{"paper_id":"424eabe2-9cb7-4751-9d9a-0ff1752f7b9a","body_text":"Are we adhering to guidelines for follow-up imaging in neonates with simple congenital heart defects? What are the healthcare costs of non-adherence? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Are we adhering to guidelines for follow-up imaging in neonates with simple congenital heart defects? What are the healthcare costs of non-adherence? Zein Al Abideen Hammad, Helen Coo, Haarini Suntharalingam, Shaam Alhamwi, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9580129/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Simple congenital heart defects (CHDs) are frequently identified via neonatal echocardiograms (“echos”). In 2020, the American Heart Association/American College of Cardiology issued guidelines for follow-up imaging of CHDs. In this retrospective study, we evaluated adherence to these guidelines at an academic health center in Southeastern Ontario. The cohort included neonates who had one or more simple CHDs diagnosed in the first 30 days of life between April 1, 2020, and March 31, 2024. We reviewed electronic medical records up to September 30, 2025 to examine a) rates of non-adherence to guideline-recommended follow-up imaging; b) factors that may contribute to non-adherence; and the costs of excessive imaging. Among 248 patients, 376 echos were performed over the study period; adherence status could be determined for 320. Follow-up for 39.7% of echos did not adhere to the guidelines, primarily because repeat echos were performed earlier than recommended. Non-adherence was substantially higher for lesions requiring surveillance imaging, as per guidelines, compared with lesions where follow-up imaging is not recommended or findings were normal (91.9% vs. 12.0%; OR = 83.4, 95% CI: 37.5-185.5). Pediatric cardiologist’s recommendation was documented for 74.5% of echos, but only 48.9% of recommendations aligned with the guidelines. Non-adherence was higher when recommendations were not documented or deviated from the guidelines. Sixty-two echos were deemed excessive, corresponding to $ 13,339 in extra imaging costs. The high rate of non-adherence to guideline-recommended follow-up imaging for simple CHDs highlights an opportunity to reduce unnecessary healthcare costs though consistent documentation of guideline-aligned follow-up recommendations by pediatric cardiologists. Simple congenital heart disease neonatal echo follow-up imaging guideline adherence healthcare costs Figures Figure 1 Introduction Simple congenital heart defects (CHDs), including patent foramen ovale (PFO), secundum atrial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA), are commonly identified in early infancy by echocardiogram (“echo”) [ 1 ]. Many of these lesions, particularly small defects, close spontaneously within the first 12 to 18 months of life [ 2 – 6 ]. In 2020, the American Heart Association (AHA) and the American College of Cardiology (ACC) published guidelines for imaging surveillance and clinical follow-up in patients with CHDs, based on the severity and type of cardiac lesion [ 7 ]. Under these recommendations, follow-up echocardiograms (“echos”) are considered inappropriate for a PFO or tiny silent PDA. In contrast, repeat imaging is recommended every 3–5 years for a small secundum ASD or small muscular VSD, every 1–2 years for a small non-muscular VSD, and every 3–6 months for a small audible PDA during the first year of life, followed by every 1–2 years until closure. Before publication of these guidelines, follow-up imaging for patients with simple CHDs was primarily based on individual pediatric cardiologists’ judgment, leading to considerable practice variation [ 6 ]. Despite standardized recommendations, a 2021 survey of pediatric cardiologists revealed substantial differences in follow-up practices for newborns with non-emergent echo findings [8]. For example, 15% of respondents recommended a follow-up echo for an isolated PFO in a term infant, even though routine surveillance of these patients is not supported by the AHA/ACC guidelines. A retrospective chart review of 95 infants with secundum ASD, muscular VSD, and/or PDA revealed that repeat echos were generally performed earlier than recommended by the guidelines [ 9 ]. None of these patients required cardiac interventions two to six years following their initial echo, suggesting that early follow-up, which likely contributed to increased resource utilization, did not provide significant clinical benefits. Ziebell et al. explored the consequences of non-adherence to locally established guidelines, similar to those published by the AHA/ACC, for follow-up of ASD and PFO diagnosed within the first year of life [ 10 ]. They concluded that adherence to optimal follow-up protocols could have reduced patient charges by $ 242,472 over three years. To our knowledge, no Canadian studies have evaluated adherence to the AHA/ACC guidelines for follow-up imaging in neonates with simple CHDs, or examined factors associated with non-adherence. The primary objective of this study was to determine the prevalence of non-adherence to guideline-recommended follow-up imaging for simple CHDs at an academic hospital in Southeastern Ontario, Canada. Secondary objectives were to explore factors that may contribute to non-adherence and to quantify the costs associated with performing excessive follow-up echos over the study period. These findings may inform the development of locally relevant, awareness-raising strategies to improve guideline adherence and reduce unnecessary healthcare resource utilization. Materials and methods The study protocol was approved by the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board (File #6043957) prior to data collection. Study design and setting This single-site retrospective cohort study was conducted at the Kingston Health Sciences Centre (KHSC), Southeastern Ontario’s largest acute-care academic hospital. Three pediatric cardiologists were employed at KHSC during the study period, including the principal investigator (MA) and one co-investigator (JP). Study cohort We included neonates who underwent echo within the first 30 days of life at KHSC between April 1, 2020, and March 31, 2024, inclusive (“accrual period”), and who were diagnosed with one or more simple CHDs, namely a PFO, tiny or small PDA, small secundum ASD small muscular VSD and/or small restrictive perimembranous VSD (“study lesions”). Patients who had multiple echos during their neonatal hospital admission for conditions such as a large PDA were eligible for inclusion if a study lesion was identified on their final pre-discharge echo, but no other cardiac lesions were present. In such instances, that final pre-discharge echo was considered the “initial” echo for this study, even if performed after 30 days of life, as post-discharge follow-up imaging recommendations would have been based on those findings. Patients with other cardiac lesions and patients who required outpatient follow-up echos for other significant comorbidities (e.g., chronic lung disease, pulmonary hypertension were excluded. Key definitions Adherence to guideline-recommended follow-up imaging Adherence was assessed using the 2020 AHA/ACC guidelines for follow-up imaging of CHDs. Adherence status was determined in relation to the findings on the initial echo and each subsequent follow-up echo performed during the observation window (date of initial echo to September 30, 2025) where one or more study lesions were present; if a non-study cardiac lesion was identified on follow-up, adherence status was not assessed in relation to that echo. Guideline-recommended follow-up intervals are shown in Table 1 . No further echos are recommended when a PFO and/or a tiny silent PDA are the only findings. Accordingly, any subsequent echo performed during the observation window for these findings was considered non-adherent. Similarly, any echo performed after a “normal” finding on a follow-up echo was considered non-adherent. If an initial of follow-up echo revealed a small secundum ASD, small muscular VSD, small perimembranous VSD, or small audible PDA, follow-up was classified as adherent if the subsequent echo was performed within ± 25% of the guideline-recommended interval. If the observation window was shorter than + 25% of the recommended follow-up interval, adherence status was classified as “indeterminate.” The ± 25% window was chosen to account for scheduling variability at the health system level (e.g., wait times) and patient level (e.g., travel, illness) that may render it unrealistic to expect appointment times to fall exactly within the recommended follow-up interval. When multiple study lesions were detected on an echo, the shortest guideline-recommended follow-up interval was used to determine adherence. Table 1 Definitions of non-adherence to guideline-recommended follow-up imaging for simple CHDs Finding on echo Guideline-recommended follow-up imaging interval Definition of non-adherence PFO or tiny silent PDA None Any follow-up echo Small secundum ASD or small muscular VSD 3–5 years Follow-up echo at < 821 or > 2281 days Small audible PDA during first year of life 3–6 months Follow-up echo at < 68 or >225 days Small perimembranous VSD or small audible PDA after first year of life 1–2 years Follow-up echo at < 274 or > 913 days Alignment of pediatric cardiologists’ recommendations with guidelines We reviewed echo reports, pediatric cardiology clinical notes, and discharge summaries for documentation of pediatric cardiologist’s recommendations regarding follow-up imaging. When such documentation was available, we assessed whether it aligned with the guideline-recommended follow-up intervals from Table 1 . If the cardiologist recommended a clinic visit only for study lesions where the guidelines specified a follow-up imaging interval, or if they recommended a clinic visit with a follow-up echo but the patient’s chart did not contain a recommendation pertaining to the timing of that echo, alignment with guidelines recommendations were classified as “indeterminate.” Excessive echos All follow-up echos that exceeded the number a patient should have received during the observation window according to the guideline-based definitions in Table 1 