A MODELED ECONOMIC EVALUATION OF ALTERNATIVE STRATEGIES TO REDUCE SUDDEN CARDIAC DEATH IN YOUNG ATHLETES

   

Purpose: Screening strategies to reduce sudden cardiac death (SCD) in young athletes are widely debated.  Cost is an important concern.  We sought to evaluate the cost-effectiveness of adding ECG screening to the preparticipation history and physical exam (H&P) to reduce SCD.     

Methods: A state-transition Markov model was constructed. The model begins at age 14, when screening occurs, and covers a lifetime divided in annual Markov cycles.  Taking a societal perspective, we compared the cost-effectiveness of three screening strategies: (1) performing H&P with cardiology referral if abnormal (standard of care); (2) H&P plus ECG and cardiology referral if either are abnormal; and (3) ECG only, with cardiology referral if ECG is abnormal.  Risks, incidence, test characteristics, costs, and QALYs were derived from the literature and expert opinion.  Athletes identified with SCD-associated diagnoses were restricted from competitive sports and treated according to their level of risk with observation, medication, and/or implantable cardioverter defibrillators.      

Results: The expected incremental cost-effectiveness (Strategy 1 is baseline) of Strategy 2 is $68,840/QALY and for Strategy 3 is $37,730/QALY.  Probabilistic analysis demonstrates that the probability of cost-effectiveness compared to Strategy 1 at the $50,000/QALY threshold was 29% for Strategy 2 and was 67% for Strategy 3. An additional 264 sudden deaths are averted with Str. 2 at a cost of $444,000/life while an additional 257 sudden deaths are averted with Str. 3 at a cost of $295,000/life. Sensitivity analysis demonstrates that the incremental cost-effectiveness of Str. 2 and Str. 3 in reference to Str. 1 is sensitive to two groups of parameters: (a) effectiveness of the screening procedures (specificities and sensitivities of H&P, ECG, and cardiology evaluation), and (b) SCD related parameters (SCD incidence, annual probability of SCD for non-athletes, incremental risk of playing competitive sports, and upper age limit for competitive sport activity). The model is not sensitive to utilities or to costs (exception is the ECG cost, which is of restrained importance). The two most critical parameters are: (1) the effective specificity of cardiology evaluation and (2) the difference between the specificities of ECG and H&P tests.    

Conclusions: The addition of the ECG as a part of the preparticipation evaluation (Str. 2) for athletes is not cost-effective (Str. 2). A screening strategy involving only ECG (Str. 3) is borderline cost effective.