Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes

Abstract

Background: Inclusion of 12-lead electrocardiography (ECG) in preparticipation screening of young athletes is controversial because of concerns about cost-effectiveness.

Objective: To evaluate the cost-effectiveness of ECG plus cardiovascular-focused history and physical examination compared with cardiovascular-focused history and physical examination alone for preparticipation screening.

Design: Decision-analysis, cost-effectiveness model.

Data sources: Published epidemiologic and preparticipation screening data, vital statistics, and other publicly available data.

Target population: Competitive athletes in high school and college aged 14 to 22 years.

Time horizon: Lifetime.

Perspective: Societal.

Intervention: Nonparticipation in competitive athletic activity and disease-specific treatment for identified athletes with heart disease.

Outcome measure: Incremental health care cost per life-year gained.

Results of base-case analysis: Addition of ECG to preparticipation screening saves 2.06 life-years per 1000 athletes at an incremental total cost of $89 per athlete and yields a cost-effectiveness ratio of $42 900 per life-year saved (95% CI, $21 200 to $71 300 per life-year saved) compared with cardiovascular-focused history and physical examination alone. Compared with no screening, ECG plus cardiovascular-focused history and physical examination saves 2.6 life-years per 1000 athletes screened and costs $199 per athlete, yielding a cost-effectiveness ratio of $76 100 per life-year saved ($62 400 to $130 000).

Results of sensitivity analysis: Results are sensitive to the relative risk reduction associated with nonparticipation and the cost of initial screening.

Limitations: Effectiveness data are derived from 1 major European study. Patterns of causes of sudden death may vary among countries.

Conclusion: Screening young athletes with 12-lead ECG plus cardiovascular-focused history and physical examination may be cost-effective.

Primary funding source: Stanford Cardiovascular Institute and the Breetwor Foundation.

Figure 1

Decision Model. Diagram of the decision analysis model. ECG plus H&P, 12-lead electrocardiogram plus cardiovascular-focused history and physical. CV focused H&P, cardiovascular-focused history and physical; ECG alone, 12-lead electrocardiogram without cardiovascular-focused history and physical. M, Markov node.

Figure 2

Univariate Sensitivity Analyses. The incremental cost-effectiveness ratio of ECG plus cardiovascular focused history and physical versus no screening (A) and ECG plus cardiovascular focused history and physical vs. cardiovascular focused history and physical alone (B) are shown as changed by varying critical parameters through possible ranges. The base case estimates (A, $76,100 per life year saved and B, $42,900 per life year saved) are shown (vertical lines). Horizontal solid boxes represent the incremental cost effectiveness ratio resulting from inputting the described variable over the expected range of the mean value (also used in probabilistic sensitivity analysis); horizontal lines represent incremental cost effectiveness ratio found using expected minimum and maximum inputs, which may be applicable to certain specific subgroups or to particular payors. The accompanying table lists, from left to right: the low value input, the low input used for probabilistic sensitivity analysis, the high value input used for probabilistic sensitivity analysis, and the high value input for each variable or combination of variables. In (B), note the incremental cost effectiveness ratio between ECG plus H&P and H&P alone is not dependent on H&P cost, but is dependent on the interpretation of H&P results prior to ECG interpretation. ECG plus H&P, 12-lead electrocardiogram plus cardiovascular-focused history and physical. CV focused H&P, cardiovascular-focused history and physical. Risk ratio, Athlete vs. DQ represents the mortality risk reduction associated with disqualification and treatment of athletes with underlying occult heart disease versus continued participation without diagnosis. ECG cost, cost of ECG above H&P cost. All screening costs, all cost parameters including primary and secondary screening tests, initial and recurring screening related treatment costs input into model concurrently. SCD, sudden cardiac death, DQ, disqualified, SN, sensitivity; SP, specificity. † ECG plus cardiovascular focused history and physical cost and life saving versus comparator. * Base case assumption.

Figure 3

Probabilistic Sensitivity Analysis. (A) Scatter plot of simulation performed for each of three base case comparisons, varying each input variable over the expected range of the population median. Note that in nearly all simulations, history and physical is weakly dominated by ECG plus history and physical, as it is less costly, less effective, and has a higher incremental cost-effectiveness ratio. Incremental cost effectiveness ratios can be determined by dividing the discounted life years saved by the incremental discounted cost. Reference lines for incremental cost effectiveness ratios of $50,000 per life year saved and $100,000 per life year saved are shown. Dots below each of these lines represent simulations with incremental cost-effectiveness ratios falling below these willingness to pay thresholds. (B) Willingness to pay curves for comparisons between ECG plus history and physical and history and physical (dark gray); between ECG plus history and physical and no screening (black), and between history and physical and no screening (gray). Proportion of simulations plotted versus incremental cost-effectiveness ratio for each of three base case comparisons. Simulations that were not life saving are included in the proportion of simulations above $300,000 per life year saved. The probability of preferring ECG plus H&P compared to H&P alone is 68% at a willingness to pay threshold of $50,000 per life year saved and 99.9% at $100,000 per life year. ECG plus H&P is cost- and life-saving in 0.2% of simulations vs. H&P alone. The probability of preferring ECG plus H&P compared to no screening is 0% at a willingness to pay threshold of $50,000 per life year and 79.9% at $100,000 per life year. The probability of preferring H&P compared to no screening is 0% at $100,000 per life year.