were classified as \"excessive.” Data collection Data were collected by retrospective review of electronic medical records and entered into a REDCap database. The principal investigator (MA) conducted a one-day training session for the data abstractors (HS, SA, ZH). Each abstractor reviewed 10 charts independently. Discrepancies were discussed and resolved by consensus. A further 10 charts were then reviewed to ensure acceptable inter-rater agreement, defined as greater than 90%, before proceeding with full data abstraction. Information was collected on patient demographics, including gestational age, sex, and date of birth, as well as details relating to the initial and all follow-up echos performed up to and including September 30, 2025. That information included echo dates, detected cardiac lesion(s), referring provider, initial echo location (e.g., inpatient vs. outpatient), and the pediatric cardiologist’s follow-up recommendations. Data analysis The data were downloaded and analyzed in SPSS version 29.0.2.0 (IBM Corporation, Armonk, NY). Summary statistics (frequency distributions, medians and interquartile ranges [IQRs]) were generated to describe the sample. To distinguish echo findings where follow-up imaging is and is not recommended, small secundum ASD, small muscular VSD, small perimembranous VSD and small audible PDA were categorized as “Group 1”, while PFO, tiny silent PDA, or a “normal” finding were categorized as “Group 2.” Adherence status was cross-tabulated with a) the echo finding and Group 1/Group 2 membership; b) lesion load (single or multiple lesions detected); and c) whether there was documentation of a pediatric cardiologist’s recommendation and if so, whether it aligned with or deviated from the guidelines. Unadjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using MedCalc to determine the odds of non-adherence to guideline- recommended follow-up. We further examined adherence within four provider groups (neonatologist; pediatrician or subspecialist at KHSC; midwife or nurse practitioner at KHSC; family doctor, or midwife or pediatrician external to KHSC), cross-tabulated with alignment of the pediatric cardiologist’s recommendations with the guidelines, or the absence of documented recommendations. The “responsible provider” was deemed to be a) the referring provider for any echo where no follow-up imaging was performed during the study period, or b) the referring provider for the follow-up echo. To explore the potential impact of inter-provider communication on adherence, we also cross-tabulated documentation of the pediatric cardiologist’s recommendation in the discharge summary (yes/no) with adherence status for the subgroup of initial echos that met the following criteria: a) performed in an inpatient setting; b) the pediatric cardiologist’s recommendation (documented in any of the sources searched) aligned with the guidelines; and c) the findings were classified as Group 2 (follow-up imaging not recommended) or, in the case of Group 1 lesions, the follow-up echo was arranged by a different provider. Echos where the same provider ordered both the initial and follow-up echos were excluded, as discharge summary documentation would be unlikely to have influenced follow-up actions. To quantify the costs associated with performing excessive follow-up echos, we first calculated how many echos each patient should have had during their observation window, based on the guidelines. That number was then subtracted from the actual number of echos they received. Any result that exceeded zero was multiplied by $ 215.15 (the total reimbursement for technical and professional fees for a standard echo in the 2026 Ontario Health Insurance Plan Schedule of Benefits). Those results were then summed to quantify the total costs incurred for excessive follow-up echos in our cohort. For patients with only a PFO and/or a tiny silent PDA, any subsequent echo performed was considered excessive. For patients with any of the other study lesions, we used the minimum values shown in the third column of Table 1 to determine the appropriate number of follow-up echos. For example, a patient with a small perimembranous VSD on their initial, first and second follow-up echos, with no further echos and an observation window of 423 days, would appropriately have had one follow-up echo only. (Per Table 1 , a follow-up echo could have been performed as early as 274 days following the preceding echo to be considered adherent. Two follow-up echos would therefore require an observation window of at least 548 days to avoid one of them being labelled excessive.) Since the patient had two follow-up echos and should have had only one during their observation window, they had one excessive echo. It is important to note that we did not consider adherence status per se in the determination of whether a patient had one or more excessive echos. For example, if a patient had a small perimembranous VSD on their initial echo and a subsequent echo after 150 days, the follow-up would have been considered non-adherent. However, if they had no further follow-up echos and an observation window of 423 days, that first follow-up echo would not have been considered excessive. Results A total of 437 charts were assessed for eligibility. Of these, 189 were excluded for the reasons shown in Fig. 1 . The charts for the remaining 248 patients were included. Slightly over half of our study population was male (n = 133, 53.6%). The median birthweight was 3110 g (IQR: 2332–3647), and median gestational age was 38.1 weeks (IQR: 35.9–39.1). Initial echos were performed at a median age of 6.0 days (IQR: 2.0–19.0). *A patient may have had more than one reason to be excluded, and hence the numbers sum to more than the total number excluded . Slightly more than half our cohort (n = 136, 54.8%) did not receive any follow-up echo during the study period. Ninety-six patients (38.7%) had one follow-up echo and 16 (6.5%) had two follow-up echos. This yielded a total of 376 echos (248 initial and 128 follow-up echos); eight were excluded from all analyses because seven revealed cardiac lesions that were outside the scope of this study, and one showed a PDA where closure was recommended rather than routine surveillance. Adherence status was determinable for 320 echos, while the observation window was too short to determine adherence status for the other 48. The overall rate of non-adherence was 39.7% (Table 2 ) and was more prevalent in Group 1 than Group 2 (91.9% versus 12.0%, respectively; OR [95% CI] = 83.4 [37.5-185.5]). Among the lesions where follow-up imaging is recommended (Group 1), 90 follow-up echos were performed earlier than recommended; 4 later than recommended; and for 8, there was no subsequent follow-up echo, despite the observation window extending to + 25% of the guideline-recommended interval’s upper limit. The presence of more than one study lesion on an echo was associated with higher odds of non-adherence in Group 2 (50.0% vs 8.4%; OR 10.94, 95% CI 3.80–31.45) (Table 3 ). Table 2 Non-adherence to guideline-recommended follow-up imaging, overall and by lesion type Guideline-recommended follow-up imaging n (row %) Odds ratio (95% CI) for non- adherence, Group 1 vs. Group 2 (referent) Non-adherent Adherent Overall (n = 320) 127 (39.7) 193 (60.3) Group 1 (n = 111) 102 (91.9) 9 (8.1) 83.4 (37.5-185.5) Small secundum ASD or small muscular VSD (n = 95) 88 (92.6) 7 (7.4) Small perimembranous VSD (n = 2) 2 (100) 0 Small audible PDA (n = 14) 12 (85.7) 2 (14.3) Group 2 (n = 209) 25 (12.0) 184 (88.0) PFO or tiny silent PDA (n = 147) 23 (15.6) 124 (84.4) Normal (n = 62) 2 (3.2) 60 (96.8) ASD: atrial septal defect; CI: confidence interval; PDA: patent ductus arteriosus; PFO: patent foramen ovale; VSD: ventricular septal defect Table 3 Lesion load cross-tabulated with adherence status Finding on echo Adherence to guideline-recommended follow-up imaging n (row %) Odds ratio (95% CI) for non-adherence, multiple vs. single lesion (referent) Non-adherent Adherent Group 1 (small secundum ASD, small muscular VSD, small perimembranous VSD, small audible PDA) (n = 111) Multiple lesions 60 (92.3) 5 (7.7) 1.14 (0.29–4.51) Single lesion 42 (91.3) 4 (8.7) Group 2 (sPFO, tiny silent PDA, “normal”) (n = 209) Multiple lesions 9 (50.0) 9 (50.0) 10.94 (3.80-31.45) Single lesion or “normal” 16 (8.4) 175 (91.6) ASD: atrial septal defect; CI: confidence interval; PDA: patent ductus arteriosus; PFO: patent foramen ovale; VSD: ventricular septal defect The pediatric cardiologist’s recommendations regarding follow-up imaging were documented for 274 of 368 echos (74.5%). About half of those recommendations aligned with the guidelines (n = 132/270 [48.9%]; data not shown in tabular format). Four echos were excluded from the denominator for the reasons outlined in the Table 4 footnote. Per Table 4 , the odds of non-adherence to guideline-recommended follow-up imaging were much higher when the pediatric cardiologist’s recommendations were not documented, or when those recommendations deviated from the guidelines (note that an additional 48 echos were excluded from this table because the observation window was too short to determine adherence status). Guideline adherence in Group 2 exceeded 90% even when no recommendations were documented but was much lower (27.3%) if the documented recommendations deviated from the guidelines. Table 4 Alignment of pediatric cardiologist’s recommendations with guideline-recommended follow-up imaging, cross-tabulated with adherence status Pediatric cardiologist’s recommendations Adherence to guideline-recommended follow-up imaging n (row %) Odds ratio (95% CI) for non-adherence, combined category of recommendations not documented/deviated from guidelines vs. recommendations aligned with guidelines (referent) Non-adherent Adherent Group 1 (small secundum ASD, small muscular VSD, small perimembranous VSD, small audible PDA) (n = 108) Not documented 14 (82.4) 3 (17.6) 49.0 (4.4-544.8) Deviated from guidelines 84 (96.6) 3 (3.4) Aligned with guidelines 1 (25.0) 3 (75.0) Group 2 (PFO, tiny silent PDA, “normal”) (n = 208) Not documented 6 (8.5) 65 (91.5) 17.5 (4.0-76.7) Deviated from guidelines 16 (72.7) 6 (27.3) Aligned with guidelines 2 (1.8) 113 (98.2) ASD: atrial septal