title: Focused cardiac ultrasound screening for rheumatic heart disease by briefly trained health workers: a study of diagnostic accuracy.
abstract: Echocardiographic screening for rheumatic heart disease (RHD) can identify individuals with subclinical disease who could benefit from antibiotic prophylaxis. However, most settings have inadequate resources to implement conventional echocardiography and require a feasible, accurate screening method. We aimed to investigate the accuracy of screening by non-expert operators using focused cardiac ultrasound (FoCUS).
  
  
  
  In this prospective study of diagnostic accuracy, we recruited schoolchildren aged 5 to 15 years in Fiji to undergo two blinded tests. The index test was a FoCUS assessment of mitral and aortic regurgitation, performed by nurses after an 8-week training programme. The reference standard was the diagnosis of RHD by a paediatric cardiologist, based on a standard echocardiogram performed by a skilled echocardiographer. The primary outcome was the accuracy of the index test with use of the most sensitive criteria (any regurgitation).
  
  
  
  We included 2004 children in the study. The index tests were done between September, 2012, and September, 2013, by seven nurses in eight schools in Fiji. The diagnostic accuracy of the screening test (area under receiver operator characteristic curve) was 0·89 (95% CI 0·83-0·94). When the primary cut-off point (any regurgitation) was used for analysis, sensitivity was 84·2% (72·1-92·5) and specificity was 85·6% (83·9-87·1). The sensitivity of individual nurses ranged from 66·7% to 100% and specificity 74·0% to 93·7%.
  
  
  
  Screening by briefly trained nurses using FoCUS was accurate for the diagnosis of RHD. Refinements to training and screening test methods should be studied in a range of settings, and in parallel with investigations of the long-term clinical and cost-effectiveness of screening for RHD.
  
  
  
  Cure Kids, New Zealand; the Fiji Water Foundation provided funding for portable ultrasound equipment; see acknowledgments for further details of funders.
authors.affiliation: Centre for International Child Health, University of Melbourne, Royal Children's Hospital, Melbourne, VIC, Australia; Group A Streptococcal Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Parkville, VIC, Australia. Electronic address: daniel.engelman@rch.org.au.
authors.forename: Daniel
authors.initials: D
authors.lastname: Engelman
authors.affiliation: College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji; Department of Paediatrics, Colonial War Memorial Hospital, Suva, Fiji.
authors.forename: Joseph H
authors.initials: JH
authors.lastname: Kado
authors.affiliation: Royal Darwin Hospital, Tiwi, NT, Australia; Menzies School of Health Research, Charles Darwin University, Casuarina, NT, Australia.
authors.forename: Bo
authors.initials: B
authors.lastname: Reményi
authors.affiliation: Centre for International Child Health, University of Melbourne, Royal Children's Hospital, Melbourne, VIC, Australia; Group A Streptococcal Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Parkville, VIC, Australia; Menzies School of Health Research, Charles Darwin University, Casuarina, NT, Australia.
authors.forename: Samantha M
authors.initials: SM
authors.lastname: Colquhoun
authors.affiliation: Telethon Kids Institute, University of Western Australia, West Perth, WA, Australia; Princess Margaret Hospital for Children, Subiaco, WA, Australia.
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Carapetis
authors.affiliation: Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Melbourne, VIC, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Royal Children's Hospital, Parkville, VIC, Australia.
authors.forename: Susan
authors.initials: S
authors.lastname: Donath
authors.affiliation: Starship Hospital, Auckland, New Zealand; University of Auckland, Auckland, New Zealand.
authors.forename: Nigel J
authors.initials: NJ
authors.lastname: Wilson
authors.affiliation: Centre for International Child Health, University of Melbourne, Royal Children's Hospital, Melbourne, VIC, Australia; Group A Streptococcal Research, Murdoch Childrens Research Institute, Royal Children's Hospital, Parkville, VIC, Australia.
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Steer
mesh_terms: D000293:Adolescent; D001022:Aortic Valve Insufficiency / Q000175:diagnosis / Q000000981:diagnostic imaging; D002648:Child; D002675:Child, Preschool; D002983:Clinical Competence; D005260:Female; D005367:Fiji; D006295:Health Resources; D006351:Heart Valves / Q000000981:diagnostic imaging*; D006801:Humans; D007318:Inservice Training; D008297:Male; D008403:Mass Screening / Q000379:methods*; D008944:Mitral Valve Insufficiency / Q000175:diagnosis / Q000000981:diagnostic imaging; D009726:Nurses; D011446:Prospective Studies; D012372:ROC Curve; D012016:Reference Values; D012214:Rheumatic Heart Disease / Q000175:diagnosis* / Q000000981:diagnostic imaging; D012680:Sensitivity and Specificity; D014463:Ultrasonography / Q000379:methods*