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Cost and Yield of Adding Electrocardiography to History and Physical in Screening Division I Intercollegiate Athletes: A 5-Year Experience
Study Questions:
What is the cost and the yield of a 5-year electrocardiogram (ECG) screening program at a US Division I college?
Methods:
At the University of Virginia, all 1,473 competitive athletes over the course of 5 years were screened with history and physical and with ECGs using European Society of Cardiology (ESC) guidelines, with follow-up testing as dictated by clinical symptoms and ECG findings.
Results:
History and physical alone uncovered five significant cardiac abnormalities. ECGs were abnormal in 275 (19%), resulting in 359 additional tests. Additional testing confirmed eight significant cardiac abnormalities that were not found by history and physical: one bicuspid aortic valve, four rapidly conducting accessory pathways, one long QT patient, one with frequent premature ventricular contractions and low ejection fraction, and one with frequent premature ventricular contractions, but normal ejection fraction. No cases of hypertrophic cardiomyopathy were found. The total cost of the program was US $894,870. Cost of history and physical screening alone was $343,725 or $68,745 per finding. The marginal cost of adding ECG screening, including resulting tests and procedures, was $551,145 or $68,893 per additional finding.
Conclusions:
The authors concluded that ECG screening of US college athletes can uncover significant cardiac pathology not discovered by history and physical alone. Although ECG screening also results in many false positives resulting in additional tests, the overall cost per diagnosis of adding ECG screening is similar to that of history and physical screening alone.
Perspective:
The American Heart Association (AHA) and the ESC have different criteria for screening amateur athletes, including college athletes. Although cost has been cited as a reason not to perform a screening ECG on amateur athletes in the United States, this study suggests that cost is not prohibitive. Not surprisingly, this study found that some structural cardiac abnormalities not detected on history or physical examination are detectable on ECG, or on tests that follow an abnormal screening ECG. Of clinical pertinence, though, is whether athletes were or were not appropriately or inappropriately excluded from participation, at what cost (both financial cost, and in terms of how many athletes who were not at-risk also were excluded from participation), and whether lives were saved. If there is a goal to detect all detectable structural heart disease, then this study can be extrapolated to support ECG screening of the entire US population, with more tests to follow. Whether fishing for asymptomatic structural heart disease should be confined to (and mandated for) student athletes relies on demonstration of incremental clinical benefit in that group––precisely the crux of a debate that remains unanswered.
Keywords: Athletes, Follow-Up Studies, Cardiomyopathy, Hypertrophic, Electrocardiography, United States
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