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PHN Z Score Photo with spacer-01.jpgPediatric Heart Network (PHN) and Carelon Research researchers develop ‘Z Score’ calculator for assessment of pediatric cardiovascular diseases 


Varying scoring systems used for measuring pediatric heart development make it difficult to evaluate and treat children with genetic and acquired heart diseases. A Z-score by PHN and Carelon Research (formerly HealthCore) can help set the average straight and help clinicians understand the effects of factors such as age, sex, race, and ethnicity on heart measurements.

Enterprise Analytics Core domain(s): Quality of care

Summary

Background

The ability to measure the heart is crucial for evaluating and treating children with genetic and acquired heart diseases. Clinicians use the Z-score, a scoring system for measuring pediatric heart development, to determine how far above or below the cardiac structure is from the mean, or “average.”

The existence of a wide range of Z-scores for a single measurement has made it difficult for clinicians to determine a consistent or reliable average for different aspects of the heart. In addition, there is limited data on the effects of age, sex, race, and ethnicity on heart measurements.

Objective

Past studies did not use a large enough sample size to adequately show how effects of age, sex, race, and ethnicity might impact echocardiographic measurements. This means that existing Z-score calculators may produce several different results for the same measurements in the same patient, making it difficult for clinicians to decide which Z-score calculator to use. The goal of this multicenter retrospective chart review study was to determine Z-scores for common measurements adjusted for body surface area (BSA) and stratified by age, sex, race, and ethnicity.

Method

Data collected from 3,566 healthy nonobese children ≤18 years of age at 19 centers with a normal echocardiogram included age, sex, race, ethnicity, height, weight, echocardiographic images, and measurements. BSA values were utilized and transformed in building the Z-score models. Raw measurements from models with and without these effects were compared, and a >5% difference was considered clinically significant to account for the effects of age, sex, race, and ethnicity.


Results

Statistical analyses showed that there were some differences in cardioechographic measurements when compared by age, sex, race, and ethnicity, but body surface area had the greatest impact on Z-scores.

Key takeaways

  • The Echo Z-Score study established a large normative database that showed that age, sex, and race did not have a clinically significant effect on the relationship between the sizes of cardiovascular structures and body size, but that body surface area is a good measure to evaluate the effect of body size on the sizes of cardiovascular structures.
  • This database has made it possible for PHN investigators to compare previously published Z-Score models, emphasizing that systematic differences among Z-scores should be considered in clinical decisions.
  • Z-scores are an easily determined, important part of clinical decision making and being able to track serial echocardiographic measurements as children grow may prevent inappropriate or premature escalation of care, as well as detect critical and abnormal changes in heart structure. Access to a validated, free Z-score calculator simplifies this process.


Publications

Lopez L, Colan S, Stylianou M, et al. Relationship of Echocardiographic Z Scores Adjusted for Body Surface Area to Age, Sex, Race, and Ethnicity: The Pediatric Heart Network Normal Echocardiogram Database. Circ Cardiovasc Imaging. 2017;10(11):e006979.

Truong D, Lopez L, Frommelt PC, et al. Challenges and lessons learned from the Pediatric Heart Network Normal Echocardiogram Database study. Cardiol Young. 2020;30(4):456-461.

Lopez L, Frommelt PC, Colan SD, et al. Pediatric Heart Network Echocardiographic Z Scores: Comparison with Other Published Models J Am Soc Echocardiogr. 2021;34(2):185-192.

Pediatric Heart Network Z-Score Calculator


Carelon Research project team: Felicia Trachtenberg, Julie Miller



For more information on a specific study or to connect with the Actionable Insights Committee, contact us at [email protected].

This study conducted by the Pediatric Heart Network (PHN) and Carelon Research (formerly HealthCore), serving as the Data Coordinating Center for the PHN, and was funded by the National Heart, Lung, and Blood Institute (NHLBI). The PHN is a multi-center consortium of major pediatric cardiovascular academic centers in the U.S. and Toronto, Canada, which has been conducting cardiovascular disease studies in children since 2001.

Dissemination and sharing of the Newsletter is limited to Elevance Health and its subsidiaries and included findings and implications are for Elevance Health and its affiliates’ internal use only.

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