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

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