While excellent accuracy in the clinical assessment of heart murmurs by pediatric cardiologists has been well documented, little is known of the accuracy of other health care providers. We sought to determine screening characteristics of general pediatricians (PED) in community-based practice in differentiating heart murmurs in children. Each of 30 PED blindly examined a random sample of between 5 to 9 ambulatory children with murmurs (n=37), and recorded their assessments (191 observations). Sensitivity and specificity were calculated for each PED, and were related to PED characteristics on a separate questionnaire. Mean age of PED was 52 years (range, 40 to 76) and 70% were male. Patient age ranged from 1 year to 15.5 years, with 21 patients having innocent murmurs and 16 (43%) having echocardiographically documented simple heart lesions, a case-mix similar to a pediatric cardiologist's outpatient practice. Mean (±SD) sensitivity for PED was 81%±24% with mean specificity of 74%±23%. Inter-rater reliability for assessments of the same patient by different PED was low with a kappa statistic of 0.05. PED indicated that they would refer for cardiology consultation or echocardiography 105 of 191 (54%) observations--39% of those with innocent murmurs and 77% of those with pathology. The addition of a referral strategy increased mean sensitivity to 87%±20% with decreased specificity of 61%±29%. Screening characteristics were not significantly related to PED age, gender, education or practice characteristics. Increased proportion of study patients referred was significantly correlated with higher sensitivity (r=45; p<.02) and lower specificity (r=0.47; p<.009), and was related to increased number of echocardiograms requested in PED practice (r=41; p<.03). All PED were confident in assessing infants and older children, while 43% did not feel confident in assessing murmurs in newborns. Decreased confidence in assessing newborns was significantly correlated with decreased specificity (r=46; p<.02) but not sensitivity (r=17; p=.37). Conclusion: Screening characteristics in the clinical assessment of murmurs by PED are less optimal than by pediatric cardiologists. Decreased confidence and increased reliance on consultation or echocardiography are associated with a greater “over-call” of pathology. Interventions aimed at educating pediatricians may improve specificity and decrease inappropriate referrals.
