ECG Screening for Heart Conditions in ADHD Children is Borderline Cost Effective
• Science Update
Obtaining an electrocardiogram (ECG) to screen for heart conditions in children prior to prescribing stimulant medication to treat attention deficit hyperactivity disorder (ADHD) may save some lives but it is borderline cost-effective, according to an NIH study published online ahead of print March 8, 2010, in Circulation: Journal of the American Heart Association.
Stimulant medications, such as methylphenidate (Ritalin and Concerta) and amphetamines (Adderall), are used to treat ADHD in children. These medications may increase the risk for sudden cardiac deaths (SCD) in some children with certain underlying heart conditions. Peter Denchev, Ph.D., of NIMH and colleagues at NIMH and the National Heart, Lung and Blood Institute developed a model to compare the cost-effectiveness of three strategies for screening for the risk of heart disease and SCD among children being treated with stimulants.
The three strategies are:
- conducting a history and physical exam (H&P) and referral to a cardiologist if the exam showed anything abnormal (considered usual standard of care),
- H&P plus an ECG and referral to cardiologist if either showed abnormal results,
- H&P plus ECG and referral to cardiologist only if the ECG showed abnormal results.
Results of the Study
The authors measured the cost-effectiveness of each strategy by estimating its cost per quality-adjusted life year (QALY). A QALY is a type of outcome measure that takes both length and quality of life into account. Denchev and colleagues found that compared to strategy 1, strategy 2 would cost $39,300 per additional QALY, and strategy 3 would cost $27,200 per additional QALY. According to the modeling data, both strategy 2 and 3 would likely prevent 13 SCDs per 400,000 children seeking stimulant treatment for ADHD over a 10-year period. Assuming that society would be willing to pay up to $50,000 per (QALY), the authors conclude that ECG screening for heart conditions in children with ADHD is borderline cost-effective.
The authors conclude that adding ECG to the current standard of care may identify more children at risk for SCD prior to starting them on stimulants for treating ADHD. It also would afford an opportunity to discourage at-risk children from playing competitive sports, which could bring on a cardiac event. However, adding ECG as a matter of course is borderline cost-effective.
The authors caution that the economic analysis is meant only to provide information to decision-makers, not affect diagnostic or treatment recommendations. The American Heart Association currently recommends that doctors consider obtaining an ECG prior to prescribing stimulants if they believe it is warranted.
Denchev P, Kaltman J, Schoenbaum M, Vitiello B. A modeled economic evaluation of alternative strategies to reduce sudden cardiac death among children treated for attention deficit/hyperactivity disorder. Circulation: Journal of the American Heart Association. Online ahead of print March 8, 2010.