defect; CI: confidence interval; PDA: patent ductus arteriosus; PFO: patent foramen ovale; VSD: ventricular septal defect ** Alignment of the pediatric cardiologists’ recommendations with guideline−recommended follow−up imaging could not be assessed for three initial echos (clinic visit only was recommended [n=1] or clinic visit with follow−up echo was recommended but the timeline for follow−up was missing [n=2]). Alignment could not be assessed for one follow−up echo because clinic follow−up for hypertension, rather than the cardiac lesion, was recommended . Adherence was high in all the non-cardiologist provider groups when the pediatric cardiologist’s recommendations aligned with the guidelines for follow-up imaging, reaching 90–100% in all provider groups (Table 5 ). Conversely, it was markedly lower when recommendations deviated deviated from guidelines, with an adherence of 20% or less among all provider groups. When no recommendation was documented, adherence remained high, ranging from 70% to 100% across providers. Table 5 Adherence to guideline-recommended follow-up imaging among referring provider groups, cross-tabulated with alignment of pediatric cardiologist’s recommendations with guidelines Referring provider* Alignment of pediatric cardiologist’s recommendations with guidelines for follow-up imaging Overall Aligned with guidelines n (column %) Deviated from guidelines n (column %) Recommendation not documented n (column %) n (column %) Neonatologist Adherent 58 (100) 2 (5.7) 29 (85.3) 89 (70.1) Non-adherent 0 33 (94.3) 5 (14.7) 38 (29.9) Pediatrician or subspecialist at KHSC Adherent 19 (90.5) 0 11 (73.3) 30 (63.8) Non-adherent 2 (9.5) 11 (100.0) 4 (26.7) 17 (36.2) Midwife or nurse practitioner at KHSC Adherent 4 (100) 0 2 (100.0) 6 (60.0) Non-adherent 0 4 (100.0) 0 4 (40.0) Family doctor, or midwife or pediatrician external to KHSC Adherent 15 (93.8) 5 (20.0) 20 (71.4) 40 (58.0) Non-adherent 1 (6.2) 20 (80.0) 8 (28.6) 29 (42.0) KHSC: Kingston Health Sciences Centre *Referring provider for echo if no further follow−up imaging performed during study period; otherwise, referring provider for follow−up echo. Analysis excludes echos ordered by pediatric cardiologist . The subgroup analysis included 56 echos performed in an inpatient setting where the pediatric cardiologist’s recommendations aligned with the guidelines and where the findings revealed a Group 2 lesion (n = 53) or a Group 1 lesion where the follow-up echo was arranged by a different provider (n = 3). The pediatric cardiologist’s recommendation was documented in 35 discharge summaries (62.5%). Adherence status could not be determined for one echo. Among the remaining 55, only one follow-up echo (Group 1, pediatric cardiologist’s recommendation documented in discharge summary) was non-adherent. Fifty-four patients had one excessive echo during the study period and four patients had two excessive echos. Based on an estimated cost of $ 215.15 per echo according to the Ontario Health Insurance Plan Schedule of Benefits, these 62 echos resulted in excess costs of $ 13,339. Discussion In this single-center retrospective study, the follow-up for 40% of echos was non-adherent to guideline recommendations for surveillance imaging. Non-adherence was substantially higher for lesions requiring surveillance imaging according to the guidelines (Group 1: small secundum ASD, small muscular or perimembranous VSD, and small audible PDA) as compared to lesions where follow-up imaging is not recommended (Group 2: PFO and tiny silent PDA, or normal findings). The pediatric cardiologist’s follow-up recommendation was documented for three-quarters of echos, and approximately half of those documented recommendations aligned with the guidelines. For Group 2 lesions, non-adherence remained low (< 10%) even when no follow-up recommendation was documented, likely reflecting the widespread recognition among referring providers that findings such as a PFO or tiny silent PDA do not require routine follow-up imaging. However, non-adherence increased substantially in this group to more than 70% when the cardiologist’s recommendation was not aligned with the guidelines, suggesting that referring providers tend to adopt follow-up practices advised by pediatric cardiologists even when they differ from the guidelines.In contrast, non-adherence was higher (> 80%) for Group 1 lesions when no follow-up recommendation was documented. In the absence of clear recommendations, referring providers may be uncertain about the appropriate timing for follow-up echos, making these cases more prone to variation and deviation from guideline-recommended practice. The higher rate of non-adherence for Group 1 lesions was largely driven by earlier-than-recommended follow-up echos. Several factors may explain this finding. Clinicians may prefer earlier reassessment of septal defects or PDAs because of concerns about lesion progression or parental anxiety. In addition, clinicians may rely on historical follow-up practices that predate the publication of the 2020 AHA/ACC guidelines [ 7 ]. Our findings are consistent with previous studies demonstrating considerable variation in follow-up practices for simple CHDs. A survey of pediatric cardiologists that asked about their follow-up recommendations for presumed cases of non-emergent echocardiographic findings in asymptomatic newborns reported substantial variability among providers [8]. Similarly, a study of newborns diagnosed with ASD, VSD, and PDA have shown that repeat echos are frequently performed earlier than recommended, without clear evidence of clinical benefit [ 9 ]. When cardiologists’ recommendations aligned with the guidelines, non-adherence was low across all referring provider groups, ranging from 0 to 10%. In contrast, when cardiologists’ reccomendations deviated from the guidelines, non-adherence increased markedly to 80% or more among most provider groups. Notably, in approximately 20% of cases—when the referring provider was a family physician, midwife, or pediatrician external to KHSC—the cardiologist’s recommendation was not followed and the follow-up was adherent. Another notable finding was the greater likelihood of non-adherence when two or more Group 2 lesions were identified on an echo. The presence of multiple minor findings may drive clinician uncertainty and contribute to more conservative follow-up strategies, even if each lesion individually would not warrant routine follow-up imaging. Non-adherence remained low in the inpatient subgroup regardless of whether the pediatric cardiologists’ recommendations were documented in the discharge summary. Most of the echos included in this analysis revealed Group 2 lesions, which are widely recognized among providers as not requiring routine follow-up imaging [ 11 ]; accordingly, practice may have remained guideline-aligned even without explicit documentation. Sixty-two echos were classified as “excessive,” corresponding to $ 13,339 in imaging costs over the study period. Although the cost of an individual echo is modest, over time the cumulative burden of excessive echos can meaningfully impact healthcare expenditures. Improved adherence to guideline-based follow-up recommendations would contribute to more efficient resource utilization, particularly in publicly funded healthcare systems such as Canada’s. It would also lessen the indirect burden on families caused by the need for additional appointments, travel, and emotional strain [ 12 ]. Our findings highlight several practical opportunities to improve adherence to guideline-recommended follow-up imaging. First, there should be consistent documentation of follow-up recommendations, including a section that notes whether follow-up imaging is required and, if so, within what time interval. Second, visual aids or point-of-care reference tools for pediatric cardiologists may improve alignment with guideline-recommended follow-up intervals at the time of reporting the echos. Finally, targeted quality improvement initiatives and educational efforts directed toward pediatric cardiologists and referring providers may promote alignment of follow-up practices and reduce variation in care. These strategies could reduce unnecessary costs to the healthcare system caused by excessive imaging. To our knowledge, this is the first Canadian study to evaluate adherence to guideline-recommended follow-up imaging in neonates with simple CHDs. However, several limitations should be considered. First, we analyzed data from one center with a small pediatric cardiology division, which may limit the generalizability of our findings to other institutions with different patient populations or practice patterns. Second, although the AHA/ACC guidelines reccomendations were used as the reference standard, clinical considerations not captured in the medical record may have influenced follow-up decisions in individual cases. Third, while we explored factors that may contribute to non-adherence, our study was not designed to test hypotheses with the use of a priori sample size calculations and adequate control for confounding. Finally, the cost calculations for excessive echos are based only on provincial reimbursement rates and do not capture the full costs to the healthcare system and to families associated with excessive imaging. The high rate of non-adherence to guideline-recommended follow-up echocardiography for simple CHDs diagnosed in neonates highlights an opportunity to avoid excessive imaging and to reduce healthcare costs. Consistent documentation of cardiology follow-up recommendations and targeted strategies to improve their alignment with guidelines are needed to promote more cost-effective care. Declarations Funding declarations This study was funded by an operating grant from the 2025 CTAQ (Clinical Teachers' Association of Queen's University) Research Endowment Fund. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. References Fenster ME, Hokanson JS (2018) Heart murmurs and echocardiography findings in the normal newborn nursery. Congenit Heart Dis 13:771-775. https://doi.org/10.1111/chd.12651 Yildirim A, Aydin A, Demir T, Aydin F, Ucar B, Kilic Z (2016) Echocardiographic follow-up of patent foramen ovale and the factors affecting spontaneous closure. 