Elsevier

Heart Rhythm

Volume 17, Issue 10, October 2020, Pages 1649-1655
Heart Rhythm

Clinical
Comparison of cardiovascular screening in college athletes by history and physical examination with and without an electrocardiogram: Efficacy and cost

https://doi.org/10.1016/j.hrthm.2020.04.032Get rights and content

Background

Preparticipation screening for conditions associated with sudden cardiac death (SCD) is required in college athletes. Previous cost analyses used theoretical models based on variable assumptions, but no study used real-life outcomes.

Objective

The purpose of this study was to compare disease prevalence, positive findings, and costs of 2 different screening strategies: history and physical examination alone (H&P) or with an electrocardiogram (H&P+ECG).

Methods

De-identified preparticipation data (2009–2017) from Pacific-12 Conference institutions were abstracted for cardiovascular history questions, cardiovascular physical examination, and ECG result. Secondary testing, cardiac diagnoses, return to play outcomes, and complications from testing were recorded. The costs of screening and secondary testing were based on the Centers for Medicare & Medicaid Services Physician Fee Schedule.

Results

A total of 8602 records (4955 H&P, 3647 H&P+ECG) were included. Eleven conditions associated with SCD were detected (2 H&P only, 9 H&P+ECG). The prevalence of cardiovascular conditions associated with SCD discovered with H&P alone was 0.04% (1/2454) compared to 0.24% (1/410) when ECG was added (P = .01) (odds ratio 5.17; 95% confidence interval 1.28–20.85; P = .02). Cost of screening and secondary testing with H&P alone was $130 per athlete and in the ECG-added group was $152 per athlete. The cost per diagnosis was $312,407 in the H&P group and $61,712 in the ECG-added group. There were no adverse outcomes from secondary testing or treatment.

Conclusion

H&P with the addition of ECG is 6 times more likely to detect a cardiovascular condition associated with SCD than without. The addition of ECG improves the cost efficiency per diagnosis by 5-fold and should be considered at college institutions with appropriate resources.

Introduction

The objective of the preparticipation physical evaluation (PPE) is the identification of potentially life-threatening conditions, which are primarily cardiac.1,2 There is no agreement on optimal cardiovascular screening methods. The American Heart Association (AHA) recommends the use of a 14-element history and physical examination (H&P) (AHA-14), whereas others have advocated for the addition of a 12-lead electrocardiogram (ECG).3,4 The overall cost of ECG and secondary testing, the potential for false-positive interpretations, time lost from sport, and adverse outcomes related to secondary testing or treatment are cited as reasons not to include an ECG with cardiovascular screening.2,3 The high false-positive response rate of H&P and increased sensitivity to identify cardiovascular conditions associated with sudden cardiac death (SCD) are presented as reasons to add ECG.5,6

The National Collegiate Athletic Association (NCAA) requires a PPE before participation in sport and recommends the AHA-14 or the Pre-Participation Physical Evaluation Monograph, although it recognizes many institutions add ECG to their screening protcol.7 The purpose of this study was to examine cardiovascular screening practices in the Pacific-12 (Pac-12) Conference, with schools using different strategies; to compare outcomes for the identification of cardiovascular conditions associated with sudden death, time lost from sport, and complications from secondary testing or treatment; and to perform a cost analysis using real-life data.

Section snippets

Methods

Pac-12 institutions conduct PPEs upon matriculation of athletes, before participation in team athletic-related activity. The medical staff at each institution includes board-certified physicians who review intake questionnaires, perform the physical examination, consult with specialists as indicated, and determine clearance for participation and whether additional testing is required. Information from PPEs conducted at 11 of the 12 Pac-12 schools from 2009–2017 was abstracted into a REDCap

Results

A total of 8602 records were included in the study (4955 H&P, 3647 H&P+ECG). There were 4889 males (57%) and 3713 (43%) females. Racial/ethnic breakdown was 3935 white (68%), 1071black (19%), 290 Asian (5%), 157 Hispanic (3%), 117 Pacific Islander (2%), and 218 other (4%). Sports included 2056 football (24%), 1016 crew (12%), 875 track and field (10%), 556 soccer (7%), 552 basketball (6%), and 529 baseball (6%). Complete demographics are given in Table 1.

The prevalence of cardiovascular

Discussion

This study demonstrated the combination of H&P with an ECG was 6 times more likely to detect a cardiovascular condition associated with SCD, and the cost per diagnosis is nearly one-fifth that of H&P alone. No studies have compared the actual yield, testing, and costs of H&P alone or with the addition of ECG. This study represents a “real-world” look at the performance and costs of these 2 different screening strategies. Although some of the conditions detected in the H&P+ECG group had either a

Conclusion

This is the first study to directly compare 2 alternative cardiovascular screening strategies for both yield and cost-effectiveness. Adding ECG to the H&P improves the identification of cardiovascular conditions associated with SCD by 6-fold and is more cost-effective. The incremental cost of adding ECG to a screening program is a relatively modest $22 per athlete. Universities with the resources and clinical expertise to add ECG to their cardiovascular screening programs should strongly

Acknowledgments

The authors wish to acknowledge Dana Friske, Sabrina Gay, Marissa Holliday, Dixie Jackson, Brianna Kubric, Russ Romano, Kari Ward, and Chelsea Williamson for assistance with data abstraction, and Amy Gest, Sunday Henry, Lindsay Huston, and Russ Romano for research coordination.

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    This project was supported with a grant from the Pac-12 Conference’s Student-Athlete Health and Well-Being Initiative. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the Pac-12 Conference, or its members.

    Disclosures: The authors have no conflicts of interest to disclose.

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