Physician Barriers and Facilitators for Screening for Congenital Heart Disease With Routine Obstetric Ultrasound

Abstract

Objectives-Prenatal detection of congenital heart disease with obstetric screening remains at less than 50% in most population studies, far from what is thought to be achievable. We sought to identify barriers/facilitators for screening from the perspective of interpreting physicians and to understand how these barriers/facilitators may be associated with interpretation of screening images.Methods-Our mixed-methods studies included 4 focus groups in centers across the United States with obstetric, maternal-fetal medicine, and radiology providers who interpreted obstetric ultrasound studies. Themes around barriers/facilitators for fetal heart screening were coded from transcripts. A national Web-based survey was then conducted, which quantitatively measured reported barriers/facilitators and measured physicians' ability to interpret fetal heart-screening images. Multivariable generalized linear random-effect models assessed the association between barriers/facilitators and the accuracy of image interpretation at the image level.Results-Three main themes were identified in the focus groups: intrinsic barriers (ie, comfort with screening), external barriers (ie, lack of feedback), and organizational barriers (ie, study volumes). Among 190 physician respondents, 104 interpreted ultrasound studies. Perceptions of barriers varied by practice setting, with nontertiary providers having lower self-efficacy and perceived usefulness of cardiac screening. Facilitators associated with the odds of accurate interpretation of screening images were knowledge (odds ratio, 2.54; P = .002) and the volume of scans per week (odds ratio, 1.01 for every additional scan; P = .04).Conclusions-Some of the main barriers to cardiac screening identified and prioritized by physicians across the United States were knowledge of screening and minimal volumes of scans. Targeting these barriers will aid in improving prenatal detection of congenital heart disease.

Impact of Socioeconomic Status, Race and Ethnicity, and Geography on Prenatal Detection of Hypoplastic Left Heart Syndrome and Transposition of the Great Arteries

“…7,11,17,[23][24][25] Initial screening begins with obstetricians or radiologists who obtain cardiology or maternal fetal medicine consultation for screening indications or concerns of abnormality. Barriers to communication between these specialists may exist, 26 so further effort is needed to study providers in the areas outlined in this article.…”

The Left Outflow Tract in Fetal Cardiac Screening Examination

“…Certification related to fetal cardiac examination, similar to that required for first‐trimester assessments, could be considered in an attempt to improve screening of CHD. Indeed, in some countries, regular audits for maintaining certification or quality control have been successful 21–23 . Since then, the notion of quality control and auditing has developed in the field of fetal cardiac examination, with first‐trimester cardiac screening examinations in low‐risk populations, 19 as well as cardio‐thoracic ratio measurement, 24 the use of four‐chamber views, 17,18 and the outflow tracts 16,17 .…”

“…Indeed, in some countries, regular audits for maintaining certification or quality control have been successful. [21][22][23] Since then, the notion of quality control and auditing has developed in the field of fetal cardiac examination, with first-trimester cardiac screening examinations in lowrisk populations, 19 as well as cardio-thoracic ratio measurement, 24 the use of four-chamber views, 17,18 and the outflow tracts. 16,17 With regards to the fourchamber view, apical or basal views are recommended in order to respect the quality criteria proposed.…”

A “holistic” sonographic view on congenital heart disease: How automatic reconstruction using fetal intelligent navigation echocardiography eases unveiling of abnormal cardiac anatomy part II—Left heart anomalies

“…According to the results from a very recent national survey of physicians, the main barriers preventing effective cardiac screening were knowledge of CHD screening guidelines and minimal volumes of cardiac scans 92 . Detailed characterization of fetal cardiac function in normal and abnormal fetal hearts is feasible and well described using conventional 2D US.…”

“…90,91 According to the results from a very recent national survey of physicians, the main barriers preventing effective cardiac screening were knowledge of CHD screening guidelines and minimal volumes of cardiac scans. 92 Detailed characterization of fetal cardiac function in normal and abnormal fetal hearts is feasible and well described using conventional 2D US. Functional assessment of the fetal heart applying volume datasets has been shown to provide reliable information on cardiac integrity irrespective of the fetal position in utero.…”