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Ron Keren, MD, MPH; Michele Tereschuk, BS; Xianqun Luan, MS

Arch Pediatr Adolesc Med. 2005;159:329-334.

Objective  To determine if heart murmur intensity grading performance can be improved using the heart sounds as an internal reference.

Methods  Single-blind controlled trial of 100 medical students, residents, and pediatric attending physicians at a children’s hospital. Groups of 1 to 3 participants were alternately assigned to intervention and control groups, reported their method of grading heart murmur intensity, and then graded the intensity of a random sample of 20 recorded murmurs on a 6-point scale. Before rating another random sample of 20 murmurs, the intervention group was taught a system that uses the heart sounds as an internal reference. Primary outcomes were change in accuracy (percentage correct), interrater agreement (), and consistency (). Subgroup analyses were performed by training level and heart murmur grade.

Results  Grading accuracy improved more in the intervention group than the control group ( improvement, 5%; 95% confidence interval [CI], –0.1%-10.0%]). This was most pronounced among attending physicians ( improvement, 11%; 95% CI, 0.4%-22%) and students ( improvement, 12%; 95% CI, 3%-20%) and for grade 2 murmurs ( improvement, 20%; 95% CI, 10%-31%). Relatively greater improvements in consistency were observed after the intervention for attending physicians ( improvement, 0.17; 95% CI, 0.01-0.32) and grades 2 ( improvement, 0.22; 95% CI, 0.09-0.36) and 3 murmurs ( improvement, 0.16; 95% CI, 0.05-0.28).

Conclusions  A system that uses the heart sounds as an internal reference for grading heart murmur intensity quickly improves accuracy and consistency for some providers and specific murmurs.

Author Affiliations: Division of General Pediatrics, Pediatric Generalist Research Group (Dr Keren), and Division of Biostatistics and Epidemiology (Mr Luan), Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pa; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia (Dr Keren); and New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark (Ms Tereschuk).