Preventing Athlete Deaths with ECG Screening
ECG screening of athletes is endorsed by the European Society of Cardiology, but a recent analysis suggests that replicating the strategy of ECG screening in the United States would result in enormous costs per life saved.
In this corner: we recently talked to a pair of investigators—Sami Viskin, MD, director of the Cardiac Hospitalization Unit at Tel Aviv Medical Center, and Antonio Pelliccia, MD, medical director of the Institute of Sports Medicine, The Italian National Olympic Committee—with very different views on this topic, both of which were featured recently in separate papers in JACC.
Will Cost Analysis Kill Mandatory ECG Testing of Athletes?
Sudden death in an athlete is tragic. It's a somewhat rare event, but certainly high profile when it happens. What about screening? Dr. Viskin, you coauthored the paper "Preventing Sudden Death of Athletes with ECG Screening: What is the Absolute Benefit and What is the Cost?" Let's talk about this article in JACC: what did you find?
Sami Viskin, MD: The whole recommendation by the European Society of Cardiology about mandatory screening of athletes with ECG is based on a single study that was performed in Italy. It was a retrospective study that showed a dramatic reduction in sudden death rate in athletes. The relative rate reduction was 75% and the investigators claimed it was entirely due to mandatory ECG screening in Italy.
There are many problems with that paper, but we took it as a given that it is true, then we just wanted to calculate how much it was going to cost to implement a similar strategy in the United States at a national level, because the main issue with this study in Italy is that mandatory screening is repeated on a yearly basis, so 8.5 million US athletes would have to undergo ECG screening once every year and then about 9% would undergo additional testing every year that could be anything from echocardiography to cardiac MRI. The cost of all that would reach a staggering number: $65 billion.
We also calculated the number of lives saved if both athletes and physicians in the States behaved in a similar manner as what happened in Italy, then the screening would save about 4,000 lives over 20 years. So, the cost per life saved using this strategy would be $10 million per life saved. And that is assuming that the data from Italy are exactly the way it is presented.
In Israel such screening is mandated, correct? What do you recommend? What is the clinical lesson to be learned from this?
Dr. Viskin: First, we as physicians ought to recommend screening only for tests that we have already shown by well-performed studies will identify asymptomatic individuals and will distinguish them from healthy individuals.
Second, screening should be recommended only when there is therapy that will improve the prognosis of an individual who is asymptomatic. The typical example is measuring of blood pressure, because detecting hypertension in asymptomatic individuals is very likely to prolong life—it prevents stroke and prevents heart attacks. For ECG screening, in my opinion, we do not have data showing that you improve prognosis by doing ECG screening because there are a lot of false positives. Also, we see an abnormality on the ECG that we perceive is high risk, but we do not really know how high the risk is, whether we should really stop all activities altogether or just diminish them.
So, we have a test that will very often give us abnormal results and we do not always know what to do with the results, despite the fact that in countries like my own, [ECG screening] is becoming mandatory. To make it worse, it becomes the responsibility of the doctor, not the athlete, to decide what to do with the results. It makes more sense to come to an athlete and to say, "Okay, we performed this test, and we found this abnormality. This could represent some risk for you, and you have to decide what you want to do." However, in many countries in Europe and in Israel, it is actually the physician's role to decide who can play and who cannot play.
For colonoscopy, it has been shown very clearly that you can reduce the risk of mortality from colon cancer, but we don't have laws mandating adults to undergo a colonoscopy against their own will; we recommend that they [have a colonoscopy], but don't force them to. And here with athletes we have a test that has not really been shown by prospective, randomized studies to improve lives and we are making this mandatory for all athletes to undergo ECG screening, which does not make much sense to me.
In the United States, is the best approach to try to select high-risk kids and put them through some kind of screening test? If their father, for example, passed away at age 35 from sudden cardiac death, that would certainly raise a red flag, correct? Dr. Viskin: The criticism about the way it is run in the United States is that approach will miss many cases, but the truth of the matter is that I don't think we have anything better at this stage. We certainly need more studies and it's okay to do ECG screenings as part of science, as part of an investigation or study, but it is too early to make it mandatory for all.
ECG Screening for Athletes: Don't Make a Federal Case Out of It
Dr. Pelliccia, you were the author of the JACC commentary accompanying the paper by Dr. Viskin and colleagues. What did you think about the analysis published in JACC?
Antonio Pelliccia, MD: Thank you for the opportunity to express our opinion because I think it will be very useful to give our perspective for a better comprehension of these much debated issues.
Regarding the cost of the screening, there are two misconceptions: number one, that the screening problem would add a huge cost to the health system, and number two, that the individual cost of the screening is relatively high.
I will tell you why this represents a false conception; in our country [Italy], there is a screening process mandated by law but it is not supported economically by the states. We don't think about amateur or leisure time activities, we are just talking about competitive athletes—people who spend a substantial part of their time training and competing. The law is obliging these people to have medical clearance; however, the medical clearance is paid by athletes themselves, which means for young children [costs are paid] by the family; for athletes, [costs are paid] by the athletic association; for other people participating in individual sports [costs are paid] by themselves.
This law that obliges Italian people to pay for playing sports is accepted and has been implemented for 25 years. Why? Because the cost is low; it's remarkably low. The average cost, without additional investigation, is about 60 US dollars, including history, physical examination, electrocardiogram, and so on. And that's true for the overwhelming majority of people undergoing this medical clearance. Obviously, we have borderline cases, and we have requests for additional tests in about 5% of the cases.
Why do you think your model may eventually be considered for implementation in other countries?
Dr. Pelliccia: Because the [testing] should not be referred to the specialist. To do the screening, we don't have to pay nurses for the ECG, cardiologists for reading the ECG, or general physicians for doing the medical clearance. We actually believe that this program can be run uniquely by team physicians or by general practitioners. One of the major obstacles is teaching the team physicians how to read the electrocardiogram, and leave the cardiologists just for a second opinion, or as a referral specialist just to solve very borderline, very tough cases.
Required testing is accepted and has been implemented [in Italy] also because our social and cultural milieu is obviously different from the United States. With social medicine, preventative medicine is emphasized much more than possibly here. We do believe young people are going to be exposed to intensive training and competition and may be at higher risk than the general population, so cardiac screening for the competitive athletes has not been seen as a discriminatory policy.
Your argument is that if cost is the reason to avoid screening, it shouldn't be?
Dr. Pelliccia: It shouldn't be if you think of it as a package that is going to be made by just one physician at a very reasonable low price. This should be one more reason to assess, eventually, the feasibility to implement this screening program in the United States. I'm not talking about mandating a national program for everyone, but I would like to see a program particularly addressing people engaged in competition and this should not be done at a hospital, cannot and should not be done by just a cardiologist; this is a kind of social medicine, preventative medicine, so it's out of hospital.
The discussion in the United States often breaks along total cost estimates; the global billions that such an effort would run rather than the one-on-one cost of such screening.
Dr. Pelliccia: Correct. The federal government should not be paying for this. This should not be an "Obama Care" discussion. This is a discussion between coach and parent. I say, "Your boy needs proper shoes if he's going to play soccer; he also is going to need a very cost-effective screening to prevent disaster."
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