Letter to the Editor.

Abstract

In times of stress, the best thing we can do for each other is to listen with our ears and our hearts and to be assured that our questions are just as important as our answers. – Mister Fred Rogers We read with interest the recent publication by Ip et al. entitled ‘Impact of Echocardiography on Parental Anxiety in Children with Innocent Murmurs’.1 Innocent murmurs and parental anxiety are important facets in the cardiac care of children; we commend the authors for their work. However, we question some key points. Echocardiography is an invaluable tool in evaluating for cardiac abnormalities; however multiple reports have shown that echocardiograms are neither cost-effective nor of high diagnostic yield for the indication of heart murmurs in children.2, 3 Health-care expenditures are on the rise, and avoiding low-yield, high-cost diagnostic testing has become particularly important. This importance is affirmed by the host of professional organisations represented in the appropriate use criteria (AUC) for the initial use of outpatient paediatric echocardiograms in 2014.2 The primary principal of these AUC documents is to promote high-quality and cost-effective care.2 Our group has estimated significant medical cost savings with cardiology referrals, as opposed to echocardiograms ordered by primary care physicians.3 Those estimations are with the caveat that the cardiologist only orders echocardiograms for possible pathologic murmurs. Due to the high frequency of innocent murmurs in the general paediatric population, a strategy suggesting echocardiograms for obviously innocent murmurs is not only impractical, but runs counter to the efforts of these medical societies. The study methodology has several limitations that impede making strong inferences. There was no control group; all patients received an echocardiogram. There was a single cardiologist evaluated in this study. It is unclear the amount of time spent or the effectiveness with which the cardiologist was able to provide family reassurance prior to the echocardiogram. In addition, parental time to digest the findings of the cardiologist's assessment may have played a role in decreased anxiety. The reported interpretation of the results seems biased. A different perspective is despite ordering a low-yield diagnostic test, 5 of 23 (~20%) high-anxiety families had no change or higher anxiety leaving the office. The authors report 30 of 48 (63%) parents expected investigation as part of the evaluation, which may be due to referring physicians' lack of understanding of appropriate echocardiogram use. Our group reported primary care providers and trainees have had limited exposure to the 2014 AUC document and incorrectly identified many ‘rarely appropriate’ echocardiogram indications as ‘appropriate’ (specifically innocent heart murmurs).4 If a parent arrives to a cardiology evaluation expecting an echocardiogram, then an unexplained deviation from this expected plan is likely to produce anxiety. Primary-care-based studies suggest maternal satisfaction relates to fulfilment of expectations toward communication during the sick-visit and not necessarily therapies such as antibiotic prescription.5, 6 This indicates perhaps more time should be spent communicating with referring providers about appropriate echocardiogram use and with families reassuring them about innocent heart murmurs. In conclusion, Ip et al. should be commended for highlighting the significant issues paediatric cardiologists must recognise regarding parental anxiety and referring provider expectations in patients presenting with innocent heart murmurs. We would argue, however, the way to handle these issues is listen to Mister Rogers and devote time to effective communication with the families and our primary care colleagues, rather than placating them with unnecessary, expensive testing.