Sunday, March 06, 2011

The Costs of Screening Programs

It was another tragic story of a young 16 year-old high school athlete collapsing suddenly after winning a championship basketball game. An autopsy discloses a dilated cardiomyopathy. People wonder: could this happen to my son? The cries for screening to catch such cardiac disease before it manifests are raised. Hospital systems respond, ushering in free or reduced-fee screening electrocardiograms for all student athletes, arguing that such testing would likely capture heart trouble before it happens.

This story from Sue Thoms of the Grand Rapids Press sheds light on the cost and magnitude of testing required to capture heart disease in this population. From the article:
In the past two and a half years, the hospital has examined 5,200 students at Healthy Heart Checks held regularly around the Detroit area. The screening includes a medical history, blood pressure check and an ECG. About 15 to 20 percent of the students also undergo an echocardiogram.

Through the screenings, the doctors found three students who had serious underlying structural abnormalities of the heart that could have led to sudden cardiac arrest, Haines said. About 30 students had conditions that were serious enough that they were advised to stop playing sports -- though in some cases, they were able to resume sports after undergoing treatment.
Unfortunately we don't know much about the later 30 students: did they require additional invasive procedures, like radiofrequency catheter ablation of an accessory pathway and what were the costs involved? We really don't know these students' circumstances, so, in the interest of simplicity, we'll leave them out of our analysis for now, but should assume they added even more costs to the overall screening cost.

In summary, we find from this article that 5,200 EKG's were performed at a "reduced rate" of $8 each (doctors and volunteers' time was donated for free), "15-20%" then went on to an echocardiogram (we'll use 17.5%) to find three "true positive" cases of a heart condition that could potentially result in SCA. The inability to detect the severe cardiac disease with an EKG alone meant that the EKGs had a "false positive" rate of about 17.5% (minus the three "true positives"). In real numbers, about 907 echocardiograms had to be performed as a result of the screening program.

What does this mean financially to the hospital?

If the cost of this testing were paid for from fees or insurance payments, assuming a conservative estimate of $500 per echocardiogram for the technical fee to do the study and another $200 for the professional reading of the echocardiogram, a cool $634,900 was garnered for this test alone.

And don't forget the costs for office "consultations" to discuss the findings and the other invasive or imaging tests that might be required "just to be sure."

Very conservatively, this relatively small screening program cost about $676,500.

Armed with the data, we should ask if the costs were worth it so, as their athletic director said, we can all "breathe a little easier and sleep a little better knowing that all of our student athletes are safe?"

Costs and known false positive and false negative problems with EKGs is a large reason screening programs were not recommended recently by the American College of Cardiology. Rather EKG screening was only recommended if a person's medical or family history suggested a higher-than-normal chance of finding a problem.

But it is much easier to want to do things proactively when tragedy strikes and far harder to do nothing: everyone wants to feel like their doing what's best for their child or loved one going forward.

But our need to "sleep better" after such a tragedy should be balanced with the keen appreciation of the relatively low frequency of the problem in our students and the costs to our health care system for this reassurance. Nothing in medicine is "free" these days, no matter what health care systems may suggest in their promotion of these programs.

Take a moment as ask yourself if there might be teenagers who die from a cardiac death despite having had all of these tests?

Very possibly. But it's unlikely that such a story will ever make the headlines.

That's because such a story of the false negative rate of all these screening tests might be very bad for business.



Blake Hurst said...

Not sure why you want to exclude 30kids that tested positive from the discussion. If they required follow-up treatment that is not a cost of screening. That is the cost of treating a child with a heart rhythm disorder. The numbers you shared suggest that 1 in 157 kids required follow-up for a problem thatcould cause cardiac arrest. Those are pretty short odds if you are a parent. The cost of QALY saved for paediatric ECG screening is already well within acceptable ranges and would fall even more if we did more screening

DrWes said...


Not sure why you want to exclude 30kids that tested positive from the discussion.

Since the discussion is about preventing sudden death in young athletes, what problems did these other 30 kids have? Were they life threatening problems, or just conveniently identified strictly electrical disorders that might warrant treatment and didn't need a follow-up echo? We do not know. We only know that three kids definitely had structural disorders that suggested a potential for sudden cardiac death and, therefore, were "true positives." These structural disorders could ONLY be confirmed by follow-up echocardiogram.

The problem with EKG's as a screening test in this (and most) case was that "15-20%" of the kids (a very high 1 in 5) had to have a confirmatory echocardiogram. EKGs alone cannot define if a person has a structural heart problem or not; it only suggests if more testing is needed. Therefore, the EKG quickly becomes a VERY expensive means to define an at-risk population for sudden cardiac arrest (SCA).

If the Chicago Public Schools had, say, 100,000 kids to screen, based on the above data, they might need 20,000 echos performed at a cost of $14 million to find 58 possible students that might be at risk.

Is that cost worth it to screen all these kids?

Depends on how much we're all willing to pay...