No Cardiac Screening For Amateur Athletes

Last week the New York Times published an article describing the cardiac screening program for athletes currently in place at the University of Tennessee. Such screening programs are uncommon. According to the Times, "Cardiologists and other heart experts say that the screenings could help save the lives of the 125 American athletes younger than 35 who die each year of sudden cardiac death. Most show no symptoms of heart disease until it becomes fatal."

The screening performed by the University of Tennessee includes an echocardiogram, a non-invasive test useful for diagnosing hypertrophic cardiomyopathy (HCM). HCM is the most common cause of sudden death in apparently healthy young athletes. Echocardiographic screening, however, would cost an average of $1000 per athlete.

The annual cost to screen the estimated 2.5 million amateur athletes in the U.S. in this way would be about $2.5 billion, and if this screening would save 125 young lives (as asserted by the Times' experts), it would cost $20 million per life saved. Screening by ECG alone (a pretty good screening method, though not as accurate as the echocardiogram and certainly not up to the standards of the New York Times) would still cost about $2 million per life saved. Either of these values represents a cost-effectiveness hurdle that is just too high by any reasonable measure.

This cost-effectiveness consideration is apparently the main reason that the official American Heart Association guidelines, released only last year, recommend against routinely screening young athletes for heart disease.

DrRich Comments:

There are many things we routinely pay for in our society whose cost effectiveness is at least as inefficient as the cardiac screening of athletes. These include seat belts, smoke alarms, and carbon monoxide detectors. In each of these cases, the dollars spent per life actually saved reaches multiple millions of dollars.

There are two differences between smoke alarms and cardiac screening, however, that make smoke alarms reasonable and cardiac screening unreasonable. First, individual smoke alarms are inexpensive enough that most families can afford them. Second, smoke alarms are not considered a "medical service," and thus it is not considered a travesty against nature to ask individuals to buy one for themselves.

But for a moment let's suspend the laws of nature, and think about what would happen we were to deem it advisable for individuals to pay for the cardiac screening of young athletes in their own families. First, the cost effectiveness calculus would change radically, since individuals tend to value their own children's lives far higher (often that value approaches infinity) than society does. The $20 million per life saved would no longer appear a relevant roadblock. (Consider: If paying for smoke alarms were the responsibility of the healthcare system - since, like cardiac screening, smoke alarms are essentially a preventative measure aimed at reducing the odds of some very nasty medical outcomes - then the cost of $10 or $20 million to save one life would render them, too, a lamented but unrealistic option.)

Second, if cardiac screening were moved out of the realm of "medical service" and into the realm of consumer service, then entrepreneurs would bring readily available technology to bear to make echocardiographic screening for HCM simple, cheap and easy to perform. For an investment of, say, $40 and 15 minutes, you could have your child screened by both ECG and echocardiogram by your family doctor, or even at your local WalMart. (Similarly, if paying for smoke alarms were the responsibility of the healthcare system, then these devices would no longer be elegantly simple and cheap, but instead would be driven by regulatory and bureaucratic demands to great complexity and high cost, and installing each Products of Combustion Detection and Notification Unit would require a medical professional with a nuclear license.)

The way things actually are, of course, the cardiac screening of athletes is indeed considered a medical service, so it's not OK to ask people to pay for it themselves. Echocardiographic screening for HCM will remain a heavily regulated, expensive, complex process which can only be performed by members in good standing of the cardiologists' "guild." And because the cost effectiveness calculus of routinely screening young athletes will remain prohibitive for society, despite the opinion of the New York Times it looks like saving those 125 robust young lives each year will remain a sadly unachievable dream.