Odpowiedź dają włoscy lekarze. Tematyka była poruszona na specjalnej sesji podczas Kongresu MKOl w Monaco wiosną bieżącego roku, a teraz powtórzona podczas Kongresu Europejskiego Towarzystwa Kadiologicznego
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http://www.medscape.com/viewarticle/748774?src=nl_topic Italian Preparticipation Sports Screening Cost-EffectiveMichael O'Riordan
August 29, 2011 (Paris, France) — The Italian model for a preparticipation sports screening program, one that includes a 12-lead electrocardiogram (ECG) for all individuals participating in athletics, is a cost-effective mass-screening program, according to researchers who performed the analysis. The cost for one additional year of life saved for individuals disqualified from sports for genetic cardiomyopathies is worthwhile, considering the long time these patients will live if excluded from high-risk physical activity, state the researchers.
"Young competitive athletes with a genetic disorder have a good outcome and life expectancy that is nearly normal," lead investigator Dr Domenico Corrado (University of Padova, Italy) said during a session on preparticipation screening of athletes at the European Society of Cardiology (ESC) 2011 Congress. Assuming the individual lives for an additional 20 or 30 years, the cost for one year of life saved (YLS) is €50 000 and €33 000, respectively, "which is within the limits of cost-effectiveness for considering medical therapy efficient," said Corrado.
Italy has led the way in screening young athletes before allowing them to compete in sports. The Italian model, which includes a physical examination, family history, and screening with a 12-lead ECG, was instituted in 1982. During that time, the annual incidence rates of sudden cardiovascular death (SCD) in competitive athletes aged 12 to 35 years old in the Veneto region of Italy declined 89%, down from four events per 100 000 person-years in unscreened athletes to 0.4 events per 100 000 person-years in screened individuals.
Different Screening Approaches WorldwideThe cost of widespread screening, as well as the risk of false-positive ECGs that might prevent healthy individuals from participating in sports and the battery of unnecessary tests they will face, have limited the adoption of mass-screening programs in other countries. In the US, the American College of Cardiology and the American Heart Association limit screening to a physical examination and medical history, while the ESC and International Olympic Committee recommend resting 12-lead ECG to detect cardiac abnormalities.
In the present study, investigators assessed the cost-effectiveness of widespread screening in Italy. Based on data from their experience, they assumed that 40 SCDs occurred for every million patients who went unscreened compared with just four events for every one million patients who underwent screening (four and 0.4 events, respectively, per 100 000 person-years), leading to 36 lives saved for every million patients screened with 12-lead ECGs.
Speaking during the ESC session, Corrado said the cost of family history, physical examination, and an ECG in Italy is €30, leading to a total cost of €30 million for one million patients screened. Of these, approximately 100 000 patients with positive findings would be expected to undergo further testing at a cost of €60 per patient, leading to an additional cost €6 million. In total, the cost of screening is €36 million.
Based on 36 lives saved, the total cost of screening for one life saved is €1 million. Using different estimates of additional life-years lived, the investigators developed models that calculated the cost of one YLS. If the patient lived 10, 20, or 30 years, the cost of one YLS is €100 000, €50 000, and €33 000, respectively.
Dr Sanjay Sharma (St George's University of London, UK), who chaired the ESC session on preparticipation screening, questioned the analysis, saying that the low cost of initial screening and cost of additional testing jumped out at him, noting that if these numbers were higher, as they likely are in other countries, the cost-effectiveness analysis of widespread preparticipation screening would be questionable.
"The cost of just €30 for history, examination, and ECG and the cost of just €60 for additional investigation might be possible in places like Italy, where you have the infrastructure and lots and lots of sports cardiologists, but I don't think we can echo the same sentiments in most of the Western countries," said Sharma. "For example, in the UK, just to shake hands with a cardiologist you're €200 down."
Corrado agreed, saying the cost-effectiveness analysis applies only to the Italian experience. In different countries, without the requisite health infrastructure, these costs would be higher.
HCM With and Without ECG AbnormalitiesIn another study, Dr Chiara Calore (University of Padova) focused on the clinical characteristics of hypertrophic-cardiomyopathy (HCM) patients who present with either a normal ECG or isolated QRS voltage criteria for left ventricular hypertrophy. In their initial survey of 245 patients with documented HCM, 11 patients (5%) presented with a normal ECG, while just six patients had an increased in QRS voltage. Speaking during the ESC session, Calore said that these patients differed from HCM patients with an abnormal ECG in that they had a lower maximal left ventricular wall thickness and had left ventricular hypertrophy confined to the basal septum.
The researchers also noticed a trend toward reduced arrhythmic events among the HCM patients with normal ECGs or isolated QRS criteria for left ventricular hypertrophy compared with HCM patients with abnormal ECGs. This led to the critical question about whether or not HCM patients with normal ECGs should be allowed to participate in sports.
Although Calore said the question was difficult to answer, Corrado, who was also involved in the research, said the study hints at the possibility of one day selecting low-risk HCM patients who might be eligible for athletic activity. During the question-and-answer session, others noted that age is an important factor in determining whether a patient should be allowed to play sports. HCM is a disease that progresses during the second decade of life, so a normal ECG finding in an HCM patient at 15 years old differs significantly from a normal ECG in a 40-year-old individual with HCM.
