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Mandatory ECG screening of US athletes associated with high costs
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A national electrocardiographic screening program of young competitive athletes in the United States would cost between $51 billion and $69 billion and could potentially save 4,813 lives over 20 years, researchers reported in the Journal of the American College of Cardiology.
Moreover, the cost per life saved is expected to range from $10.6 million to $14.4 million, according to new estimates.
For the study, Amir Halkin, MD, of the department of cardiology at Tel-Aviv Medical-Center, Israel, and colleagues established a cost-projection model based on a previous observational study conducted in 2006 in Italy that showed mandatory ECG screening of athletes led to an 89% relative risk reduction in sudden cardiac death during a 20-year period. Their goal was to estimate the number of athletes who would need to undergo screening if it were required in the United States, compute the costs and determine the number of lives that could be saved. The number of athletes eligible for screening was estimated from data provided by the National Collegiate Athletic Association and the National Federation of State High School Associations; diagnostic test costs were determined from Medicare reimbursement rates.
“Our cost-projection model suggests that replicating the Italian strategy of ECG screening in the United States would result in enormous costs per life saved,” the researchers concluded.
Worldwide controversy
The issue of mandatory ECG screening of athletes has been widely debated among experts in sports cardiology. Based on results of the 2006 Italian study, the European Society of Cardiology recommends mandatory ECG screening of all competitive athletes, whereas the American Heart Association recommends a physical examination and family history questionnaire as first-line screening with further examination based on results of those initial assessments, according to a press release issued by the American College of Cardiology.
“While this research focuses on the monetary costs of mandatory ECG screening, it is important to consider the human costs of false positives, which can result in additional, potentially unnecessary tests and removal from play of athletes who are not actually at risk. Most in this discussion agree that physicals, thorough training in CPR and availability of automated external defibrillators save lives from sudden cardiac arrest.
William Zoghbi
“Based on [the data from Halkin et al] … 8.5 million athletes would undergo annual ECG screening over 20 years, with 2% ultimately disqualified as a result of follow-up screenings each year. That equates to 170 million screening tests and 3.4 million disqualifications over 2 decades,” William Zoghbi, MD, FACC, president of the ACC, stated in the release.
Preventive screening debated
In a related commentary published in JACC, Antonio Pelliccia, MD, of the Institute of Sport Medicine and Science, Rome, said the new study overestimates costs because the screenings are part of a preventive program that targets young people who are healthy, is conducted outside of hospitals and is performed by a team of physicians who are not cardiologists.
“We acknowledge that reimbursement of pre-participation screening as a preventive medicine program does not currently exist in the Medicare system, and this represents a major obstacle, in our opinion, to implementation of the ECG-based pre-participation screening. Legitimacy for pre-participation screening reimbursement with Medicare, however, will require a change in the cultural attitude and current medical policy in the United States, where preventive medicine programs are unlikely to be federally supported. Therefore, we acknowledge that most of the alleged obstacles to implementing ECG-based pre-participation screening reflect the cultural and social differences existing between our societies rather than being rooted in economic reasons,” Pelliccia wrote.
Other obstacles cited in the editorial include legal consequences related to misinterpretation of an ECG and lack of knowledge of the sports cardiology profession.
According to Pelliccia, in Italy, where ECG screening is mandatory for athletes, the cost is about $60 per person, including history, physical and 12-lead ECG.
For more information:
Halkin A. J Am Coll Cardiol. 2012;60:2271-2276.
Pelliccia A. J Am Coll Cardiol. 2012;60:2277-2279.
Disclosure: Halkin and colleagues and Pelliccia report no relevant financial disclosures. Zoghbi is president of the ACC.
Perspective
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Joseph Marek, MD
The study by Halkin et al is an elegant, economic analysis of ECG screening of young athletes. Their analysis is based on cost projections.
One should keep in mind that there is a vast difference between financial projections and real-world costs. Anyone who has had a sad investing experience knows that financial projections are often far off the mark. That is because the assumptions made often deviate from real-world experience for a variety of reasons. Conclusions also become shakey when assumptions are further based on assumptions, as the researchers did in this study. The take home message is that the “costs” discussed in the article are not real; they are only projections.
Several of the assumptions the authors make are subject to reasonable debate. First is the assumption that a large percentage of ECGs would be abnormal and in need of further costly evaluation. That assumption is based on outdated ECG interpretation standards. In February 2012, Dr. Drezner convened an international summit of sports physicians to develop better standards for interpreting ECGs in athletes. These new standards should result in a much smaller percentage of “abnormal” ECGs and therefore significantly reduce downstream cardiac evaluation costs.
Additionally, estimates for the cost of the tests are based on Medicare reimbursements. This assumption ignores innovation in testing currently being employed around the country that can reduce testing in the future.
Finally, the authors presented their conclusions as a cost per life saved. Consequently, the amount seems astronomical. Typically, however, health care economic analyses are presented as a cost per year life saved. When dealing with young adults who have an additional 50 or more years of life expectancy, the costs of screening spread over that time span would be much less. Just changing these few assumptions can reduce the cost per year life saved to an amount that health care economists consider “cost effective.” Dr. Schoenbaum and colleagues have conducted cost estimates for screening that fall into this acceptable range.
In 2006, we began an ECG screening program for high school students called Young Hearts for Life (YH4L). To date, we’ve performed over 90,000 ECGs, demonstrating that mass screening is not only feasible but can be done for less than $12 per ECG.
Ultimately, I don’t believe that ECG screening should be mandatory. I believe our role as physicians is to inform families of risks and offer available options for evaluation and help them to decide what is best for them. Most parents, if you tell them that $25 or $50 could reduce the chance of their child dying suddenly, would say “yes” to testing.
As in all of life, there is no perfect solution but I believe that evidence is mounting that ECG testing is more efficacious and cost effective than the current approach of pre-participation history and physical exam.
For more information:
Schoenbaum M. Pediatrics. 2012;130:e380-389.
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