Schaapman, E.W. (2017) Interobservervariatie bij de auscultatoire beoordeling van hartruis bij kinderen. thesis, Medicine.
Full text available on request.Abstract
Background: A heart murmur is a common clinical finding in pediatrics. Most heart murmurs are innocent. Accurate diagnosis is important not only for timely treatment, but also to reassure parents when there is an innocent murmur, however most pediatricians find it difficult to differentiate between pathologic and innocent heart murmurs. Objective: The aim of this study was to determine the reliability and interobserver variation in the assessment of heart murmurs through auscultation by pediatricians. Methods: Patients 0-18 years of age, visiting the pediatric outpatient clinic of Isala for heart murmurs were assessed by two pediatricians; one with additional expertise in cardiology (further described as PC) and one general pediatrician. In addition, the child was assessed by a resident and/or a medical intern. All observers assessed the children through auscultation without any knowledge of medical history. The findings were filled out on a standardized form, independent and blinded for each other’s scores. All patients received an echocardiography after they were assessed by the different observers. We considered the results of the echocardiography the gold standard. The agreement between the assessment of the pediatrician and the results of the echocardiographic findings was depicted by likelihood ratios. The interobserver variation was calculated using Cohen’s kappa, Fleiss kappa and the intraclass correlation coefficient, depending on the type of variable (nominal or continuous) and the number of observers. Results: 59 patients were included. 34% of the echocardiographic results showed heart defects. The PC differentiated correctly between a pathologic and innocent murmur in 90% of the patients, the pediatricians in 80% and the medical interns in 76% of the patients. The predictive value of the assessment of heart murmur by the PC was: LR+ (positive likelihood ratio) 11.05 and LR- (negative likelihood ratio) 0.16. The pediatricians and medical interns had lower predictive values: LR+ 4.9 and LR- 0.35, LR+ 3.7 and LR- 0.73 respectively. In this study, the PC missed 15% of the pathological murmurs, the pediatricians 26% and the medical interns 43%. The interobserver variation for the individual items was: timing in the cardiac cycle κ=0.202, punctum maximum κ=0.216, intensity ICC=0.385, differentiation pathologic/innocent κ=0.285. Conclusions: This study shows that auscultatory evaluation of heart murmur in pediatrics is difficult. Interobserver variation is considerable and the validity of auscultation in discriminating pathologic from innocent murmurs is insufficient. Especially the chance that an underlying heart defect will be missed is relatively large. Experience improves the discriminative power, still it remains questionable if this is sufficient. We suggest that echocardiography should be readily available when assessing heart murmurs in children.
| Item Type: | Thesis (Thesis) |
|---|---|
| Supervisor name: | Facultair begeleider: and Bekhof, Dr. J. |
| Supervisor name: | Tweede begeleider: and Unen, H. van and Isala Klinieken Zwolle, Afdeling Kindergeneeskunde |
| Faculty: | Medical Sciences |
| Date Deposited: | 25 Jun 2020 10:39 |
| Last Modified: | 25 Jun 2020 10:39 |
| URI: | https://umcg.studenttheses.ub.rug.nl/id/eprint/91 |
Actions (login required)
 |
View Item |