{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,4]],"date-time":"2026-11-04T01:25:16Z","timestamp":1793755516028,"version":"4.6.1"},"reference-count":20,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2022,3,22]],"date-time":"2022-03-22T00:00:00Z","timestamp":1647907200000},"content-version":"unspecified","delay-in-days":21,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000968","name":"American Heart Association","doi-asserted-by":"publisher","award":["17SFRN33670607"],"award-info":[{"award-number":["17SFRN33670607"]}],"id":[{"id":"10.13039\/100000968","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2022,1,28]]},"published-print":{"date-parts":[[2022,3]]},"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To determine the ability to accurately diagnose acute rheumatic fever (ARF) given the resources available at three levels of the Ugandan healthcare system.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Using data obtained from a large epidemiological database on ARF conducted in three districts of Uganda, we selected variables that might positively or negatively predict rheumatic fever based on diagnostic capacity at three levels\/tiers of the Ugandan healthcare system. Variables were put into three statistical models that were built sequentially. Multiple logistic regression was used to estimate ORs and 95% CI of predictors of ARF. Performance of the models was determined using Akaike information criterion, adjusted R2, concordance C statistic, Brier score and adequacy index.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>A model with clinical predictor variables available at a lower-level health centre (tier 1) predicted ARF with an optimism corrected area under the curve (AUC) (c-statistic) of 0.69. Adding tests available at the district level (tier 2, ECG, complete blood count and malaria testing) increased the AUC to 0.76. A model that additionally included diagnostic tests available at the national referral hospital (tier 3, echocardiography, anti-streptolysin O titres, erythrocyte sedimentation rate\/C-reactive protein) had the best performance with an AUC of 0.91.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Reducing the burden of rheumatic heart disease in low and middle-income countries requires overcoming challenges of ARF diagnosis. Ensuring that possible cases can be evaluated using electrocardiography and relatively simple blood tests will improve diagnostic accuracy somewhat, but access to echocardiography and tests to confirm recent streptococcal infection will have the greatest impact.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2021-050478","type":"journal-article","created":{"date-parts":[[2022,3,22]],"date-time":"2022-03-22T11:55:20Z","timestamp":1647950120000},"page":"e050478","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":15,"title":["Modelling study of the ability to diagnose acute rheumatic fever at different levels of the Ugandan healthcare system"],"prefix":"10.1136","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6853-4787","authenticated-orcid":false,"given":"Emma","family":"Ndagire","sequence":"first","affiliation":[{"name":"Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas","family":"Ollberding","sequence":"additional","affiliation":[{"name":"Division of Biostatistics and Epidemiology, Cincinnati Children\u2019s Hospital Medical Center, Cincinnati, Ohio, USA"},{"name":"Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rachel","family":"Sarnacki","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Children\u2019s National Hospital, Washington, DC, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Murali","family":"Meghna","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Children\u2019s National Hospital, Washington, DC, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7955-3481","authenticated-orcid":false,"given":"Jafesi","family":"Pulle","sequence":"additional","affiliation":[{"name":"Department of RHD Research, Uganda Heart Institute, Kampala, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jenifer","family":"Atala","sequence":"additional","affiliation":[{"name":"Department of RHD Research, Uganda Heart Institute, Kampala, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Collins","family":"Agaba","sequence":"additional","affiliation":[{"name":"Department of RHD Research, Uganda Heart Institute, Kampala, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosemary","family":"Kansiime","sequence":"additional","affiliation":[{"name":"Department of RHD Research, Uganda Heart Institute, Kampala, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Asha","family":"Bowen","sequence":"additional","affiliation":[{"name":"Telethon Kids Institute, Perth, Western Australia, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chris T","family":"Longenecker","sequence":"additional","affiliation":[{"name":"Case Western Reserve University, Cleveland, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Linda","family":"Oyella","sequence":"additional","affiliation":[{"name":"Department of RHD Research, Uganda Heart Institute, Kampala, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joselyn","family":"Rwebembera","sequence":"additional","affiliation":[{"name":"Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emmy","family":"Okello","sequence":"additional","affiliation":[{"name":"Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tom","family":"Parks","sequence":"additional","affiliation":[{"name":"London School of Hygiene & Tropical Medicine, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huaiyu","family":"Zang","sequence":"additional","affiliation":[{"name":"Division of Cardiology, The Heart Institute, Cincinnati Children\u2019s Medical Center, Cincinnati, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan","family":"Carapetis","sequence":"additional","affiliation":[{"name":"Telethon Kids Institute, Perth, Western Australia, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Craig","family":"Sable","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Children\u2019s National Hospital, Washington, DC, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea Z","family":"Beaton","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio, USA"},{"name":"Division of Cardiology, The Heart Institute, Cincinnati Children\u2019s Medical Center, Cincinnati, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2022,3,22]]},"reference":[{"key":"2025101814345122000_12.3.e050478.1","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/S0140-6736(05)66874-2","article-title":"Acute rheumatic fever","volume":"366","author":"Carapetis","year":"2005","journal-title":"The Lancet"},{"key":"2025101814345122000_12.3.e050478.2","doi-asserted-by":"crossref","first-page":"713","DOI":"10.1056\/NEJMoa1603693","article-title":"Global, regional, and national burden of rheumatic heart disease, 1990\u20132015","volume":"377","author":"Watkins","year":"2017","journal-title":"N Engl J Med Overseas 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Health systems strengthening for prevention of rheumatic heart disease in Zambia: a novel clinic-based curriculum to help advance knowledge and skills of health workers 2018.","DOI":"10.1542\/peds.142.1MA6.511"},{"key":"2025101814345122000_12.3.e050478.19","first-page":"63","article-title":"Awareness about sore-throat, rheumatic fever and rheumatic heart disease in a rural community","volume":"36","author":"Arya","year":"1992","journal-title":"Indian J Public Health"},{"key":"2025101814345122000_12.3.e050478.20","doi-asserted-by":"crossref","DOI":"10.1093\/eurheartj\/ehy764","article-title":"Who resolution on rheumatic heart disease","volume":"39","author":"White","year":"2018","journal-title":"Eur Heart J"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2021-050478","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,18]],"date-time":"2025-10-18T21:35:00Z","timestamp":1760823300000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2021-050478"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,3]]},"references-count":20,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2022,3,22]]},"published-print":{"date-parts":[[2022,3]]}},"alternative-id":["10.1136\/bmjopen-2021-050478"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2021-050478","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,3]]}}}