title: Task shifting to clinical officer-led echocardiography screening for detecting rheumatic heart disease in Malawi, Africa.
abstract: BACKGROUND
  Echocardiographic screening for rheumatic heart disease in asymptomatic children may result in early diagnosis and prevent progression. Physician-led screening is not feasible in Malawi. Task shifting to mid-level providers such as clinical officers may enable more widespread screening. Hypothesis With short-course training, clinical officers can accurately screen for rheumatic heart disease using focussed echocardiography.
  
  
  METHODS
  A total of eight clinical officers completed three half-days of didactics and 2 days of hands-on echocardiography training. Clinical officers were evaluated by performing screening echocardiograms on 20 children with known rheumatic heart disease status. They indicated whether children should be referred for follow-up. Referral was indicated if mitral regurgitation measured more than 1.5 cm or there was any measurable aortic regurgitation. The κ statistic was calculated to measure referral agreement with a paediatric cardiologist. Sensitivity and specificity were estimated using a generalised linear mixed model, and were calculated on the basis of World Heart Federation diagnostic criteria.
  
  
  RESULTS
  The mean κ statistic comparing clinical officer referrals with the paediatric cardiologist was 0.72 (95% confidence interval: 0.62, 0.82). The κ value ranged from a minimum of 0.57 to a maximum of 0.90. For rheumatic heart disease diagnosis, sensitivity was 0.91 (95% confidence interval: 0.86, 0.95) and specificity was 0.65 (95% confidence interval: 0.57, 0.72).
  
  
  CONCLUSIONS
  There was substantial agreement between clinical officers and paediatric cardiologists on whether to refer. Clinical officers had a high sensitivity in detecting rheumatic heart disease. With short-course training, clinical officer-led echo screening for rheumatic heart disease is a viable alternative to physician-led screening in resource-limited settings.
authors.affiliation: 1Department of Cardiology,Baylor College of Medicine,Texas Children's Hospital,Houston,Texas,United States of America.
authors.forename: Amy
authors.initials: A
authors.lastname: Sims Sanyahumbi
authors.affiliation: 2Department of Cardiology,Children's National Medical Center,Washington,District of Columbia,United States of America.
authors.forename: Craig A
authors.initials: CA
authors.lastname: Sable
authors.affiliation: 1Department of Cardiology,Baylor College of Medicine,Texas Children's Hospital,Houston,Texas,United States of America.
authors.forename: Melissa
authors.initials: M
authors.lastname: Karlsten
authors.affiliation: 3University of North Carolina Project,Lilongwe,Malawi.
authors.forename: Mina C
authors.initials: MC
authors.lastname: Hosseinipour
authors.affiliation: 4Baylor International Pediatric AIDS Initiative,Lilongwe,Malawi.
authors.forename: Peter N
authors.initials: PN
authors.lastname: Kazembe
authors.affiliation: 5Dan L. Duncan Institute for Clinical and Translational Research,Baylor College of Medicine,Houston,Texas,United States of America.
authors.forename: Charles G
authors.initials: CG
authors.lastname: Minard
authors.affiliation: 1Department of Cardiology,Baylor College of Medicine,Texas Children's Hospital,Houston,Texas,United States of America.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Penny
mesh_terms: D000293:Adolescent; D000072096:Cardiologists; D002648:Child; D002675:Child, Preschool; D018618:Echocardiography, Doppler, Color / Q000379:methods*; D005260:Female; D006801:Humans; D015994:Incidence; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008403:Mass Screening / Q000379:methods*; D011237:Predictive Value of Tests; D012372:ROC Curve; D015203:Reproducibility of Results; D012214:Rheumatic Heart Disease / Q000175:diagnosis* / Q000453:epidemiology
keywords: Rheumatic heart disease; echocardiography; global cardiology; paediatric cardiology; screening; task shifting