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Sickle cell trait associated with a RR of death of 37 times in National Collegiate Athletic Association football athletes: a database with 2 million athlete-years as the denominator |
Harmon KG, Drezner JA, Klossner D, Asif IM |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary The aim was to explore the cost-effectiveness of different methods of screening for sickle cell trait, which is a cause of sudden death, in athletes. The authors concluded that if the identification of athletes with sickle cell trait was effective in preventing their deaths, then screening of high-risk groups was cost-effective. There were some limitations to the methods and reporting of the study, so the authors’ conclusions should be considered with caution. Type of economic evaluation Cost-effectiveness analysis Study objective The objective was to explore the cost-effectiveness of different methods of screening for sickle cell trait, which is a cause of sudden death, in athletes. Interventions Three screening tests were examined: a $5, a $30 and a $150 test. The $5 test was a laboratory haemoglobin solubility test, the $30 test was haemoglobin electrophoresis, and the $150 test was haemoglobin electrophoresis. The three tests were evaluated for black football players, all football players, all black athletes, and all athletes. Methods Analytical approach:The authors used a basic modelling approach to combine the estimates of the relative risk of exertional death, in those with sickle cell trait, compared with those without, with assumptions on the effectiveness of screening, to estimate its cost-effectiveness. The time horizon of the analysis was lifetime. The authors did not state the perspective. Effectiveness data:The main effectiveness inputs were the relative risk of exertional death, in those with sickle cell trait compared with those without. These estimates were based on an analysis of data on deaths in athletes, from two sources – the National Collegiate Athletic Association (NCAA) Resolutions list and the Parent Heart Watch (PHW) database – from 2004 to 2008. Screening was assumed to be 100% sensitive and specific, and identification prevented all deaths from exertion. The main clinical effectiveness estimate was the number of athletes with sickle cell trait screened, which equated to the number of deaths averted. Monetary benefit and utility valuations:Not relevant. Measure of benefit:Life-years gained were the primary summary benefit measure. The authors assumed that the identification of an athlete with sickle cell trait would prevent their death, yielding an additional 50 years of life (the average life expectancy for a college-aged athlete). Cost data:The cost categories were the costs of the screening test, which were contracted between the NCAA and member institutions, at October 2011 prices, for the $5 and $30 options, and estimated at $150 for haemoglobin electrophoresis. All costs were in US $. Analysis of uncertainty:No analysis of uncertainty was conducted. Results The total cost of screening ranged from $202,900 for black football players with the $5 test, to $119,539,920 for all athletes with the $150 test. The cost to prevent one death over five years (from 2004 to 2008) ranged from $40,580 if screening was restricted to black football players, using the $5 test, to $23,907,984 if all athletes were screened, using the $150 test. The cost per life-year saved ranged from $812 for black football players screened with a $5 test, to $478,160 for all athletes screened with the $150 haemoglobin electrophoresis. If only incoming athletes were screened, using the $30 test, the cost per life-year saved ranged from $2,435 for black football players, to $47,816 for all athletes. Authors' conclusions The authors concluded that if the identification of athletes with sickle cell trait was effective in preventing their deaths, then screening of high-risk groups was cost-effective. CRD commentary Interventions:The description of the intervention was adequate, but some detail of the process and methods of screening would have enhanced the understanding of the procedures being carried out. The screening interventions may be relevant for other settings. Effectiveness/benefits:The risk of death from exertion was from a source highly relevant to the study population, but the methods used to derive the estimates were not described. The identification of an athlete with sickle cell trait was assumed to prevent their death, which is a very strong assumption and was not supported by the evidence nor varied in the sensitivity analysis. This could affect the results and conclusions. It was unclear if the life-years were discounted, which would have been appropriate for the lifetime horizon. Costs:The authors did not state the study perspective, but they considered only the direct costs of the purchase of the test; so it seems that a payer perspective was selected (the payer being the student's institute). The sources for the resource use and prices were not referenced, and it was unclear how much variation there was in the price of the tests, particularly for haemoglobin electrophoresis. The validity of the costs and their applicability to other settings were difficult to assess, with this lack of information. The cost implications of a diagnosis of sickle cell trait were not considered, and the indirect costs and benefits to society of successful screening were not considered. Analysis and results:It was appropriate for the authors to compare the relative cost-effectiveness of different options, but the synthesis of the costs and outcomes was very basic. The reporting of the results was adequate. The impact of uncertainty in the results was not considered, and the limitations of the cost-effectiveness analysis were not discussed. Concluding remarks:There were some limitations to the methods and reporting of the study, so the authors’ conclusions should be considered with caution. Bibliographic details Harmon KG, Drezner JA, Klossner D, Asif IM. Sickle cell trait associated with a RR of death of 37 times in National Collegiate Athletic Association football athletes: a database with 2 million athlete-years as the denominator. British Journal of Sports Medicine 2012; 46(5): 325-330 Indexing Status Subject indexing assigned by NLM MeSH Cause of Death; Cost-Benefit Analysis; Death, Sudden /etiology /prevention & Early Diagnosis; Football /statistics & Humans; Physical Exertion /physiology; Risk Factors; Sickle Cell Trait /complications /diagnosis /mortality; Sports Medicine /economics; United States; control; numerical data AccessionNumber 22012021903 Date bibliographic record published 04/12/2012 Date abstract record published 15/04/2013 |
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