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Ann Pediatr Cardiol 15:44-52 Lawoko S, Soares JJ (2002) Distress and hopelessness among parents of children with congenital heart disease, parents of children with other diseases, and parents of healthy children. J Psychosom Res 52:193-208 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 May, 2026 Reviewers agreed at journal 07 May, 2026 Reviewers invited by journal 03 May, 2026 Editor assigned by journal 01 May, 2026 Submission checks completed at journal 01 May, 2026 First submitted to journal 30 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9580129\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":636456309,\"identity\":\"db81ada5-595f-4ce2-a6ed-b5a06de27406\",\"order_by\":0,\"name\":\"Zein Al Abideen Hammad\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Queen's University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Zein\",\"middleName\":\"Al Abideen\",\"lastName\":\"Hammad\",\"suffix\":\"\"},{\"id\":636456311,\"identity\":\"1df03276-9d77-435d-95b3-83e1243b0114\",\"order_by\":1,\"name\":\"Helen Coo\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Queen's University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Helen\",\"middleName\":\"\",\"lastName\":\"Coo\",\"suffix\":\"\"},{\"id\":636456312,\"identity\":\"e4b3f9c8-cf66-4804-aee1-f365547b8266\",\"order_by\":2,\"name\":\"Haarini Suntharalingam\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Queen's University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Haarini\",\"middleName\":\"\",\"lastName\":\"Suntharalingam\",\"suffix\":\"\"},{\"id\":636456314,\"identity\":\"6fd75a8d-7d52-491c-8e6a-a04c5d4b29c5\",\"order_by\":3,\"name\":\"Shaam Alhamwi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Queen's University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Shaam\",\"middleName\":\"\",\"lastName\":\"Alhamwi\",\"suffix\":\"\"},{\"id\":636456315,\"identity\":\"63399852-459c-45c8-acf1-6803630d0c96\",\"order_by\":4,\"name\":\"Joshua Penslar\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Queen's University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Joshua\",\"middleName\":\"\",\"lastName\":\"Penslar\",\"suffix\":\"\"},{\"id\":636456320,\"identity\":\"5e452747-b597-4d39-9d2c-7c7268e7e810\",\"order_by\":5,\"name\":\"Mahmoud Alsalehi\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"\",\"institution\":\"Queen's University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Mahmoud\",\"middleName\":\"\",\"lastName\":\"Alsalehi\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-04-30 17:39:06\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9580129/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9580129/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":109099932,\"identity\":\"1cc1fe31-36af-4b0c-b7ed-32f64c9c5ca7\",\"added_by\":\"auto\",\"created_at\":\"2026-05-12 14:19:24\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":273498,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eCohort selection\\u003c/p\\u003e\\n\\u003cp\\u003e*A patient may have had more than one reason to be excluded, and hence the numbers sum to more than the total number excluded.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9580129/v1/82bdd8fbc9b0b09440ed0e96.png\"},{\"id\":109100183,\"identity\":\"7070c8bb-b19b-4797-9c1d-b69fe2c4bcf4\",\"added_by\":\"auto\",\"created_at\":\"2026-05-12 14:20:29\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":519614,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9580129/v1/9b7f4e5d-0630-4252-838e-1ea51019f13d.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Are we adhering to guidelines for follow-up imaging in neonates with simple congenital heart defects? What are the healthcare costs of non-adherence?\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eSimple congenital heart defects (CHDs), including patent foramen ovale (PFO), secundum atrial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA), are commonly identified in early infancy by echocardiogram (\\u0026ldquo;echo\\u0026rdquo;) [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. Many of these lesions, particularly small defects, close spontaneously within the first 12 to 18 months of life [\\u003cspan additionalcitationids=\\\"CR3 CR4 CR5\\\" citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn 2020, the American Heart Association (AHA) and the American College of Cardiology (ACC) published guidelines for imaging surveillance and clinical follow-up in patients with CHDs, based on the severity and type of cardiac lesion [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. Under these recommendations, follow-up echocardiograms (\\u0026ldquo;echos\\u0026rdquo;) are considered inappropriate for a PFO or tiny silent PDA. In contrast, repeat imaging is recommended every 3\\u0026ndash;5 years for a small secundum ASD or small muscular VSD, every 1\\u0026ndash;2 years for a small non-muscular VSD, and every 3\\u0026ndash;6 months for a small audible PDA during the first year of life, followed by every 1\\u0026ndash;2 years until closure. Before publication of these guidelines, follow-up imaging for patients with simple CHDs was primarily based on individual pediatric cardiologists\\u0026rsquo; judgment, leading to considerable practice variation [\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eDespite standardized recommendations, a 2021 survey of pediatric cardiologists revealed substantial differences in follow-up practices for newborns with non-emergent echo findings [8]. For example, 15% of respondents recommended a follow-up echo for an isolated PFO in a term infant, even though routine surveillance of these patients is not supported by the AHA/ACC guidelines. A retrospective chart review of 95 infants with secundum ASD, muscular VSD, and/or PDA revealed that repeat echos were generally performed earlier than recommended by the guidelines [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. None of these patients required cardiac interventions two to six years following their initial echo, suggesting that early follow-up, which likely contributed to increased resource utilization, did not provide significant clinical benefits. Ziebell et al. explored the consequences of non-adherence to locally established guidelines, similar to those published by the AHA/ACC, for follow-up of ASD and PFO diagnosed within the first year of life [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. They concluded that adherence to optimal follow-up protocols could have reduced patient charges by \\u003cspan\\u003e$\\u003c/span\\u003e242,472 over three years.\\u003c/p\\u003e \\u003cp\\u003e To our knowledge, no Canadian studies have evaluated adherence to the AHA/ACC guidelines for follow-up imaging in neonates with simple CHDs, or examined factors associated with non-adherence. The primary objective of this study was to determine the prevalence of non-adherence to guideline-recommended follow-up imaging for simple CHDs at an academic hospital in Southeastern Ontario, Canada. Secondary objectives were to explore factors that may contribute to non-adherence and to quantify the costs associated with performing excessive follow-up echos over the study period. These findings may inform the development of locally relevant, awareness-raising strategies to improve guideline adherence and reduce unnecessary healthcare resource utilization.\\u003c/p\\u003e\"},{\"header\":\"Materials and methods\",\"content\":\"\\u003cp\\u003e The study protocol was approved by the Queen\\u0026rsquo;s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board (File #6043957) prior to data collection.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStudy design and setting\\u003c/h2\\u003e \\u003cp\\u003e This single-site retrospective cohort study was conducted at the Kingston Health Sciences Centre (KHSC), Southeastern Ontario\\u0026rsquo;s largest acute-care academic hospital. Three pediatric cardiologists were employed at KHSC during the study period, including the principal investigator (MA) and one co-investigator (JP).\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eStudy cohort\\u003c/h3\\u003e\\n\\u003cp\\u003eWe included neonates who underwent echo within the first 30 days of life at KHSC between April 1, 2020, and March 31, 2024, inclusive (\\u0026ldquo;accrual period\\u0026rdquo;), and who were diagnosed with one or more simple CHDs, namely a PFO, tiny or small PDA, small secundum ASD small muscular VSD and/or small restrictive perimembranous VSD (\\u0026ldquo;study lesions\\u0026rdquo;). Patients who had multiple echos during their neonatal hospital admission for conditions such as a large PDA were eligible for inclusion if a study lesion was identified on their final pre-discharge echo, but no other cardiac lesions were present. In such instances, that final pre-discharge echo was considered the \\u0026ldquo;initial\\u0026rdquo; echo for this study, even if performed after 30 days of life, as post-discharge follow-up imaging recommendations would have been based on those findings. Patients with other cardiac lesions and patients who required outpatient follow-up echos for other significant comorbidities (e.g., chronic lung disease, pulmonary hypertension\\u003c/p\\u003e \\u003cp\\u003ewere excluded.\\u003c/p\\u003e\\n\\u003ch3\\u003eKey definitions\\u003c/h3\\u003e\\n\\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAdherence to guideline-recommended follow-up imaging\\u003c/h2\\u003e \\u003cp\\u003e Adherence was assessed using the 2020 AHA/ACC guidelines for follow-up imaging of CHDs. Adherence status was determined in relation to the findings on the initial echo and each subsequent follow-up echo performed during the observation window (date of initial echo to September 30, 2025) where one or more study lesions were present; if a non-study cardiac lesion was identified on follow-up, adherence status was not assessed in relation to that echo.\\u003c/p\\u003e \\u003cp\\u003eGuideline-recommended follow-up intervals are shown in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. No further echos are recommended when a PFO and/or a tiny silent PDA are the only findings. Accordingly, any subsequent echo performed during the observation window for these findings was considered non-adherent. Similarly, any echo performed after a \\u0026ldquo;normal\\u0026rdquo; finding on a follow-up echo was considered non-adherent.