Cost to Save One Athlete's Life With ECG Screening? More Than $10 Million

November 27, 2012

TEL AVIV, Israel — Screening every young competitive athlete in the US with an ECG to prevent sudden cardiac death would cost more than $10 million per life saved, according to a new economic analysis tackling the controversial concept [1]. A new cost-projection model found that a 20-year program of preparticipation ECG screening would cost at least $50 billion and would save approximately 4800 lives, report the investigators.

Given the "staggering costs" of widespread screening, the researchers, led by Dr Amir Halkin (Tel Aviv University, Israel), say widespread ECG screening of high school and college athletes participating in competitive sports would have an enormous impact on US society. "Given the limited resources available to healthcare in the United States and the limited lifesaving 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," the researchers state in their paper, published in the November 27, 2012 issue of the Journal of the American College of Cardiology.

In an editorial [2], however, Dr Antonio Pelliccia (Institute of Sport Medicine and Science, Rome, Italy) argues that if cost is the issue, then medical screening without the ECG, as is the current standard of practice in the US, should be abandoned, as it too is expensive and inefficient at detecting cardiac disease risk. Pelliccia also believes the cost of ECG screening could be reduced if it was packaged as part of a preventive-medicine program rather than individual diagnostic testing. For example, the packaged screening program in Italy is approximately $60 per athlete, a fee that most athletes can afford (it is also reimbursed for low-income athletes).

"The rationale to implement a mandatory screening program, which conveys an obligatory cost to citizens participating in sport, is based on the widely accepted perception that individuals engaged in competitive sport are exposed to an increased risk and, for this reason, deserve greater public attention," writes Pelliccia. "Screening athletes, therefore, is not seen in Italy as a discriminatory policy targeting a subset of our population, but as an expression of our attitude for preventive medical programs, which are widely accepted."

AHA and ACC Opposed to ECG-Based Screening

At present, the American Heart Association (AHA) and American College of Cardiology (ACC) do not recommend the use of ECGs for cardiovascular screening of athletes at any level, nor does the Canadian Heart and Stroke Foundation. In contrast, the European Society of Cardiology and International Olympic Committee recommend resting 12-lead ECG to detect cardiac abnormalities.

In terms of countries, Italy has led the way in screening young athletes before allowing them to compete in sports. The Italian model, which includes a physical examination, family history, and screening with a 12-lead ECG, was instituted in 1982. Researchers have previously presented data, most recently at the ESC 2011 Congress, suggesting that the preparticipation screening was cost-effective, with the cost of one life-year saved in Italy ranging from €33 000 to €100 000. However, other experts questioned these numbers, noting the low costs of screening and additional investigation in Italy, a country with a large number of sport cardiologists.

In the latest analysis, Halkin and colleagues performed the cost-projection analysis using the costs of diagnostic tests obtained from Medicare reimbursement rates. The cost of medical screening, family history, and the ECG were estimated to be $263 per athlete in the US, a figure that is substantially higher than the $60 cost in Italy. The size of the screening-eligible population was estimated using data from the National Collegiate Athletic Association and the National Federation of State High School Associations.

Overall, 8.5 million US athletes would be eligible for screening each year; if the program were followed for 20 years, this would translate into 170 million screening processes. Using these data, they estimate the cost of screening, as well as secondary tests for a limited number of athletes, would cost between $51 and $69 billion. Using the same mortality data as the Italians, the researchers estimated that 20 years of screening would save 4813 lives, resulting in a cost per life saved that ranges from $10.6 to 14.4 million.

Pelliccia, in his editorial, takes issue with a dollars-and-cents interpretation of the data, noting that an assessment of the ECG benefit purely in terms of lives per year saved and the Medicare costs "is simplistic and misleading."

"Forgotten benefits include, for example, individuals timely identified with cardiovascular abnormalities who will be treated appropriately and avoid sudden death, as well as the several disorders affecting the skeletal, ocular, and other noncardiac systems, which do not convey risk for death and can be appropriately treated," writes Pelliccia. "Eventually, [preparticipation screening] represents the occasion for educational activities targeted to prevent metabolic and cardiovascular disease in young athletes and their families."

Large-Scale Screening to Be Very Expensive

To heartwire , Dr Aaron Baggish (Massachusetts General Hospital, Boston), who was not involved in the analysis, said the study is likely to open up a "can of worms" in terms of the ongoing debate about the benefit and cost of preparticipation screening for competitive athletes. While there are questions regarding the manner in which Halkin et al performed the analysis, Baggish said, "The study confirms what all of us know, and that is that any large-scale screening program in the US is going to be very costly."

The cost of screening per life saved is far above what he expected, however, and is likely the result of not reflecting how an effective screening program would be conducted.

For example, Baggish notes that Halkin et al assume that all 8.5 million athletes would be screened every year, something that is unnecessary and wasteful. He said the costs (from the Medicare reimbursement data) reflect the charge if a single patient came into the office to undergo screening before participating in an athletic event. The real cost savings and improvements in quality would derive from doing group screenings, such as bringing large numbers of athletes in at a time to see the sports medicine doctors and cardiologists.

Speaking with heartwire , Baggish said he simply doesn't know if ECG-based screening in the US will come to pass. The AHA and ACC position, he added, is the only responsible position for such a potential nationwide mandate, one that is complex and includes more issues than cost. He added that the accuracy of the ECG for the detection of cardiac arrhythmias remains unknown, and no program should be implemented until it is improved, with the detection of cardiac abnormalities down to the 1% to 2% range.

"That is why the AHA and ACC recommendations are what they are," said Baggish. "There is an acknowledgement of the fact that doctors, not only family-medicine doctors but also cardiologists, are unfamiliar with ECG changes in the athlete. So one of our big tasks, and the AHA and ACC recognize this, is to improve our educational campaigns, to really let providers know what's happening and let them learn what they need to know to do this well."