ORLANDO -- Cost issues should no longer keep electrocardiograms out of most schools' efforts to screen student athletes for potentially fatal heart problems, researchers said here.
Recent declines in the price of ECG machines mean that students can be screened for a cost of less than $3 each after an initial investment of under $500 per school, according to a study led by Thomas DeBauche, MD, of Cypress Cardiology in Cypress, Texas.
Action Points
- Note that the American Heart Association and American College of Cardiology guidelines suggest ECG as optional for preparticipation screening of student athletes.
- Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered preliminary until published in a peer-reviewed journal.
Addition of 12-lead ECG to screening would cost just $300 per year of life saved, DeBauche's group reported at the American Heart Association meeting.
This price was so far below the typical cost-effectiveness threshold of $50,000 per life-year that there should no longer be any question about adopting ECG in screening, DeBauche said.
His group set up a program to add a one-time ECG for every student participating in competitive sports in their suburban Houston school district.
Although high school football is enormously popular in Texas where games can draw tens of thousands of spectators, like most other states, Texas requires only a perfunctory physical exam and completion of a questionnaire on possible symptoms and family cardiac history for participation.
ECG is universally acknowledged as more likely to identify serious cardiac problems, and it has been adopted as an international standard for screening in much of the world.
One prior study from a region in Italy, which pioneered nationwide screening of athletes with ECG in the late 1990s, revealed a 90% drop in sudden cardiac events after the screening program began. (See National Screening Slows Sudden Cardiac Deaths Among Athletes)
But ECG has not been advocated in national guidelines for the U.S. in large part because of the cost, Douglas Zipes, MD, of Indiana University and a past president of the American College of Cardiology, noted.
"The U.S. is behind the times when it comes to screening athletes," he said, calling current efforts in much of the country woefully inadequate.
Scattered U.S. programs have adopted ECG following the Italian model. "Everybody agrees, yes, it should be done, but it's optional because we don't think we can afford, on a national level, a mandated program," DeBauche said.
At current reimbursement levels, sending all student athletes to the hospital or a physician's office for an ECG at about $100 each would cost over an estimated $1 billion, DeBauche said.
The program his group designed, though, would cost under $2 million to screen all 200,000 U.S. athletes in the ninth grade, which is an optimal age to catch problems -- before high school sports but after onset of puberty, he said.
The program included providing laptop-based ECG machines for each of 10 high schools in the school district.
Athletic trainers and other school employees were trained to apply the ECG leads according to a diagram, take the ECG with the push of a button, and forward the HIPAA compliant electronic file to DeBauche's team for interpretation.
Of the 2,057 freshmen screened, 9% (186 students) had an abnormal ECG result and were advised to set up a consultation, get a screening echocardiogram for diagnosis, or both.
Only 0.6% had a serious enough abnormality to eliminate them from participation in competitive sports.
Among the 173 who accepted further examination for their abnormal findings, the diagnoses included:
- Eight cases of Wolff-Parkinson-White syndrome
- 23 cases of left ventricular hypertrophy
- Three cases of moderate severity mitral valve regurgitation
- Six cases of right ventricular pulmonary hypertension
- One case of cardiomyopathy
- 17 cases of mitral valve prolapse.
One student was found to have noncompaction cardiomyopathy, a clearly life-threatening condition that subsequently led to implantation of a defibrillator and waitlisting for a heart transplant.
A second case of aortic coartication and the right ventricular abnormalities "certainly had major clinical significance," the researchers said.
An echocardiogram to follow-up on abnormal cases could be carried out by commercial screening firms specializing in large numbers of relatively easy studies and reimbursed by all major insurers, DeBauche said.
The ECG itself would cost only $0.50 per ECG for electrodes and about $2.00 for interpretation.
"When you find something this good you should do it," DeBauche said.
Barry Franklin, PhD, of William Beaumont Hospital in Royal Oak, Mich., agreed that this type of screening wouldn't necessarily need a clinical cardiologist since a nurse or other trained staff could administer the ECG.
"It's a very simple test," he said.
The biggest costs involve setting up the infrastructure, Zipes added.
"We're talking about the lives of youngsters," he said. "If that were your son or daughter, you would want it done."
Disclosures
The researchers reported no conflicts of interest.
Franklin reported no conflicts of interest. Zipes reported being a consultant for Medtronic.
Primary Source
American Heart Association
Source Reference: DeBauche T, et al "Cost effective complete screening of athletes in a large district" AHA 2009: Abstract 865.