The Success of State Newborn Screening Policies for Critical Congenital Heart Disease

Abstract

To the Editor Dr Cifu 1 stated in his Viewpoint that diagnostic calibration is "…the relationship between diagnostic accuracy and physician confidence in that accuracy" and suggested static and dynamic influences determine diagnostic calibration. We agree with Cifu and Meyer et al 2 that the most worthwhile effort in improving diagnostic calibration is receiving regular feedback on diagnostic accuracy.However, we also advocate practicing metacognition and physicians educating themselves on the myriad cognitive biases that affect diagnostic decisions. These strategies promote the self-awareness that we believe is important for achieving appropriately calibrated confidence and diagnostic excellence.Static and dynamic influences determine diagnostic calibration and other factors such as fatigue, ambient conditions, and team dynamics contribute to diagnostic accuracy. Often, these static and dynamic factors lead physicians down an appropriate cognitive pathway or "cognitive disposition to respond" and to provide a correct diagnosis. 3 However, during periods of uncertainty, the summation of numerous static and dynamic factors may promote diagnostic misadventures.Awareness of these factors may be promoted during realtime clinical decision making. For example, by conducting "cognitive and affective autopsies" or a "diagnostic timeout" on rounds, trainees can increase their awareness of static and dynamic factors and review their actual cognitive response. Physicians in practice may find a similar approach helpful by routinely asking themselves the simple question, "What else could this be?" These brief reflections allow learners and practicing clinicians alike to refine their diagnoses in the context of associated dispositions and response. More importantly, they give physicians pause and an opportunity to recognize their level of diagnostic confidence.Cognitive errors or errors in data synthesis or faulty knowledge are purportedly the most common cause of diagnostic error. 4 Cognitive errors often occur as a result of overconfidence and overreliance on intuitive modes of thinking. 5 Using metacognition forces use of more analytical modes of thinking. Coupled with regular feedback on diagnostic performance, awareness of factors that influence decisions may realign clinicians' diagnostic confidence and accuracy. In effect, diagnostic calibration itself may be recalibrated toward diagnostic harmonization.

Characteristics and operative outcomes for children undergoing repair of truncus arteriosus: A contemporary multicenter analysis

“…23 As of 2017, all states except Idaho and Kansas mandate newborn screening for critical congenital heart disease. 24 Data on the adherence to these practices at individual centers, however, are sparse. In one recent report from a center where the practice of routine pulse oximetry screening for congenital heart disease was adopted and then audited, compliance with their protocol was 88%, which is good but not optimal.…”

Newborn Screening for Critical Congenital Heart Disease: Appropriately Evaluating This Public Health Program

“…Newborn screening for CCHD has been a public health success [4]. Yet, as with any program, its impact is expected to vary between centers and states.…”

Challenge in the Treatment of Children with Congenital Heart Disease: Reducing Waiting Time for Cardiac Surgery

“…3,6 The early diagnosis of critical congenital heart disease, performed during prenatal care by fetal echocardiography, and neonatal screening by pulse oximetry have enabled the planning of appropriate treatment, increase in survival in the neonatal period and consequent improvement in the prognosis. 7 However, despite changes in the diagnosis and treatment of congenital heart disease, both prognosis and mortality may vary widely among the countries, due to poor access to healthcare services in developing countries, that show higher mortality rates compared with developed countries. 8 In Brazil, a continental-size country, there is also inequality between its geographic regions, with treatment gaps of nearly 90% in the northern and northeastern regions.…”