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Heart Murmurs. If You Allow for Mistakes Costs Are Even Higher!

In Reply.—
 Dr Toews' thoughtful letter highlights an important assumption which we made in our analysis of costs of specific strategies in the evaluation of heart murmurs in children. The presumption is made that echocardiography is performed in a diagnostically definitive fashion so that diagnostic inaccuracies are not encountered in the echocardiography-first strategy. We agree that this presupposes the availability of echocardiographic equipment appropriate for use in infants and children, technical support staff with adequate training and ongoing experience, and experienced pediatric echocardiographers to interpret the images.