Editor's Note: Based on the article Halkin A, Steinvil A, Rosso R, Adler A, Rozovski U, Viskin S. Preventing Sudden Death of Athletes With Electrocardiographic Screening: What Is the Absolute Benefit and How Much Will it Cost? J Am Coll Cardiol 2012; 60:2271-6.¹

Summary

It is estimated that close to 100 young athletes per year die suddenly in the United States. In a well-known prior epidemiological study from Italy by Corrado et al.² comparing a time period before versus after institution of a national ECG screening program for athletes, ECG screening reduced the incidence of SCD in young athletes from 4/100,000 to 0.43/100,000. The current study combined estimates of efficacy from that study with US athletic population estimates and Medicare reimbursement rates, to estimate the cost-effectiveness of a program of ECG screening for athletes in the US.

Methods

A cost-projection model was based on the Italian study, replicating its data in terms of athlete characteristics and physician performance, with a resulting assumed reduction of death in young athletes from 4/100,000 in year one, decreasing linearly to 0.43/100,000 at year 20. Percentages with positive findings and use of follow-up diagnostic testing were also estimated based on the Italian study. The size of the screening-eligible population, approximately 8.5 million athletes, was estimated from data from the National Collegiate Athletic Association and the National Federation of State High School Associations. The costs of diagnostic tests were obtained from Medicare reimbursement rates.

Results

A 20-year program of yearly ECG screening of young competitive athletes in the United States would cost between $51 and $69 billion and could be expected to save 4,813 lives. Accordingly, the cost per life saved is likely to range between $10.6 and $14.4 million.

Conclusion:

The authors conclude in the abstract, "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," and conclude the manuscript, "Given the limited resources available to healthcare in the United States and the limited life-saving potential of ECG screening, it is clear that mandating such a program, rather than applying it selectively, is likely to hinder the penetration of other preventive measures for cardiac arrest victims."

Perspective:

How best to protect young athletes from dying suddenly, and whether ECG screening would be effective and cost-effective, is a matter of intense debate.^3,4 The best available data to date on the efficacy of ECG screening to date is the report of the Italian experience above, in which initiation of a nationwide mandatory screening program resulted in a dramatic decrease in deaths in young athletes.² Based on this data, both the European Society for Cardiology and the International Olympic Committee have added ECG to pre-participation screening recommendations.⁵ The American Heart Association recommendations, most recently updated in 2007,⁶  do not include ECG screening, however, but rather targeted history and physical (H&P), with ECG only if indicated by findings on H&P. Lack of infrastructure and resources are given as the primary rationale for excluding ECG from routine pre-participation screening. This study, using the efficacy data from the Italian study, would seem to support that recommendation.

However, a closer view of the data analysis may lead to different conclusions. First, and most importantly, while the title describes the benefits and cost of preventing sudden death with ECG screening, the data presented in fact describe the cost of a strategy of screening including H&P, ECG, and the resultant follow-up testing. The cost of the H&P, which is currently recommended by the AHA and is standard of care in this country,⁶ accounts for 75% of the total costs, (Table 1 in the manuscript) leaving the cost of the ECG accounting for at most 25% of the total, (assuming most conservatively that all of the resultant testing was generated by the ECG). The cost effectiveness ratio for the ECG requires estimation of the incremental benefit of addition to ECG, divided by the excess cost of the ECG, which was not done in this study. The sensitivity of H&P for detection of cardiovascular disease in athletes is poor. In an autopsy study of 134 athletes who died suddenly, 115 had undergone H&P screening of whom 3% had a suspected abnormality.⁷ In one study of over 5,000 athletes screened with H&P and ECG, the ECG improved sensitivity for diagnosis of significant cardiac abnormalities from 15% to 68%.⁸ In a later study comparing these two strategies using echocardiographic abnormalities as the endpoint, addition of the ECG doubled sensitivity from 45% to 90% while decreasing specificity fairly minimally from 94% to 82%.⁹ Because of this increased sensitivity, several studies have found that addition of the ECG to H&P, while increasing cost, actually improves cost-effectiveness.^3,10

Also importantly, the authors have chosen to express the cost-effectiveness ratio in cost per life saved, rather than the more usual cost per year of life saved. The authors argue that this is necessary because the athletes whose lives are saved may not have normal lifespans. However, while the natural history of hypertrophic cardiomyopathy, the most common cause of sudden cardiac arrest in young athletes in this country, is variable, most patients with HCM will live a normal lifespan.¹¹ Asymptomatic individuals identified in the teenage years may have many years remaining. If they live just ten years, cost-per-year-of-life saved becomes one million rather than 10, if they live to age 70, a normal lifespan, the cost becomes under $200,000 per year of life saved.

Further, the costs are based on yearly screening as used in the Italian study.² A prior cost-analysis also based primarily on the Italian study but using a one-time screen found a cost-effectiveness of $76,100 per year of life saved for the combination of H&P and ECG, with the incremental cost-effectiveness of the ECG $42,900¹⁰ well within the societally-accepted range. The optimum interval for repeating an ECG is unknown, but it is likely that yearly is not required.

Finally, as described by Pellicia in the accompanying editorial,¹² Medicare fee-for-service is not the only economic model. In addition to a change to the type of bundled prevention services he describes, another option might be to add the ECG to routine pediatric care at relevant intervals when an H&P is already ongoing, rather than as a separate program for athletes. All children are screened with ECGs at intervals in Japan, with resultant effectiveness and an estimated cost-effectiveness of just $8,800 for the ECG.¹³ New criteria defining an "abnormal" ECG, as recently suggested by the European Society of Cardiology,¹⁴ may also decrease cost by improving specificity and thus decreasing use of follow-up testing.

To recommend abandoning the concept of screening in favor of pursuing improvements in resuscitation, as the authors argue, is not the best we can do for young athletes and their families. The current survival from sudden cardiac arrest remains under 10%^15,16 and the incidence of psychopathology in the few who do survive is high.¹⁷ Research into resuscitation and post-arrest care, such as therapeutic hypothermia, as well as improvements in community response, such as use of automated external defibrillators¹⁶ all are crucial to improving survival from sudden cardiac arrest. But an ounce of prevention will always be better than a pound of cure. Rather than abandon the concept of ECG screening, let's work to improve it, by considering alternative economic models, by improving specificity, and by sufficiently large-scale research into effectiveness.

For more commentary on this article with replies from the author, see Letters to the Editor in upcoming issues of JACC. Let us know your opinion on this subject by commenting below.

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References

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Keywords: Cost-Benefit Analysis, Electrocardiography, Epidemiologic Studies, Athletes

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