\\u003c/p\\u003e \\u003cp\\u003e If an initial of follow-up echo revealed a small secundum ASD, small muscular VSD, small perimembranous VSD, or small audible PDA, follow-up was classified as adherent if the subsequent echo was performed within \\u0026plusmn;\\u0026thinsp;25% of the guideline-recommended interval. If the observation window was shorter than +\\u0026thinsp;25% of the recommended follow-up interval, adherence status was classified as \\u0026ldquo;indeterminate.\\u0026rdquo; The \\u0026plusmn;\\u0026thinsp;25% window was chosen to account for scheduling variability at the health system level (e.g., wait times) and patient level (e.g., travel, illness) that may render it unrealistic to expect appointment times to fall exactly within the recommended follow-up interval. When multiple study lesions were detected on an echo, the shortest guideline-recommended follow-up interval was used to determine adherence.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDefinitions of non-adherence to guideline-recommended follow-up imaging for simple CHDs\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"3\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFinding on echo\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eGuideline-recommended\\u003c/p\\u003e \\u003cp\\u003efollow-up imaging\\u0026nbsp;interval\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eDefinition of non-adherence\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePFO or tiny silent PDA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNone\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAny\\u0026nbsp;follow-up\\u0026nbsp;echo\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmall secundum ASD or small muscular VSD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3\\u0026ndash;5 years\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eFollow-up echo at \\u0026lt;\\u0026thinsp;821\\u0026nbsp;\\u003cb\\u003eor\\u003c/b\\u003e\\u0026nbsp;\\u0026gt; 2281 days\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmall audible PDA during first year of life\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3\\u0026ndash;6 months\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eFollow-up echo at \\u0026lt;\\u0026thinsp;68 \\u003cb\\u003eor\\u003c/b\\u003e\\u0026nbsp;\\u0026gt;225 days\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmall\\u0026nbsp;perimembranous\\u0026nbsp;VSD or small audible PDA after first year of life\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1\\u0026ndash;2 years\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eFollow-up echo at \\u0026lt;\\u0026thinsp;274 \\u003cb\\u003eor\\u003c/b\\u003e \\u0026gt;\\u0026thinsp;913 days\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eAlignment of pediatric cardiologists’ recommendations with guidelines\\u003c/h3\\u003e\\n\\u003cp\\u003eWe reviewed echo reports, pediatric cardiology clinical notes, and discharge summaries for documentation of pediatric cardiologist\\u0026rsquo;s recommendations regarding follow-up imaging. When such documentation was available, we assessed whether it aligned with the guideline-recommended follow-up intervals from Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. If the cardiologist recommended a clinic visit only for study lesions where the guidelines specified a follow-up imaging interval, or if they recommended a clinic visit with a follow-up echo but the patient\\u0026rsquo;s chart did not contain a recommendation pertaining to the timing of that echo, alignment with guidelines recommendations were classified as \\u0026ldquo;indeterminate.\\u0026rdquo;\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eExcessive echos\\u003c/h2\\u003e \\u003cp\\u003eAll follow-up echos that exceeded the number a patient should have received during the observation window according to the guideline-based definitions in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e were classified as \\\"excessive.\\u0026rdquo;\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eData collection\\u003c/h3\\u003e\\n\\u003cp\\u003eData were collected by retrospective review of electronic medical records and entered into a REDCap database. The principal investigator (MA) conducted a one-day training session for the data abstractors (HS, SA, ZH). Each abstractor reviewed 10 charts independently. Discrepancies were discussed and resolved by consensus. A further 10 charts were then reviewed\\u003c/p\\u003e \\u003cp\\u003eto ensure acceptable inter-rater agreement, defined as greater than 90%, before proceeding with full data abstraction.\\u003c/p\\u003e \\u003cp\\u003eInformation was collected on patient demographics, including gestational age, sex, and date of birth, as well as details relating to the initial and all follow-up echos performed up to and including September 30, 2025. That information included echo dates, detected cardiac lesion(s), referring provider, initial echo location (e.g., inpatient vs. outpatient), and the pediatric cardiologist\\u0026rsquo;s follow-up recommendations.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eData analysis\\u003c/h2\\u003e \\u003cp\\u003eThe data were downloaded and analyzed in SPSS version 29.0.2.0 (IBM Corporation, Armonk, NY). Summary statistics (frequency distributions, medians and interquartile ranges [IQRs]) were generated to describe the sample. To distinguish echo findings where follow-up imaging is and is not recommended, small secundum ASD, small muscular VSD, small perimembranous VSD and small audible PDA were categorized as \\u0026ldquo;Group 1\\u0026rdquo;, while PFO, tiny silent PDA, or a \\u0026ldquo;normal\\u0026rdquo; finding were categorized as \\u0026ldquo;Group 2.\\u0026rdquo; Adherence status was cross-tabulated with a) the echo finding and Group 1/Group 2 membership; b) lesion load (single or multiple lesions detected); and c) whether there was documentation of a pediatric cardiologist\\u0026rsquo;s recommendation and if so, whether it aligned with or deviated from the guidelines. Unadjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using MedCalc to determine the odds of non-adherence to guideline- recommended follow-up.\\u003c/p\\u003e \\u003cp\\u003e We further examined adherence within four provider groups (neonatologist; pediatrician or subspecialist at KHSC; midwife or nurse practitioner at KHSC; family doctor, or midwife or pediatrician external to KHSC), cross-tabulated with alignment of the pediatric cardiologist\\u0026rsquo;s recommendations with the guidelines, or the absence of documented recommendations. The \\u0026ldquo;responsible provider\\u0026rdquo; was deemed to be a) the referring provider for any echo where no follow-up imaging was performed during the study period, or b) the referring provider for the follow-up echo.\\u003c/p\\u003e \\u003cp\\u003e To explore the potential impact of inter-provider communication on adherence, we also cross-tabulated documentation of the pediatric cardiologist\\u0026rsquo;s recommendation in the discharge summary (yes/no) with adherence status for the subgroup of initial echos that met the following criteria: a) performed in an inpatient setting; b) the pediatric cardiologist\\u0026rsquo;s recommendation (documented in any of the sources searched) aligned with the guidelines; and c) the findings were classified as Group 2 (follow-up imaging not recommended) or, in the case of Group 1 lesions, the follow-up echo was arranged by a different provider. Echos where the same provider ordered both the initial and follow-up echos were excluded, as discharge summary documentation would be unlikely to have influenced follow-up actions. To quantify the costs associated with performing excessive follow-up echos, we first calculated how many echos each patient should have had during their observation window, based on the guidelines. That number was then subtracted from the actual number of echos they received. Any result that exceeded zero was multiplied by \\u003cspan\\u003e$\\u003c/span\\u003e215.15 (the total reimbursement for technical and professional fees for a standard echo in the 2026 Ontario Health Insurance Plan Schedule of Benefits). Those results were then summed to quantify the total costs incurred for excessive follow-up echos in our cohort.\\u003c/p\\u003e \\u003cp\\u003eFor patients with only a PFO and/or a tiny silent PDA, any subsequent echo performed was considered excessive. For patients with any of the other study lesions, we used the minimum values shown in the third column of Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e to determine the appropriate number of follow-up echos. For example, a patient with a small perimembranous VSD on their initial, first and second follow-up echos, with no further echos and an observation window of 423 days, would appropriately have had one follow-up echo only. (Per Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e, a follow-up echo could have been performed as early as 274 days following the preceding echo to be considered adherent. Two follow-up echos would therefore require an observation window of at least 548 days to avoid one of them being labelled excessive.) Since the patient had two follow-up echos and should have had only one during their observation window, they had one excessive echo.\\u003c/p\\u003e \\u003cp\\u003eIt is important to note that we did not consider adherence status \\u003cem\\u003eper se\\u003c/em\\u003e in the determination of whether a patient had one or more excessive echos. For example, if a patient had a small perimembranous VSD on their initial echo and a subsequent echo after 150 days, the follow-up would have been considered non-adherent. However, if they had no further follow-up echos and an observation window of 423 days, that first follow-up echo would not have been\\u003c/p\\u003e \\u003cp\\u003econsidered excessive.