To Screen or Not to Screen: That's Not the Only Question

Sometimes we can just agree to disagree, right?

You have watched the debates, or maybe even participated in them. It comes down to this: some cardiologists believe that youth ECG screening may save lives, or at the very least identify asymptomatic heart disease that should be treated. Others dispute the benefit, or at the very least argue that it is too expensive to recommend. And as with politics, the controversy over ECG screening often devolves into a series of arguments (however well intended) that reflect each author's biases and are published in their own echo chambers.

So let's not argue about that.

Regardless of your screening persuasion, we can probably agree that although preventive care and screening programs are frequently debated with respect to benefit and cost in the context of public health impact, we make recommendations every day as physicians that affect the individuals we care for in our clinics and hospitals. Let's think of preventive care or even screenings like a bicycle helmet. Most people who wear one will never actually experience a serious accident; strictly speaking, they never benefit from the helmet. But we do recommend helmets for cyclists anyway, with the understanding that given enough time and enough cyclists wearing helmets, we will eventually help some of them. Similarly, preventing a heart attack by prescribing statins to dozens of people over several years, or diagnosing a potentially lethal heart condition by performing an ECG on a couple hundred kids may seem worth the other unnecessary treatments and testing that are clearly not beneficial to the masses. Or maybe not. But no matter what you choose to recommend, public health recommendations become essentially personal in practice. So after you take it all in, you may still be thinking about starting a heart screening program, whether in partnership with a family foundation or as part of your own practice, university department, or service line. There are as many screening models as there are programs.

Here is how we do it.

Five years ago, I started Play Smart Youth Heart Screenings (, a free youth heart screening program in Portland, Oregon that has organized over one hundred screening events serving families from throughout Oregon and southwest Washington. We have screened over 14,000 children ages 12-18, and perform free screening echocardiograms when triggered by abnormal electrocardiograms. The majority of our screenings are performed in schools, but we do utilize hospital clinic space on regular weekday evenings and Saturday mornings every month. Our operations staff of three is supported by our employer, a leading integrated healthcare system, and is funded by our foundation, which has raised sufficient dollars to help us be sustainable. I volunteer my time, and we are also supported by a devoted cadre of clinical and nonclinical volunteers. We use traditional ECG machines at our screenings, and all echocardiograms are performed at our hospital on traditional machines. We store all of our data in EPIC. We use the most recently modified Seattle Criteria to keep our false positive rate at 2%, and have identified dozens of children with hypertrophic cardiomyopathy, long QT syndrome, and Wolff-Parkinson-White syndrome, as well as hundreds with elevated blood pressure, sometimes in alarming ranges.

Here are few questions to get you started as you consider how best to offer a screening program:

1) How many children do you plan to screen? How often? And for how much?

The more children you screen at each event, the lower cost per screening, regardless of who subsidizes it. My personal opinion is that screenings should not be used as marketing events for your practice or healthcare system. As a healthcare service, if it's important enough to do once, it's important enough to offer on an ongoing or regular basis. From a budgetary standpoint, it is helpful to consider how many people you hope to screen at each event or over the course of a year. When we were starting out, our events were smaller scale, and therefore less efficient. We now frequently screen over 100 children at the majority of our events. We made the decision early on that our program will always be free. That obviously puts the pressure on us and our foundation to raise money to support our work. But it was important to us that our screenings be accessible to families who might have more limited access to healthcare. Some screening programs have found it helpful to charge families a nominal sum to keep the programs sustainable.

2) Where do you plan to hold your screening event?

It is generally easier to reach children where they spend their time, rather than investing heavily in marketing your program to bring children into your clinic. We might screen fewer than twenty children during a weekend clinic at our hospital, but can easily screen over 150 at a high school. Given that cost is a reasonable criticism of screening programs, it makes sense to make your events as cost-efficient as possible. Developing strong partnerships with athletic directors and school principals has helped us provide more than 90% of our screenings in schools. We also view our screenings as a touchpoint to offer education about nutrition and exercise. Other screening organizations teach CPR during their school programs.

3) Where is the cardiologist?

Unless you plan to hold your screenings exclusively during the evenings or weekends, you will be competing for your cardiologists' time with their other clinical work. This makes screenings more difficult to arrange and potentially increases their cost. We have approached this issue by holding our screenings without cardiologists present. Following the screenings, our cardiologists review the ECG's, and we share normal results with patients by email, and make telephone calls for clearly abnormal results. Our free screening echocardiograms are scheduled per the family's convenience and results are shared the same day or the following day. The downside is that it does take longer overall to share results. But the benefit is that it helps our screenings remain free, and it also allows us to discuss abnormal findings with parents without being rushed or pressured to quickly move on to the next patient. Sharing abnormal results with a teenager in a crowded gym might be timely, but it probably is not the best way to communicate a new diagnosis.

4) How will you keep records?

Paper records are easier. But given that we use electronic health records for everything else, we decided that our ECG screenings deserve the same treatment. We upload all of our ECG's into EPIC, where pediatricians and other specialists will have access to them, not to mention the patients themselves. Our echocardiograms are stored in our EHR as well. Pediatricians appreciate it!

5) What will be the role of physical exams and health questionnaires?

This is an important question, because whether you include physicals and questionnaires will definitely impact your false positive rate and therefore your costs. While physical exams are helpful to identify murmurs or other significant cardiovascular physical findings, they require a physician to be present. We have decided to limit our program to ECG and echocardiogram screenings. We leave the physical examination to the pediatricians who do it well. Our approach is that an abnormal physical exam deserves a full echocardiogram - we provide a more limited study in our screening program. While questionnaires are recommended by the AHA and ACC, they also have a much higher false positive rate than ECG's, and are ultimately more cost-prohibitive than ECG's if they were to be universally adopted given the number of echocardiograms and other tests that they would likely trigger. We believe that a thorough personal and family history is more appropriately conducted in the context of a more familiar patient-doctor relationship, in which affirmative responses can be explored in further detail, rather than merely triggering a test.

Additional Resources:

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Dyslipidemia, Heart Failure and Cardiomyopathies, Sports and Exercise Cardiology, EP Basic Science, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, Nonstatins, Novel Agents, Statins, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology

Keywords: Blood Pressure, Cardiomyopathy, Hypertrophic, Cardiopulmonary Resuscitation, Dissent and Disputes, Electrocardiography, Heart, Heart Diseases, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Long QT Syndrome, Myocardial Infarction, Wolff-Parkinson-White Syndrome, Sports

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