Sports Medicine Research: In the Lab & In the Field: What is the Cost of Electrocardiographic Screening in Athletes? (Sports Med Res)
Wednesday, January 2, 2013

What is the Cost of Electrocardiographic Screening in Athletes?

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


Anonymous said...

I question the estimated costs of the ECG's. Sure, if all patients were to go to a hospital for screening then maybe? However, in the USA a majority of athletes needing this screening would probably be college aged students and being so would most likely be screened during their Pre-participatory Examination (PPE). If an institution is astute enough to weigh the benefits and purchase an ECG/EKG machine then they could potentially save lives.
Taking an ECG reading is quick, easy and painless. They can identify cardiac abnormalities, or at least justify the need for further studies.
With portable echocardiograms more readily available, providing both at a PPE should not be out of the question as well. Echo's however, would pose the need for a qualified sonographer and cardiologist or physician trained in interpreting such data. I can see how this may be difficult for smaller institutions.
In any case, I believe that obtaining ECG's on all collegiate level student athletes is both feasible and morally necessary (I'm sure if could be done at the high school level as well). But, I'm an idealist and feel that potentially saving one life offsets the costs. I'm sure many institutions (along with their legal council) may disagree.
I've worked in and know of other institutions that provide both ECG and Echos at their PPE. I'm not going to say that they've identified "many" conditions that have medically disqualified individuals but they have caught a few and arguably saved families a lot of anguish.

Anyway, these are just my personal thoughts on the matter.

Hallie Labrador said...

The ECG cost estimate used in this paper was the medicare reimbursement rate for the procedure. Depending on whether or not interpretation of the reading was factored in, this is between $10-$20. This does not reflect the amount billed for the procedure, nor does in include any fees associated with a physician's visit to have the test done. This is the absolute minimum cost to do the test. The estimate used in the paper probably low-balls the actual cost.

While it would be nice to have schools absorb some of the cost by purchasing their own machines and running the tests - this is not very realistic in terms of how the current healthcare system works. Most of the 8.5 million athlete/ year who need screening are in high school. Most high schools do not do their own PPEs. Very few high schools and even colleges have the resources necessary to do the type of screening you mention. In addition, having the ECG done is just a small part of the equation. The biggest concern is reading them. If a school is able to perform the ECGs, who is going to interpret them? Even in the best of hands, the changes concerning for SCD risk are subtle on ECG and can be missed:(

Anonymous said...

High schools should start using newer technology such as the ECG iphone app or the heartcheck pen handheld ecg device. These devices are a fraction of the cost of larger ecg machines found in hospitals and can be used by school staff to screen students reducing costs significantly. With the heartcheck pen, school staff can transmit ECG readings to a physician using any PC with an internet connection.

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