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An Ounce of Prevention Costs a Ton of Money-Preparticipation Screening of Young Athletes

December 5, 2010

A young man streaks down the basketball court with only one man to beat. A subtle head fake to the right causes his opponent’s weight to shift ever so slightly. The dribbler crosses the ball from his right hand to his left, dips his shoulder just past his opponent’s, and pushes his way forward to complete a reverse lay-up. The crowd whoops and cheers, the young man makes his turn to run to the other end of the court, and collapses.

Coaches and trainers run to his side. Panic ensues. The whole episode is captured by  a dozen home video cameras in the stands, which are gladly shared with the local TV stations. The story that the young man died leads the local news that night and makes the front page of the next morning’s newspaper. The attention paid to this story by the media makes the risk appear greater than it really is. A cardiologist from the local medical school is interviewed, and he recommends that all student athletes be thoroughly evaluated to prevent similar future tragedies.

A study earlier this year in the Annals of Internal Medicine asked the question: What is the cost-effectiveness of screening young athletes to prevent sudden cardiac death?  The authors compared a cardiovascular-focused history and physical examination plus EKG to no screening. They assumed the cost of this doctor visit and test was $199 per athlete. They concluded that this approach would result in 2.6 extended years of life per 1,000 athletes at a cost of $76,100 per year of life extended.

What I’m about to do isn’t completely methodologically kosher, but it’s close.

The actual cost is probably higher. I’ve seen adds in newspapers and advice from other medical groups that an echocardiogram (a sonogram of the heart) should be part of the screening work up. An echo might cost $800 in the private world, but I’ve seen some doctors willing to provide it for young athletes at $200. Add this figure to the $199 in the article and now the cost is well over $100,000 per year of life extended.

The more important issue causing this study to underestimate the true cost is the data source used to generate the estimates. Preparticipation testing has been mandated in Italy for several decades. A large study of its effectiveness was published in JAMA in 2006, and there are many other analyses of this program in the medical literature. These reports supplied the estimates of program effectiveness — how well screening works — that were used in the cost-effectiveness estimates.

Veneto is a region in Italy has an unusually high incidence of sudden cardiac death, up to six times higher than other American or European populations, and served as the basis for outcome estimates in this study.  Adjusting for the difference in baseline risk means the actual cost-effectiveness of screening may be closer to $400,000 per year of life extended in a more typical population. Because sudden cardiac death is much more common in boys, the figure could be much higher for girls.

To prevent sudden cardiac death, should doctors routinely screen all young athletes with a thorough interview, physical exam, and EKG? That’s up to you. The benefit is rare; the expense is high. There could be other approaches that give a better bang for the buck, such as using more selective screening for only the athletes with suspicious symptoms or family histories.

The Government Industrial Medical Coalition (GIMeC) insists it be done. I say its your money. Perhaps your family’s life would be healthier if that $199 to $399 was spent on something else. The medical establishment shouldn’t coerce you into spending your resources on healthcare. You should have that choice.

To learn more on the cost of prevention, check out one of my website pages at http://www.healthscareonline.com/prevention-saves-money/.

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