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eA total of 437 charts were assessed for eligibility. Of these, 189 were excluded for the reasons shown in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. The charts for the remaining 248 patients were included. Slightly over half of our study population was male (n\\u0026thinsp;=\\u0026thinsp;133, 53.6%). The median birthweight was 3110 g (IQR: 2332\\u0026ndash;3647), and median gestational age was 38.1 weeks (IQR: 35.9\\u0026ndash;39.1). Initial echos were performed at a median age of 6.0 days (IQR: 2.0\\u0026ndash;19.0).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003csup\\u003e*A patient may have had more than one reason to be excluded, and hence the numbers sum to more than the total number excluded\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eSlightly more than half our cohort (n\\u0026thinsp;=\\u0026thinsp;136, 54.8%) did not receive any follow-up echo during the study period. Ninety-six patients (38.7%) had one follow-up echo and 16 (6.5%) had two follow-up echos. This yielded a total of 376 echos (248 initial and 128 follow-up echos); eight were excluded from all analyses because seven revealed cardiac lesions that were outside the scope of this study, and one showed a PDA where closure was recommended rather than routine surveillance. Adherence status was determinable for 320 echos, while the observation window was too short to determine adherence status for the other 48.\\u003c/p\\u003e \\u003cp\\u003eThe overall rate of non-adherence was 39.7% (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e) and was more prevalent in Group 1 than Group 2 (91.9% versus 12.0%, respectively; OR [95% CI]\\u0026thinsp;=\\u0026thinsp;83.4 [37.5-185.5]). Among the lesions where follow-up imaging is recommended (Group 1), 90 follow-up echos were performed earlier than recommended; 4 later than recommended; and for 8, there was no subsequent follow-up echo, despite the observation window extending to +\\u0026thinsp;25% of the guideline-recommended interval\\u0026rsquo;s upper limit. The presence of more than one study lesion on an echo was associated with higher odds of non-adherence in Group 2 (50.0% vs 8.4%; OR 10.94, 95% CI 3.80\\u0026ndash;31.45) (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eNon-adherence to guideline-recommended follow-up imaging, overall and by lesion type\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003eGuideline-recommended follow-up imaging\\u003c/p\\u003e \\u003cp\\u003en (row %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003eOdds ratio (95% CI) for non-\\u003c/p\\u003e \\u003cp\\u003eadherence,\\u003c/p\\u003e \\u003cp\\u003eGroup 1 vs. Group 2\\u003c/p\\u003e \\u003cp\\u003e(referent)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNon-adherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eAdherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eOverall (n\\u0026thinsp;=\\u0026thinsp;320)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e127 (39.7)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e193 (60.3)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eGroup 1\\u0026nbsp;\\u0026nbsp;(n\\u0026thinsp;=\\u0026thinsp;111)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e102 (91.9)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e9 (8.1)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\" morerows=\\\"6\\\" rowspan=\\\"7\\\"\\u003e \\u003cp\\u003e83.4 (37.5-185.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmall secundum ASD or small muscular VSD\\u0026nbsp;(n\\u0026thinsp;=\\u0026thinsp;95)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e88 (92.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7 (7.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmall\\u0026nbsp;perimembranous\\u0026nbsp;VSD\\u0026nbsp;(n\\u0026thinsp;=\\u0026thinsp;2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2 (100)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmall audible PDA\\u0026nbsp;(n\\u0026thinsp;=\\u0026thinsp;14)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e12 (85.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (14.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eGroup 2\\u0026nbsp;(n\\u0026thinsp;=\\u0026thinsp;209)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e25 (12.0)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e184 (88.0)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePFO or tiny silent PDA\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;147)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e23 (15.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e124 (84.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNormal\\u0026nbsp;(n\\u0026thinsp;=\\u0026thinsp;62)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2 (3.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e60 (96.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003e\\u003csup\\u003eASD: atrial septal defect; CI: confidence interval; PDA: patent ductus arteriosus; PFO: patent foramen ovale; VSD: ventricular septal defect\\u003c/sup\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eLesion load cross-tabulated with adherence status\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eFinding on echo\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003eAdherence to guideline-recommended follow-up imaging\\u003c/p\\u003e \\u003cp\\u003en (row %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eOdds ratio\\u003c/p\\u003e \\u003cp\\u003e(95% CI) for non-adherence, multiple vs. single lesion (referent)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eNon-adherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAdherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eGroup 1 (small secundum ASD, small muscular VSD, small\\u0026nbsp;perimembranous\\u0026nbsp;VSD, small audible PDA)\\u0026nbsp;\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;111)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMultiple lesions\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e60 (92.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e5 (7.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003e1.14 (0.29\\u0026ndash;4.51)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSingle lesion\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e42 (91.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4 (8.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eGroup 2 (sPFO, tiny silent PDA, \\u0026ldquo;normal\\u0026rdquo;)\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;209)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMultiple lesions\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e9 (50.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e9 (50.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003e10.94 (3.80-31.45)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSingle lesion or \\u0026ldquo;normal\\u0026rdquo;\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e16 (8.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e175 (91.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003eASD: atrial septal defect; CI: confidence interval; PDA: patent ductus arteriosus; PFO: patent foramen ovale; VSD: ventricular septal defect\\u003c/sup\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe pediatric cardiologist\\u0026rsquo;s recommendations regarding follow-up imaging were documented for 274 of 368 echos (74.5%). About half of those recommendations aligned with the guidelines (n\\u0026thinsp;=\\u0026thinsp;132/270 [48.9%]; data not shown in tabular format). Four echos were excluded from the denominator for the reasons outlined in the Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e footnote.\\u003c/p\\u003e \\u003cp\\u003ePer Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e, the odds of non-adherence to guideline-recommended follow-up imaging were much higher when the pediatric cardiologist\\u0026rsquo;s recommendations were not documented, or when those recommendations deviated from the guidelines (note that an additional 48 echos were excluded from this table because the observation window was too short to determine adherence status). Guideline adherence in Group 2 exceeded 90% even when no recommendations were documented but was much lower (27.3%) if the documented recommendations deviated from the guidelines.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eAlignment of pediatric cardiologist\\u0026rsquo;s recommendations with guideline-recommended follow-up imaging, cross-tabulated with adherence status\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003ePediatric cardiologist\\u0026rsquo;s recommendations\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003eAdherence to guideline-recommended follow-up imaging\\u003c/p\\u003e \\u003cp\\u003en (row %)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eOdds ratio\\u003c/p\\u003e \\u003cp\\u003e(95% CI) for non-adherence,\\u0026nbsp;combined category of recommendations\\u0026nbsp;not documented/deviated from guidelines\\u0026nbsp;vs.\\u0026nbsp;recommendations aligned\\u0026nbsp;with guidelines\\u0026nbsp;(referent)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eNon-adherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAdherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003eGroup 1 (small secundum ASD, small muscular VSD, small\\u0026nbsp;perimembranous\\u0026nbsp;VSD, small audible PDA)\\u0026nbsp;\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;108)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNot documented\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e14 (82.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3 (17.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e49.0 (4.4-544.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDeviated from guidelines\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e84 (96.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3 (3.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAligned\\u0026nbsp;with guidelines\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1 (25.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e3 (75.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003eGroup 2 (PFO, tiny silent PDA, \\u0026ldquo;normal\\u0026rdquo;)\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;208)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNot documented\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6 (8.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e65 (91.