[Is transmission of heart murmurs via e-mail cost saving?]. / Er overføring av hjertebilyder via e-post kostnadsbesparende?

BACKGROUND: The use of pre-recorded heart murmur in an electronic referral for a remote consultation can save children and their parents from having to travel to the nearest out-patient clinic. The heart sound can be recorded by the GP at the local health clinic and sent by e-mail to the specialist. 41 clinics in the North Norway healt region have invested in equipment that makes pre-recorded sound referrals possible. This study analyses whether this investment is a cost-saving technology or not. METHODS: A yearly average of 50 children with a heart murmur are referred to a specialist in Troms. The costs of using pre-recorded telemedicine were compared to the costs of patient travelling to the nearest secondary care centre. RESULTS: Pre-recorded heart sound referrals cost from 216 000 NOK more per year than the alternative of bringing patients to the out-patient clinic. The number of children with a heart murmur needed in order to break even must exceed 195 per year, i.e. 1.7 children per GP per year. INTERPRETATION: The number of children with a heart murmur in Troms is too low for this method to be a cost-saving approach.

Evaluation of heart murmurs in children: cost-effectiveness and practical implications.

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.

Cost-effectiveness of echocardiography for evaluation of children with murmurs.

Echocardiography is widely accepted as an accurate diagnostic test to evaluate heart murmurs in children, however its costs, and the ubiquity of murmurs in children, discourage its universal application. The purpose of this article is to identify some clinical circumstances in which the cost of echocardiography is justified for the evaluation of heart murmurs in infants and children. Eight common clinical problems were selected in which a heart murmur is present and a diagnosis is called for. Effectiveness of echocardiography and less costly clinical diagnostic methods in these settings were compared. In some circumstances, echocardiography is worth the cost, because clinical evaluation is unacceptably insensitive to important disease (the premature infant with a murmur which might represent a patent ductus arteriosus, the infant with a dysmorphic syndrome and a murmur). In others, the expert clinical examination is highly accurate (the asymptomatic child with a heart murmur) and is preferred over the echocardiogram as the initial diagnostic approach on the grounds of cost. When the expert clinical examination suggests minor structural heart disease, a continuum of echocardiographic cost-effectiveness relative to the expert clinical examination exists between these extremes depending on the working diagnosis. A threshold has not yet been defined at any point on this continuum above which the public will demand the greater diagnostic detail available echocardiographically, and below which the public will refuse to accept its greater cost. Quantitative formal cost-effectiveness analysis of echocardiography for evaluation of heart murmur in infants and children is not yet feasible because the benefits of echocardiography are indirect, dependent upon the as yet unmeasured benefits of correct management of congenital heart defects. To go beyond simple comparison of efficacy of echocardiography with less costly methods, further work is required in outcomes research in congenital heart disease.

Cost assessment of the evaluation of heart murmurs in children.

Echocardiography available directly to primary care physicians represents an alternative strategy to pediatric cardiology consultation for childhood heart murmur evaluation. A decision analysis model compared the costs of two diagnostic strategies: (1) echocardiography first, referral to the cardiologist if appropriate; and (2) cardiologist evaluates murmur, echocardiography if appropriate. The model incorporated probability of heart disease, frequency of cardiologist-ordered echocardiography, and echocardiography results established by review of 388 records of consecutive patients evaluated for murmurs in a pediatric cardiology clinic. Echocardiography-first strategy costs were $257 greater than referral-strategy costs. Referral-strategy advantages were not highly sensitive to changes in model assumptions. Pediatric cardiology consultation is the preferred approach provided (1) consultation costs are moderate, (2) echocardiography costs are moderate to high, and (3) the rate at which the cardiologist orders echocardiography for patients with innocent murmurs is low.