost-effectiveness and practical implications. Journal of Pediatrics 2002;141, 504-11.
   

CAT Author: Heather L Burrows, MD, PhD

CAT Appraisers: Jon Fliegel, MD

Date appraised: November 11, 2002