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003e17.5 (4.0-76.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDeviated from guidelines\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e16 (72.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e6 (27.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAligned\\u0026nbsp;with guidelines\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (1.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e113 (98.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003eASD: atrial septal defect; CI: confidence interval; PDA: patent ductus arteriosus; PFO: patent foramen ovale; VSD: ventricular septal defect\\u003c/sup\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e\\u003csup\\u003e ** Alignment of the pediatric cardiologists\\u0026rsquo; recommendations with guideline\\u0026minus;recommended follow\\u0026minus;up imaging could not be assessed for three initial echos (clinic visit only was recommended [n=1] or clinic visit with follow\\u0026minus;up echo was recommended but the timeline for follow\\u0026minus;up was missing [n=2]). Alignment could not be assessed for one follow\\u0026minus;up echo because clinic follow\\u0026minus;up for hypertension, rather than the cardiac lesion, was recommended\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eAdherence was high in all the non-cardiologist provider groups when the pediatric cardiologist\\u0026rsquo;s recommendations aligned with the guidelines for follow-up imaging, reaching 90\\u0026ndash;100% in all provider groups (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab5\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e). Conversely, it was markedly lower when recommendations deviated deviated from guidelines, with an adherence of 20% or less among all provider groups. When no recommendation was documented, adherence remained high, ranging from 70% to 100% across providers.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab5\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 5\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eAdherence to guideline-recommended follow-up imaging among referring provider groups, cross-tabulated with alignment of pediatric cardiologist\\u0026rsquo;s recommendations with guidelines\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eReferring provider*\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c4\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003eAlignment\\u0026nbsp;of pediatric cardiologist\\u0026rsquo;s recommendations\\u0026nbsp;with\\u0026nbsp;guidelines for follow-up imaging\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eOverall\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAligned with guidelines\\u003c/p\\u003e \\u003cp\\u003en (column\\u0026nbsp;%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eDeviated from guidelines\\u003c/p\\u003e \\u003cp\\u003en (column\\u0026nbsp;%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eRecommendation not documented\\u003c/p\\u003e \\u003cp\\u003en (column\\u0026nbsp;%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003en\\u0026nbsp;(column\\u0026nbsp;%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNeonatologist\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAdherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e58 (100)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2 (5.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e29 (85.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e89 (70.1)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNon-adherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e33 (94.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e5 (14.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e38 (29.9)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003ePediatrician or subspecialist at KHSC\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAdherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e19 (90.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11 (73.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e30 (63.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNon-adherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2 (9.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e11 (100.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e4 (26.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e17 (36.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMidwife or nurse practitioner at KHSC\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAdherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4 (100)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (100.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e6 (60.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNon-adherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e4 (100.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e4 (40.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eFamily doctor, or midwife or\\u0026nbsp;pediatrician external to KHSC\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAdherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e15 (93.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5 (20.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e20 (71.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e40 (58.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNon-adherent\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 (6.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e20 (80.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e8 (28.6)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e29 (42.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"5\\\"\\u003e\\u003csup\\u003eKHSC: Kingston Health Sciences Centre\\u003c/sup\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003csup\\u003e*Referring provider for echo if no further follow\\u0026minus;up imaging performed during study period; otherwise, referring provider for follow\\u0026minus;up echo. Analysis excludes echos ordered by pediatric cardiologist\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003e The subgroup analysis included 56 echos performed in an inpatient setting where the pediatric cardiologist\\u0026rsquo;s recommendations aligned with the guidelines and where the findings revealed a Group 2 lesion (n\\u0026thinsp;=\\u0026thinsp;53) or a Group 1 lesion where the follow-up echo was arranged by a different provider (n\\u0026thinsp;=\\u0026thinsp;3). The pediatric cardiologist\\u0026rsquo;s recommendation was documented in 35 discharge summaries (62.5%). Adherence status could not be determined for one echo. Among the remaining 55, only one follow-up echo (Group 1, pediatric cardiologist\\u0026rsquo;s recommendation documented in discharge summary) was non-adherent.\\u003c/p\\u003e \\u003cp\\u003eFifty-four patients had one excessive echo during the study period and four patients had two excessive echos. Based on an estimated cost of \\u003cspan\\u003e$\\u003c/span\\u003e215.15 per echo according to the Ontario Health Insurance Plan Schedule of Benefits, these 62 echos resulted in excess costs of \\u003cspan\\u003e$\\u003c/span\\u003e13,339.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003e In this single-center retrospective study, the follow-up for 40% of echos was non-adherent to guideline recommendations for surveillance imaging. Non-adherence was substantially higher for lesions requiring surveillance imaging according to the guidelines (Group 1: small secundum ASD, small muscular or perimembranous VSD, and small audible PDA) as compared to lesions where follow-up imaging is not recommended (Group 2: PFO and tiny silent PDA, or normal findings).\\u003c/p\\u003e \\u003cp\\u003e The pediatric cardiologist\\u0026rsquo;s follow-up recommendation was documented for three-quarters of echos, and approximately half of those documented recommendations aligned with the guidelines. For Group 2 lesions, non-adherence remained low (\\u0026lt;\\u0026thinsp;10%) even when no follow-up recommendation was documented, likely reflecting the widespread recognition among referring providers that findings such as a PFO or tiny silent PDA do not require routine follow-up imaging. However, non-adherence increased substantially in this group to more than 70% when the cardiologist\\u0026rsquo;s recommendation was not aligned with the guidelines, suggesting that referring providers tend to adopt follow-up practices advised by pediatric cardiologists even when they differ from the guidelines.In contrast, non-adherence was higher (\\u0026gt;\\u0026thinsp;80%) for Group 1 lesions when no follow-up recommendation was documented. In the absence of clear recommendations, referring providers may be uncertain about the appropriate timing for follow-up echos, making these cases more prone to variation and deviation from guideline-recommended practice.\\u003c/p\\u003e \\u003cp\\u003eThe higher rate of non-adherence for Group 1 lesions was largely driven by earlier-than-recommended follow-up echos. Several factors may explain this finding. Clinicians may prefer earlier reassessment of septal defects or PDAs because of concerns about lesion progression or parental anxiety. In addition, clinicians may rely on historical follow-up practices that predate the publication of the 2020 AHA/ACC guidelines [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eOur findings are consistent with previous studies demonstrating considerable variation in follow-up practices for simple CHDs. A survey of pediatric cardiologists that asked about their follow-up recommendations for presumed cases of non-emergent echocardiographic findings in asymptomatic newborns reported substantial variability among providers [8]. Similarly, a study of newborns diagnosed with ASD, VSD, and PDA have shown that repeat echos are frequently performed earlier than recommended, without clear evidence of clinical benefit [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003e When cardiologists\\u0026rsquo; recommendations aligned with the guidelines, non-adherence was low across all referring provider groups, ranging from 0 to 10%. In contrast, when cardiologists\\u0026rsquo; reccomendations deviated from the guidelines, non-adherence increased markedly to 80% or more among most provider groups. Notably, in approximately 20% of cases\\u0026mdash;when the referring provider was a family physician, midwife, or pediatrician external to KHSC\\u0026mdash;the cardiologist\\u0026rsquo;s recommendation was not followed and the follow-up was adherent. Another notable finding was the greater likelihood of non-adherence when two or more Group 2 lesions\\u003c/p\\u003e \\u003cp\\u003ewere identified on an echo. The presence of multiple minor findings may drive clinician uncertainty and contribute to more conservative follow-up strategies, even if each lesion individually would not warrant routine follow-up imaging.