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Electrocardiogram screening for young athletes may not be cost-effective
Adding electrocardiogram screening to standard medical practices to reduce the number of sudden cardiac deaths in young athletes is not a cost-effective option for pre-participation evaluations, according to study results.
While most current clinical guidelines recommend that children considering competitive sports be screened with a careful history and physical examination beforehand, some experts advocate the addition of electrocardiograms (ECGs) to the current standard of care.
“Critics of such a strategy cite lack of evidence of effectiveness and feasibility, implications for personnel requirements, cost considerations and the negative impact of false-positive screening results,” the researchers wrote in a recent study in Pediatrics.
Michael Schoenbaum, PhD, of the National Institute of Mental Health, and colleagues conducted a modeled cost-effectiveness analysis of the following three strategies to reduce the number of sudden cardiac deaths in young athletes:
- Strategy 1: Careful history and physical examination; children with potential abnormalities would be referred for pediatric cardiology evaluation (standard care).
- Strategy 2: Careful history and physical examination followed by ECG in children with a negative history and physical examination; children with abnormalities on either test would be referred for definitive cardiology evaluation.
- Strategy 3: Cardiac risk screening based on ECG only; children would still receive a careful history and physical examination but would be referred for cardiology evaluation based solely on abnormal ECG results.
The researchers analyzed the data using a societal perspective, with outcomes measured with the Quality-Adjusted Life-Year (QALY) scale, assuming the societal willingness to pay for medical care was equal to or below $50,000 per QALY.
Compared with the first strategy (standard care), incremental cost-effectiveness is $68,800/QALY for the second strategy and $37,700/QALY for the third strategy. The second strategy had a 30% chance of incremental cost-effectiveness and the third strategy had a 66% chance of incremental cost-effectiveness compared with the first strategy. The second strategy averted 131 additional sudden cardiac deaths at $900,000 per case, and the third strategy averted 127 sudden cardiac deaths at $600,000 per case.
“Current evidence does not support adopting a policy of universal ECG screening of young athletes, in the sense that the outcomes of such a policy do not appear to warrant its costs,” Schoenbaum told Healio.com. “However, patients — or their parents — who have higher willingness to pay than we assume for society overall may reach different conclusions.”
Disclosure: Dr. Schoenbaum reports no relevant financial disclosures.
Perspective
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Sudden cardiac death (SCD) in a young adult is an emotionally staggering event for a family and the community. A National Heart, Lung, and BIood Institute working group recently published in Circulation that this problem is “a critical public health issue.” Efforts to address it via ECG screening of athletes are based on the favorable experience of the Italians. Their approach, however, has been hotly debated in this country and much of the controversy concerns the costs associated with ECG testing.
Dr. Schoenbaum et al. have reported an elegant and detailed economic analysis of three different screening strategies, i.e. the current American Heart Association recommended strategy of a careful history and physical examination alone vs. a careful history and physical examination plus ECG vs. ECG alone. These economic analyses are complicated and can make a clinician’s head spin. They also require multiple assumptions and estimates that are often subject to differences of opinion among experts. Nonetheless, their study supports the belief of many experts in the field that a careful history and physical examination alone as a screening strategy is fraught with too many false positives findings, rendering it impractical economically.
There is still much investigation to be done, however, before we abandon the careful history and physical examination altogether and rely on ECG testing alone to reduce SCD in athletes. This study by Dr. Schoenbaum and colleagues is a significant contribution to further the debate on the best screening strategy for young adults at risk for SCD.
