by Gary A. Emmett, M.D.
Recently, Pennsylvania Governor Tom Corbett signed the Sudden Cardiac Arrest Prevention Act “for preventing sudden cardiac death in student athletes ... .” This makes Pennsylvania the first state with legislation on the books protecting kids from SCA.
It is hard to be against a bill that could help prevent some of the 7,000 SCA-related deaths that happen nationally in young people each year. In sudden cardiac arrest, the heart suddenly stops beating – usually because the heart’s chambers begin to quiver rapidly and irregularly. While rare, SCA has led to the collapse and death of kids and teens who seem perfectly healthy.
The law goes into effect this summer, in time for the start of preseason practice. But I am not clear about what it will actually prevent and how expensive it will be. Without knowing those two items, a taxpayer cannot not know if his tax money, and in this case parent’s money and medical insurance money, is being spent wisely. Let me try to explain what you have to know to see if a medical mandate makes any sense. First, some terms:
- Sensitivity – how likely a test will find all those with a problem; in 100 percent sensitivity there are no negative tests found in people with the problem.
- Specificity – how likely a test will be falsely positive; in 100 percent specificity there are no positive tests in people without the problem.
- Prevalence – How common a problem is in the specific group being tested
- Cost – What does the test cost? This is not simple since costs can be money, or the pain of taking the test, or the time cost of getting a false test rechecked, or the emotional cost of giving out false information.
An example: We now test almost all newborns in the United States for deafness. The more sensitive you make a test, the less specific it becomes (and vice versa). We have made this test very sensitive so it will not miss any deaf children. But the prevalence of children born deaf in the U.S. is now very low (the almost universal use of Rubella vaccine brought the rate to around 1 in 1,000 from about 1 in 100 in 1950). The newborn hearing test marks as positive about 10 children in a thousand who do not have hearing loss as being positive for hearing loss. In 1950, if we had this test, we would have found 10 true positive and 10 false positives in a 1,000 newborns, so the specificity of this test would have been 50 percent. In 2012 there will be only 1 true positive and still 10 false positive tests, so this very sensitive test only has a specificity of about 9 percent. In short, for every 1,000 newborns tested for deafness, there will be 11 positive tests but on recheck only 1 of these 11 will actually be deaf. These tests are inexpensive, and if we ignore the cost of the time parents spent getting rechecks, it is probably worthwhile to do these checks even if we drive some parents crazy for a few weeks worrying about children who are actually hearing normally.
In the Sudden Cardiac Arrest Prevention Act , the state says that children participating in school sports or cheerleading (dance is not included) must be withheld from all sports until cleared by a medical practitioner if they develop signs of potential SCA risk such as fainting, difficulty breathing, chest pains, dizziness or a racing heart. There are some positives:
- Some children with asthma will be picked up and properly treated (and since the Pennsylvania state-wide asthma prevalence is at least 120 per thousand this is by far the most likely medical reason for these findings)
- Some child with rare heart problems will be found (if we included undiscovered congenital heart disease, enlarged hearts and rhythm disturbances we are talking about around 3 per 1,000)
But there are a lot of negative (or “we do not knows”):
- Sudden cardiac death can occur at any age and pediatricians believe that many will not have abnormalities on physical examination, EKG or echocardiogram
- From my over 30 years of office care, I know that there are at most one positive cardiac finding in 50 children (and it may be much less) with fainting, chest pains, etc. We’re talking about a lot of EKGs, cardiology visits and echocardiograms. How much will they cost? Who will pay for them? Will they cause distress?
- What grounds should a medical practitioner use for saying the child is okay to return to sports – given that signs of trouble may not show up on an EKG? In Italy, every adolescent who plays sports must have an EKG – does this make sense? The American Academy of Pediatrics thinks that is too much, but honestly I am not sure how much to explore if this child comes to my office.
Gary A. Emmett, M.D., Nemours Pediatrics, Thomas Jefferson University Hospital, Jefferson Medical College, has been a primary care pediatrician in South Philadelphia and Center City since 1979.
What do you think? How do you weigh the costs and benefits of new health mandates?