Improving the quality of pediatric murmur referrals within the National Capital Region

From the 2019 HVPAA National Conference

Dr. Joseph May (Walter Reed National Military Medical Center), Dr. Michael Mulreany (Walter Reed National Military Medical Center), Dr. Craig Dobson (Walter Reed National Military Medical Center), Ms. Theresa Taylor (Walter Reed National Military Medical Center), Dr. Lisa Gupta (Walter Reed National Military Medical Center)


While murmurs are very common among healthy children and teenagers, thought to be present in >90% at some point, the approach to murmur management varies widely among primary care providers.  Referring all patients with a murmur to a pediatric cardiologist is cost-ineffective and often results in heightened parental anxiety.  We have previously shown that, in most cases, healthy 2-18 year-old patients with a “new” murmur need not be reflexively referred to a pediatric cardiologist.  In 2016, we published an article with an algorithm that providers can follow (Figure 1) to help determine if a murmur referral is warranted; this was highlighted as a featured article in a number of educational forums, including AAP Grand Rounds.


This quality improvement project was developed with the aim to reduce by >10% the percentage of healthy military-beneficiary children and teenagers who were referred to National Capital Region (NCR) pediatric cardiologists with a “new” murmur in 2016-2018 by implementing an educational initiative among regional primary care providers working in military health treatment facilities in the NCR.


We implemented an educational initiative within the NCR primary care community using the Model for Improvement.  Iterative plan-do-study-act (PDSA) cycles included: PDSA#1: murmur lectures targeting the NCR residency programs in pediatrics and family medicine; PDSA#2: murmur lectures targeting pediatric primary care clinics in the NCR; PDSA#3: publication of murmur referral guidelines in the digital Specialty Referral Guidelines located on all NCR desktops, along with a murmur lecture at the NCR-wide pediatrics symposium; and PDSA#4-5: individual provider education, with targeted feedback through email that included supporting educational material on murmurs.  We evaluated the intervention using the baseline referral pattern in 2008-2013 for 2-18 year-old patients who were referred exclusively for evaluation of a murmur.  We then compared the percentage of “new” murmur referrals before and after implementation of these educational interventions.  We additionally assessed the percentage of murmur referrals that were in line with the algorithm we published.


The baseline referral pattern in 2008-2013 was 75.4% “new” murmurs and 24.6% “known” murmurs.  The percentage of “new” murmurs decreased to 67.2% (8.2% reduction, p=0.02) during this 2.5 year period (Figure 2).  The referral pattern by PDSA cycle is shown in Figure 3.  Overall, we found that 37.5% of referrals were in line with the algorithm we published.  Time periods with significant provider turnover (e.g., summer months) were associated with lower quality murmur referrals.  We found that formal didactic teaching and targeted feedback to providers seemed to make a bigger impact than published referral guidelines did.


This quality improvement project was associated with a statistically-significant reduction in “new” murmur referrals during 2016-2018, though this fell short of our target of >10%.  We plan to continue this educational initiative with a recurring lecture series to account for ongoing provider turnover.

Clinical Implications

In addition to reducing the anxiety that can be associated with an unneeded subspecialty referral, reducing referrals for “new” murmurs cuts unnecessary direct health care costs, with even higher cost-savings realized when accounting for missed work days by the parent(s).


1) Gupta LJ and May JW. Managing a “new” murmur in healthy children and teens. Clinical Pediatrics. 2016 Jun;5(4):357-362.

2) Murmur in the asymptomatic child and adolescent, AAP Grand Rounds. 2017 Jun;37(6):66.


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