Economic evaluation of strategies to reduce sudden cardiac death in young athletes

Abstract

Objective: There is controversy about appropriate methods to reduce sudden cardiac death (SCD) in young athletes, but there is limited evidence on costs or consequences of alternative strategies. The objective of this study was to evaluate the cost-effectiveness of adding electrocardiogram (ECG) screening to the currently standard practice of preparticipation history and physical examination (H&P) to reduce SCD.

Methods: Decision analysis modeling by using a societal perspective, with annual Markov cycles from age 14 until death. Three screening strategies were evaluated: (1) H&P, with cardiology referral if abnormal (current standard practice); (2) H&P, plus ECG after negative H&P, and cardiology referral if either is abnormal; and (3) ECG only, with cardiology referral if abnormal. Children identified with SCD-associated cardiac abnormalities were restricted from sports and received cardiac treatment. Main outcome measures were costs of screening and treatment, quality-adjusted life years (QALYs), and premature deaths averted.

Results: Relative to strategy 1, incremental cost-effectiveness is $68800/QALY for strategy 2 and $37700/QALY for strategy 3. Monte Carlo simulation revealed the chance of incremental cost-effectiveness compared with strategy 1 was 30% for strategy 2 and 66% for strategy 3 (assumed willingness to pay ≤$50000/QALY). Compared with strategy 1, strategy 2 averted 131 additional SCDs at $900000 per case, and strategy 3 averted 127 SCDs at $600000 per case.

Conclusions: Under a societal willingness to pay threshold of $50000/QALY, adding ECGs to current preparticipation evaluations for athletes is not cost-effective, with costs driven largely by false-positive findings.

FIGURE 1

Alternative strategies to screen for risk of SCD. Strategy 1 reflects current practice. Strategies 2 and 3 reflect alternative clinical decision rules for ECG and cardiologist referral.

FIGURE 2

Incremental cost and effectiveness relative to current practice. The scatter plot shows the results of 1000 Monte Carlo simulation trials for strategies 2 (green circles) and 3 (blue pluses). The 2 ellipses correspond to the 95% CIs around the 2 respective sets of results. The diagonal line represents the target societal cost threshold of $50 000/QALY, with trials to the right of that line signifying lower (ie, more favorable) ICE. Listed “P” represents the fraction of Monte Carlo trials that lie on or to the right of the target threshold.

FIGURE 3

Societal acceptability curve. The societal acceptability curve plots the probability that strategies 2 and 3, respectively, are cost effective relative to strategy 1, for different societal willingness to pay thresholds, based on Monte Carlo simulation.