title: Evaluation of heart murmurs in children: cost-effectiveness and practical implications.
abstract: 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.
authors.affiliation: Department of Internal Medicine and Institute for Health Policy and Health Services Research, University of Cincinnati Medical Center, Cincinnati, Ohio 45267-0535, USA.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Yi
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Kimball
authors.forename: Joel
authors.initials: J
authors.lastname: Tsevat
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Mrus
authors.forename: Uma R
authors.initials: UR
authors.lastname: Kotagal
mesh_terms: D000293:Adolescent; D002309:Cardiology / Q000191:economics; D002648:Child; D002669:Child Welfare; D002675:Child, Preschool; D003362:Cost-Benefit Analysis / Q000191:economics; D003661:Decision Support Techniques; D004452:Echocardiography / Q000191:economics; D004562:Electrocardiography / Q000191:economics; D006337:Heart Murmurs / Q000175:diagnosis / Q000191:economics / Q000453:epidemiology; D006801:Humans; D007223:Infant; D007229:Infant Welfare; D007231:Infant, Newborn; D010372:Pediatrics / Q000191:economics; D015995:Prevalence; D013902:Radiography, Thoracic / Q000191:economics; D012017:Referral and Consultation / Q000191:economics; D012680:Sensitivity and Specificity