title: Screening for rheumatic heart disease: quality and agreement of focused cardiac ultrasound by briefly trained health workers.
abstract: BACKGROUND
  Echocardiographic screening for rheumatic heart disease (RHD) has the potential to detect subclinical cases for secondary prevention, but is constrained by inadequate human resources in most settings. Training non-expert health workers to perform focused cardiac ultrasound (FoCUS) may enable screening at a population-level. We aimed to evaluate the quality and agreement of FoCUS for valvular regurgitation by briefly trained health workers.
  
  
  METHODS
  Seven nurses participated in an eight week training program in Fiji. Nurses performed FoCUS on 2018 children aged five to 15 years, and assessed any valvular regurgitation. An experienced pediatric cardiologist assessed the quality of ultrasound images and measured any recorded regurgitation. The assessment of the presence of regurgitation and measurement of the longest jet by the nurse and cardiologist was compared, using the Bland-Altman method.
  
  
  RESULTS
  The quality of FoCUS overall was adequate for diagnosis in 96.6%. There was substantial agreement between the cardiologist and the nurses overall on the presence of mitral regurgitation (κ = 0.75) and aortic regurgitation (κ = 0.61) seen in two views. Measurements of mitral regurgitation by nurses and the cardiologist were similar (mean bias 0.01 cm; 95% limits of agreement -0.64 to 0.66 cm).
  
  
  CONCLUSIONS
  After brief training, health workers with no prior experience in echocardiography can obtain adequate quality images and make a reliable assessment on the presence and extent of valvular regurgitation. Further evaluation of the imaging performance and accuracy of screening by non-expert operators is warranted, as a potential population-level screening strategy in high prevalence settings.
authors.affiliation: Centre for International Child Health, University of Melbourne, Parkville, Victoria, Australia. Daniel.Engelman@rch.org.au.|Group A Streptococcal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia. Daniel.Engelman@rch.org.au.|Royal Children's Hospital, Parkville, Victoria, Australia. Daniel.Engelman@rch.org.au.
authors.forename: Daniel
authors.initials: D
authors.lastname: Engelman
authors.affiliation: Department of Paediatrics, Colonial War Memorial Hospital, Suva, Fiji. Joseph_Kado@yahoo.co.uk.|College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji. Joseph_Kado@yahoo.co.uk.
authors.forename: Joseph H
authors.initials: JH
authors.lastname: Kado
authors.affiliation: Royal Darwin Hospital, Tiwi, Northern Territory, Australia. Bo.Remenyi@menzies.edu.au.|Menzies School of Health Research, Casuarina, Northern Territory, Australia. Bo.Remenyi@menzies.edu.au.
authors.forename: Bo
authors.initials: B
authors.lastname: Reményi
authors.affiliation: Centre for International Child Health, University of Melbourne, Parkville, Victoria, Australia. Samantha.Colquhoun@rch.org.au.|Group A Streptococcal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia. Samantha.Colquhoun@rch.org.au.|Menzies School of Health Research, Casuarina, Northern Territory, Australia. Samantha.Colquhoun@rch.org.au.
authors.forename: Samantha M
authors.initials: SM
authors.lastname: Colquhoun
authors.affiliation: Telethon Kids Institute, University of Western Australia, West Perth, Western Australia, Australia. Jonathan.Carapetis@telethonkids.org.au.|Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia. Jonathan.Carapetis@telethonkids.org.au.
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Carapetis
authors.affiliation: Starship Hospital, Auckland, New Zealand. NigelW@adhb.govt.nz.|University of Auckland, Auckland, New Zealand. NigelW@adhb.govt.nz.
authors.forename: Nigel J
authors.initials: NJ
authors.lastname: Wilson
authors.affiliation: Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia. Susan.Donath@mcri.edu.au.|Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Parkville, Victoria, Australia. Susan.Donath@mcri.edu.au.
authors.forename: Susan
authors.initials: S
authors.lastname: Donath
authors.affiliation: Centre for International Child Health, University of Melbourne, Parkville, Victoria, Australia. Andrew.Steer@rch.org.au.|Group A Streptococcal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia. Andrew.Steer@rch.org.au.|Royal Children's Hospital, Parkville, Victoria, Australia. Andrew.Steer@rch.org.au.
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Steer
mesh_terms: D000293:Adolescent; D001022:Aortic Valve Insufficiency / Q000175:diagnosis / Q000000981:diagnostic imaging*; D002309:Cardiology / Q000193:education; D002648:Child; D002675:Child, Preschool; D018618:Echocardiography, Doppler, Color / Q000451:nursing*; D004506:Education, Nursing; D005260:Female; D005367:Fiji; D006801:Humans; D008297:Male; D008403:Mass Screening; D008944:Mitral Valve Insufficiency / Q000175:diagnosis / Q000000981:diagnostic imaging*; D009726:Nurses; D015588:Observer Variation; D012214:Rheumatic Heart Disease / Q000175:diagnosis / Q000000981:diagnostic imaging*; D012574:Schools; D012680:Sensitivity and Specificity
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