title: Handheld echocardiographic screening for rheumatic heart disease by non-experts.
abstract: OBJECTIVE
  Handheld echocardiography (HAND) has good sensitivity and specificity for rheumatic heart disease (RHD) when performed by cardiologists. However, physician shortages in RHD-endemic areas demand less-skilled users to make RHD screening practical. We examine nurse performance and interpretation of HAND using a simplified approach for RHD screening.
  
  
  METHODS
  Two nurses received training on HAND and a simplified screening approach. Consented students at two schools in Uganda were eligible for participation. A simplified approach (HAND performed and interpreted by a non-expert) was compared with the reference standard (standard portable echocardiography, performed and interpreted by experts according to the 2012 World Heart Federation guidelines). Reasons for false-positive and false-negative HAND studies were identified.
  
  
  RESULTS
  A total of 1002 children were consented, with 956 (11.1 years, 41.8% male) having complete data for review. Diagnoses included: 913 (95.5%) children were classified normal, 32 (3.3%) borderline RHD and 11 (1.2%) definite RHD. The simplified approach had a sensitivity of 74.4% (58.8% to 86.5%) and a specificity of 78.8% (76.0% to 81.4%) for any RHD (borderline and definite). Sensitivity improved to 90.9% (58.7% to 98.5%) for definite RHD. Identification and measurement of erroneous colour jets was the most common reason for false-positive studies (n=164/194), while missed mitral regurgitation and shorter regurgitant jet lengths with HAND were the most common reasons for false-negative studies (n=10/11).
  
  
  CONCLUSIONS
  Non-expert-led HAND screening programmes offer a potential solution to financial and workforce barriers that limit widespread RHD screening. Nurses trained on HAND using a simplified approach had reasonable sensitivity and specificity for RHD screening. Information on reasons for false-negative and false-positive screening studies should be used to inform future training protocols, which could lead to improved screening performance.
authors.affiliation: Department of Pediatric Cardiology, Children's National Health System, Washington DC, USA.
authors.forename: Michelle
authors.initials: M
authors.lastname: Ploutz
authors.affiliation: Department of Pediatric Cardiology, Children's National Health System, Washington DC, USA.
authors.forename: Jimmy C
authors.initials: JC
authors.lastname: Lu
authors.affiliation: Department of Pediatric Cardiology, Children's National Health System, Washington DC, USA.
authors.forename: Janet
authors.initials: J
authors.lastname: Scheel
authors.affiliation: Department of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan, USA.
authors.forename: Catherine
authors.initials: C
authors.lastname: Webb
authors.affiliation: Department of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan, USA.
authors.forename: Greg J
authors.initials: GJ
authors.lastname: Ensing
authors.affiliation: Department of Pediatric Cardiology, Children's National Health System, Washington DC, USA.
authors.forename: Twalib
authors.initials: T
authors.lastname: Aliku
authors.affiliation: Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda.
authors.forename: Peter
authors.initials: P
authors.lastname: Lwabi
authors.affiliation: Department of Pediatric Cardiology, Children's National Health System, Washington DC, USA.
authors.forename: Craig
authors.initials: C
authors.lastname: Sable
authors.affiliation: Department of Pediatric Cardiology, Children's National Health System, Washington DC, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Beaton
mesh_terms: D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000503:physiopathology; D002648:Child; D002983:Clinical Competence; D003906:Developing Countries; D018618:Echocardiography, Doppler, Color / Q000295:instrumentation / Q000451:nursing*; D005188:False Negative Reactions; D005189:False Positive Reactions; D005260:Female; D006349:Heart Valve Diseases / Q000000981:diagnostic imaging* / Q000451:nursing* / Q000503:physiopathology; D006801:Humans; D008297:Male; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000503:physiopathology; D015588:Observer Variation; D019095:Point-of-Care Systems; D000067716:Point-of-Care Testing; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D015203:Reproducibility of Results; D012214:Rheumatic Heart Disease / Q000000981:diagnostic imaging* / Q000451:nursing* / Q000503:physiopathology; D013647:Task Performance and Analysis; D014454:Uganda