Preventing Sudden Death of Athletes With Electrocardiographic Screening: What Is the Absolute Benefit and How Much Will it Cost?
Halkin A, Steinvil A, Rosso R, Adler A, Rozovski U, Viskin S. J Am Coll Cardiol. 2012 6:22, 2271-6.
Electrocardiographic (ECG) screening of young athletes in order to prevent sudden cardiac death (SCD) is a hotly debated topic. The European Society of Cardiology has recommended universal screening, while the American Heart Association has not made such recommendations. In this study, the researchers use a financial model to predict the cost associated with implementing a screening process in the United States. They used data provided by the National Collegiate Athletic Association and the National Federation of State High School Associations to estimate the screenable population. They then used the rates identified in the keystone Italian study by Corrado, et al. to determine the incidence of abnormal ECGs, further testing required, and ultimate athletic disqualification. The Corrado study is the study on which the European Society of Cardiology’s guidelines are based as it demonstrated a significant reduction in SCD in the screened athletic population. A cost-prediction model for the United States was calculated by using current Medicare reimbursement rates, and the model predictions were carried through 20 years of screening. This study estimated that there would be 8.5 million athletes eligible for screening each year. Per the Corrado data, 91% would screen negative and 2% would be disqualified after further testing involving echocardiography for all; exercise testing for 82%; Holter monitoring for 41% and magnetic resonance imaging, catheterization or electrophysiologic studies for 5%. Seven percent would have abnormal ECG and ultimately be allowed to compete after undergoing additional testing consisting of echocardiography for all; exercise testing for 19%; Holter monitors for 5% and magnetic resonance imaging, catheterization and/or electrophysiologic studies in 1%. The estimated cost for this screening would be between $2.5 and $3.4 billion per year. The total number of lives saved over 20 years of screening is estimated to be 4,813 lives, at a cost per live saved of between $10.6 and $14.4 million.
This study is important because it clearly explains one of the most important limitations to an ECG-based screening process – it would be incredibly expensive. It also probably over-estimates the benefit and underestimates the cost. The incidence of SCD in Italy, as identified by the Corrado paper, is much higher than in the U.S. This is probably due to a genetic predisposition to arrhythmogenic right ventricular cardiomyopathy - a predictor of SCD, in Veneto, the particular region of Italy where the study was done. It is important to note that the incidence of SCD in the U.S. without any screening program is actually closer to the low rate seen in Italy after 20 years of screening (0.4 per 100,000) rather than the number used in the cost-analysis (4 per 100,000). It is also unclear from the study whether the researchers used the medicare reimbursement cost of the tests themselves or if they also included the cost of a clinician visit and interpretation of the test, which is often an additional fee and may be higher if a specialist is needed. Both of these factors would alter the risk: benefit ratio. This study does not take into account the many other issues surrounding ECG screening which have been discussed previously on this blog including the fact that pre-participation ECGs may be difficult to interpret, false positive screens are common and the psychological effect of athletics disqualification may be profound. It simply looks at the numbers. Of course it is difficult to put a price tag on a young life, but at what point does it become too much? Wouldn’t a program consisting of widespread CPR training and increasingly available AEDs at an estimated cost of $1.5 to $3.3 million per life saved work better?
Written by: Hallie Labrador MD, MS
Reviewed by: Stephen Thomas
Related Posts:Halkin A, Steinvil A, Rosso R, Adler A, Rozovski U, & Viskin S (2012). Preventing Sudden Death of Athletes With Electrocardiographic Screening: What Is the Absolute Benefit and How Much Will it Cost? Journal of the American College of Cardiology, 60 (22), 2271-6 PMID: 23194938