\\u003c/p\\u003e \\u003cp\\u003eNon-adherence remained low in the inpatient subgroup regardless of whether the pediatric cardiologists\\u0026rsquo; recommendations were documented in the discharge summary. Most of the echos included in this analysis revealed Group 2 lesions, which are widely recognized among providers as not requiring routine follow-up imaging [\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]; accordingly, practice may have remained guideline-aligned even without explicit documentation.\\u003c/p\\u003e \\u003cp\\u003eSixty-two echos were classified as \\u0026ldquo;excessive,\\u0026rdquo; corresponding to \\u003cspan\\u003e$\\u003c/span\\u003e13,339 in imaging costs over the study period. Although the cost of an individual echo is modest, over time the cumulative burden of excessive echos can meaningfully impact healthcare expenditures. Improved adherence to guideline-based follow-up recommendations would contribute to more efficient resource utilization, particularly in publicly funded healthcare systems such as Canada\\u0026rsquo;s. It would also lessen the indirect burden on families caused by the need for additional appointments, travel, and emotional strain [\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003e Our findings highlight several practical opportunities to improve adherence to guideline-recommended follow-up imaging. First, there should be consistent documentation of follow-up recommendations, including a section that notes whether follow-up imaging is required and, if so, within what time interval. Second, visual aids or point-of-care reference tools for pediatric cardiologists may improve alignment with guideline-recommended follow-up intervals at the time of reporting the echos. Finally, targeted quality improvement initiatives and educational efforts directed toward pediatric cardiologists and referring providers may promote alignment of follow-up practices and reduce variation in care. These strategies could reduce unnecessary costs to the healthcare system caused by excessive imaging.\\u003c/p\\u003e \\u003cp\\u003e To our knowledge, this is the first Canadian study to evaluate adherence to guideline-recommended follow-up imaging in neonates with simple CHDs. However, several limitations should be considered. First, we analyzed data from one center with a small pediatric cardiology division, which may limit the generalizability of our findings to other institutions with different patient populations or practice patterns. Second, although the AHA/ACC guidelines reccomendations were used as the reference standard, clinical considerations not captured in the medical record may have influenced follow-up decisions in individual cases. Third, while we explored factors that may contribute to non-adherence, our study was not designed to test hypotheses with the use of \\u003cem\\u003ea priori\\u003c/em\\u003e sample size calculations and adequate control for confounding. Finally, the cost calculations for excessive echos are based only on provincial reimbursement rates and do not capture the full costs to the healthcare system and to families associated with excessive imaging.\\u003c/p\\u003e \\u003cp\\u003e The high rate of non-adherence to guideline-recommended follow-up echocardiography for simple CHDs diagnosed in neonates highlights an opportunity to avoid excessive imaging and to reduce healthcare costs. Consistent documentation of cardiology follow-up recommendations and targeted strategies to improve their alignment with guidelines are needed to promote more cost-effective care.\\u003c/p\\u003e \"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eFunding declarations\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was funded by an operating grant from the 2025 CTAQ (Clinical Teachers\\u0026apos; Association of Queen\\u0026apos;s University) Research Endowment Fund. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.\\u003c/p\\u003e\\n\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eFenster ME, Hokanson JS (2018) Heart murmurs and echocardiography findings in the normal newborn nursery. Congenit Heart Dis 13:771-775. https://doi.org/10.1111/chd.12651\\u003c/li\\u003e\\n\\u003cli\\u003eYildirim A, Aydin A, Demir T, Aydin F, Ucar B, Kilic Z (2016) Echocardiographic follow-up of patent foramen ovale and the factors affecting spontaneous closure. Acta Cardiol Sin 32:731-737. https://doi.org/10.6515/acs20160205a\\u003c/li\\u003e\\n\\u003cli\\u003eConnuck D, Sun JP, Super DM et al (2002) Incidence of patent ductus arteriosus and patent foramen ovale in normal infants. Am J Cardiol 89:244-247. https://doi.org/10.1016/s0002-9149(01)02214-7\\u003c/li\\u003e\\n\\u003cli\\u003eRadzik D, Davignon A, Van Doesburg N, Fournier A, Marchand T, Ducharme GR (1993) Predictive factors for spontaneous closure of atrial septal defects diagnosed in the first 3 months of life. J Am Coll Cardiol 22:851-853. https://doi.org/10.1016/0735-1097(93)90202-c\\u003c/li\\u003e\\n\\u003cli\\u003eZhao Q, Niu C, Liu F, Wu L, Ma X, Huang G (2019) Spontaneous closure rates of ventricular septal defects (6,750 consecutive neonates). Am J Cardiol 124:613-617. https://doi.org/10.1016/j.amjcard.2019.05.022\\u003c/li\\u003e\\n\\u003cli\\u003eNielsen MR, Aldenryd AE, Hagstr\\u0026oslash;m S, Pedersen LM, Brix N (2022) The chance of spontaneous patent ductus arteriosus closure in preterm infants born before 32 weeks of gestation is high and continues to increase until 5 years of follow-up. Acta Paediatr 111:2322-2330. https://doi.org/10.1111/apa.16541\\u003c/li\\u003e\\n\\u003cli\\u003eSachdeva R, Valente AM, Armstrong AK, Cook SC, Han BK, Lopez L et al (2020) ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 \\u003c/li\\u003e\\n\\u003cli\\u003eWi8. Hokanson JS, Ring K, Zhang X (2022) A survey of pediatric cardiologists regarding non-emergent echocardiographic findings in asymptomatic newborns. Pediatr Cardiol 43:837-843. https://doi.org/10.1007/s00246-021-02795-8\\u003c/li\\u003e\\n\\u003cli\\u003eFaultersack J, Johnstad C, Zhang X, Greco M, Hokanson J (2024) Follow-up of secundum ASD, muscular VSD, or PDA diagnosed during newborn hospitalization. Res Sq. https://doi.org/10.21203/rs.3.rs-3871102/v1\\u003c/li\\u003e\\n\\u003cli\\u003eZiebell DS, Ghaleb S, Anderson J, Statile CJ (2020) Resource utilisation in paediatric patients with secundum atrial septal defects. Cardiol Young 30:383-387. https://doi.org/10.1017/s104795112000013x\\u003c/li\\u003e\\n\\u003cli\\u003eSaharan S et al (2022) Patent foramen ovale in children: unique pediatric challenges and lessons learned from adult literature. Ann Pediatr Cardiol 15:44-52\\u003c/li\\u003e\\n\\u003cli\\u003eLawoko S, Soares JJ (2002) Distress and hopelessness among parents of children with congenital heart disease, parents of children with other diseases, and parents of healthy children. J Psychosom Res 52:193-208\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"pediatric-cardiology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"pedc\",\"sideBox\":\"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)\",\"snPcode\":\"246\",\"submissionUrl\":\"https://submission.nature.com/new-submission/246/3\",\"title\":\"Pediatric Cardiology\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"Simple congenital heart disease, neonatal echo, follow-up imaging, guideline adherence, healthcare costs \",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9580129/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9580129/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eSimple congenital heart defects (CHDs) are frequently identified via neonatal echocardiograms (\\u0026ldquo;echos\\u0026rdquo;). In 2020, the American Heart Association/American College of Cardiology issued guidelines for follow-up imaging of CHDs. In this retrospective study, we evaluated adherence to these guidelines at an academic health center in Southeastern Ontario. The cohort included neonates who had one or more simple CHDs diagnosed in the first 30 days of life between April 1, 2020, and March 31, 2024. We reviewed electronic medical records up to September 30, 2025 to examine a) rates of non-adherence to guideline-recommended follow-up imaging; b) factors that may contribute to non-adherence; and the costs of excessive imaging. Among 248 patients, 376 echos were performed over the study period; adherence status could be determined for 320. Follow-up for 39.7% of echos did not adhere to the guidelines, primarily because repeat echos were performed earlier than recommended. Non-adherence was substantially higher for lesions requiring surveillance imaging, as per guidelines, compared with lesions where follow-up imaging is not recommended or findings were normal (91.9% vs. 12.0%; OR\\u0026thinsp;=\\u0026thinsp;83.4, 95% CI: 37.5-185.5). Pediatric cardiologist\\u0026rsquo;s recommendation was documented for 74.5% of echos, but only 48.9% of recommendations aligned with the guidelines. Non-adherence was higher when recommendations were not documented or deviated from the guidelines. Sixty-two echos were deemed excessive, corresponding to \\u003cspan\\u003e$\\u003c/span\\u003e13,339 in extra imaging costs. The high rate of non-adherence to guideline-recommended follow-up imaging for simple CHDs highlights an opportunity to reduce unnecessary healthcare costs though consistent documentation of guideline-aligned follow-up recommendations by pediatric cardiologists.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Are we adhering to guidelines for follow-up imaging in neonates with simple congenital heart defects? 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