Implementation of American Heart Association Recommendations as Part of Sport Physical Examination to Eliminate Unnecessary Cardiovascular Testing – A Value-Based Quality Improvement Initiative

From the 2019 HVPAA National Conference

Dr. Sharef Al-Mulaabed (Brookdale University Hospital Medical Center), Dr. Hetal Tangal (Brookdale University Hospital Medical Center), Dr. Husna Siddique (Brookdale University Hospital Medical Center), Dr. Joseph Mahgerefteh (Brookdale University Hospital Medical Center), Dr. Kshitij Thakur (University of Kentucky), Dr. Fernanda Kupferman (Brookdale University Hospital Medical Center)


Sudden cardiac death is the leading cause of mortality in young athletes during exercise, with incidence varies widely from 0.5–2/100,000/year. The pediatrician is often asked to conduct a sport pre-participation physical evaluation (PPE) which includes cardiovascular (CV) component. Current American Heart Association (AHA) guidelines recommend screening for CV abnormalities based on personal and family history questionnaire and physical examination. Many physicians continue to order unnecessary cardiology referral or CV testing.


Our aim was to reduce unnecessary cardiology referrals and EKG testing via implementation of AHA recommendations for screening of CV risk factors of sudden death


A Plan, Do, Study, Act (PDSA) cycles was conducted over the period from Sep 2018 to March 2019. We included all patients presenting for PPE at Brookdale Family Care Centers (BFCC), New York. Assessment at baseline, pre and post interventions was done to evaluate the change in proportion of unnecessary cardiology referrals and EKG testing.

The first intervention was done in Sep 2018. This included education of all residents and BFCC pediatricians, aiming to increase awareness of AHA guidelines and its implementation to reduce sudden cardiac death and categorize patients in terms of need for further testing. AHA Screening History Forms (image 1) were made available at all clinics to be filled by patients, and then confirmed by the pediatrician during the visit, who then completes the screening with relevant physical examination as recommended.


Baseline assessment involved reviewing a random sample of 16 patients in Jan-Jun 2018, from 8 pediatricians. Only 2/16 (12%) had complete assessment following AHA recommendations, with another 3/16 (19%) had some information and questions related to CV screening. On the other hand, 11/16 (69%) had no documentation of any question related to risk of CV death. Five out of 16 (31%) were referred to cardiology for clearance, 4 of them (4/5=80%) were unnecessary (no abnormal symptoms / signs documented in the chart).

After the first intervention, data from Oct-Dec 2018 revealed improvement in the number of unnecessary cardiology referral [baseline (69/196=35%) to (23/140=16%) post-PDSA1], figure 1. Similarly, there was reduction in unnecessary EKG testing [from baseline (80/196=41%) to (24/140=17%) post-PDSA1], figure 1. Our second intervention included ongoing verbal and electronic reminders to residents and pediatricians to use AHA screening. Post PDSA2 data (from Jan-March 2019) revealed slight increase in unnecessary cardiology referral and EKG testing, however it was still improved compared to baseline (figure 1). Assessment of change categorized by different pediatricians (figure 2) showed significant discrepancy among them in using the AHA screening and ordering unnecessary referral/testing.


Implementation of AHA questionnaire lead to reduced unnecessary EKGs and cardiology referrals in children presenting for PPE at local pediatric clinics. Some providers were still reluctant to change; hence, further education and focused one to one discussion may be helpful.

Clinical Implications

Implementation of AHA guidelines lead to reduced unnecessary testing and specialty consultation thus providing value to the patients by cutting down direct cost (insurance / out of pocket) as well as indirect cost (parents’ work hours lost and undue anxiety).


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