Sims Sanyahumbi Amy, Sable Craig A, Karlsten Melissa, Hosseinipour Mina C, Kazembe Peter N, Minard Charles G, Penny Daniel J
1Department of Cardiology,Baylor College of Medicine,Texas Children's Hospital,Houston,Texas,United States of America.
2Department of Cardiology,Children's National Medical Center,Washington,District of Columbia,United States of America.
Cardiol Young. 2017 Aug;27(6):1133-1139. doi: 10.1017/S1047951116002511. Epub 2016 Dec 19.
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.
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.
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).
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.
对无症状儿童进行超声心动图筛查风湿性心脏病可能有助于早期诊断并预防病情进展。在马拉维，由医生主导的筛查并不可行。将任务转移给临床干事等中级医疗人员可能会使筛查更为广泛。假设：经过短期培训，临床干事能够使用聚焦超声心动图准确筛查风湿性心脏病。
共有八名临床干事完成了为期三个半天的理论教学以及两天的超声心动图实际操作培训。通过对20名已知患有风湿性心脏病的儿童进行筛查超声心动图检查来评估临床干事。他们指出这些儿童是否应被转诊进行随访。如果二尖瓣反流测量值超过1.5厘米或存在任何可测量的主动脉反流，则建议转诊。计算κ统计量以衡量与儿科心脏病专家的转诊一致性。使用广义线性混合模型估计敏感性和特异性，并根据世界心脏联盟的诊断标准进行计算。
将临床干事的转诊与儿科心脏病专家的转诊进行比较，平均κ统计量为0.72（95%置信区间：0.62, 0.82）。κ值范围从最低0.57到最高0.90。对于风湿性心脏病的诊断，敏感性为0.91（95%置信区间：0.86, 0.95），特异性为0.65（95%置信区间：0.57, 0.72）。
临床干事和儿科心脏病专家在是否转诊方面存在高度一致性。临床干事在检测风湿性心脏病方面具有较高的敏感性。经过短期培训，在资源有限的环境中，由临床干事主导的超声心动图筛查风湿性心脏病是医生主导筛查的可行替代方案。
