Differences in Cardiac Management of Children by Pediatricians and Pediatric Cardiologists. † 526

Abstract

To investigate the expanded role pediatricians have been encouraged to take for the evaluation and management of pediatric cardiac disease, we compared cardiac evaluation and management by pediatricians with pediatric cardiologists. We retrospectively reviewed all 69 BCH pediatric inpatients with a cardiac consult or echocardiogram from 11/94-10/95. 40 were evaluated and managed by a pediatrician (P) with access to echo- & electrocardiograms (no consult), and 29 were evaluated by a pediatric cardiologist (consult) but managed by a P. Cardiac management was reviewed for recommendations for: 1) cardiology follow-up; 2) medications; 3) family meeting: and 4) further procedures (electrophysiology study, Holter, tilt table, catheterization, or cardiac surgery). Data for all study patients (clinical, ECG, CXR, and echo results) were retrospectively reviewed and recommendations made by two pediatric cardiologists (PC1 & PC2) blinded to the consult status, actual management and clinical outcome of the patient. The frequency of recommendations of PC1 & PC2 were compared to each other and to the actual management as summarized below. PC1 & PC2 recommended all actions at a higher rate than the pediatricians; the discrepancy was consistent regardless of the initial cardiac consult status. PC1 & PC2 agreed with the pediatricians at a slightly lower rate than they did between themselves; the major discordance came when the pediatricians recommended no action. Although the clinical significance of these differences warrants further investigation, 2 questions are raised: 1) if concordance by PC1 and PC2 represents the gold standard for management, and they made many more recommendations than the P for the same patients, what is the need for these additional recommendations since there was not an apparent difference in outcome with limited follow-up; and 2) can pediatricians, with appropriate training and supervision, play an expanded role in the evaluation and management of pediatric cardiac disease?