Preparticipation Screening of Athletes

In this issue of JAMA, the article by Glover and Maron¹ addresses the issue of improving the sensitivity of the preparticipation examination (PPE) to detect silent, clinically important cardiovascular abnormalities that place the athlete at risk for sudden cardiac death (SCD). Fortunately, SCD is rare in high school athletes. But the appeal of being able to identify risk factors and thereby prevent SCD, coupled with the legal obligation for sports organizations and institutions to provide a safe environment for athletes points to the need to consider, wherever possible, ways to improve the sensitivity of the PPE. Glover and Maron have identified the following problems with the high school PPE process: (1) 16% of states have no approved history and physical examination forms; (2) of the 84% of states that do, questions deemed essential for detecting abnormalities were missing from half of the history forms and more than 60% of the physical examination forms; and (3) only 40% of the states had questionnaires that incorporated the majority of 1996 American Heart Association recommendations.

Even before these new data were available, most clinicians who perform these examinations were aware that the PPE was not a perfect process. There are both quality and compliance issues. Bradford and Lyons² surveyed 114 public school districts in Pennsylvania and found that in one third of the cases the examinations lasted less than 5 minutes, 25% included no medical history, and 60% had no musculoskeletal examination. In addition, the PPE is considered primarily to be an examination for the purpose of assigning financial responsibility and legal liability despite the consistent finding that this examination is the only routine primary or preventive health care received by the majority of athletes.^{3 - 6} What this means is that most examinations are sport-referenced and sport specific; identification of the causes for disqualification and assessment of readiness to play are the essential attributes of most PPEs rather than the principles of health-referenced periodic examinations for patients in a given age range.

In addition, considerable resources are required to perform screening examinations, yet insurance reimbursement is not forthcoming and the institutions mandating PPEs seldom provide the resources required to do the job effectively. For instance, Stanford University spends the equivalent of 14 person-weeks in preparing, conducting, and evaluating the data from a single mass screening examination.

The findings of Glover and Maron are important because they highlight deficiencies in a process relied upon for its ability to detect risk factors for SCD; somewhere in the midst of hundreds or even thousands of normal examinations is an athlete who has clinically silent cardiovascular disease that places him or her at risk for sudden cardiac death. But, equally important for the physician in a busy office performing these examinations is the ability to identify other serious conditions that limit sport participation, such as the type of cervical spine instability that places an athlete in contact sports at risk for quadriplegia. Many other less serious problems, such as the absence of paired vital organs or the presence of weight-bearing joint instability, also must also be detected. The large number of "negative" responses to questions and normal physical examinations during mass screening examinations serves to dull the acumen of even the most careful of physicians to the point of mitigating against any improvements in the sensitivity of the PPE.

The practitioner faces the daunting task of identifying each and every condition that could potentially affect the health of the performing athlete, an issue of inclusion (sensitivity) balanced with exclusion (specificity).⁷ But more forms, more regulations, or more questions added to an already tedious process, is not the answer, particularly when compliance and resources are already part of the problem. The effort to detect rare medical conditions on screening examinations is fraught with realities that conspire against its effectiveness. For example, if the prevalence of SCD is, as Glover and Maron suggest, 1 in 200000, a PPE question or physical examination maneuver to detect it would need to be extremely sensitive. Any test with high sensitivity would typically have lower specificity, resulting in false positives. This has several implications, including the predictive value of a positive test result would be exceedingly low, new problems would arise for the athlete being labeled (falsely) as "abnormal," higher costs and inappropriate investigations inevitably would follow (associated with their own levels of morbidity), and a number of healthy individuals would be excluded from participation. In the end, there is still no guarantee that 1 true positive would be detected—even 99.99% sensitivity would miss 200 cases in a sample of 200000. The quality and compliance problems with the PPE process are directly related to the interface between the principles of sensitivity and specificity and the reality of busy practitioners examining thousands of normal young people.

Practitioners should pay attention to the data from Glover and Maron and incorporate changes to their own PPE process just as they would for any new information that improves the detection of disease or injury. But consideration should be given to revamping the PPE, not only to improve its sensitivity but to address the issues of quality and compliance inherent in any screening process. The history is the most sensitive method for detecting problems; the majority of medical and musculoskeletal problems in athletes are identified by the history rather than the physical examination.^{3 ,8 - 9} Recent studies have shown that computerized questionnaires collect health information more efficiently^{10 - 12} and with equal or greater accuracy than personal interviews or paper-based questionnaires.^{13 - 15}

We have recently created a detailed history form¹⁶ that the student athlete can complete from any remote location by accessing the World Wide Web. The questionnaire, which takes approximately 30 minutes to complete and is password protected, is a detailed version of the standard PPE components⁷ but also includes questions on disordered eating, sleep disorders, health-risk behaviors, psychological stress, and nutrition. For every athlete a 2-page printed summary is generated that details each positive response, thereby permitting time spent by the clinician to be more effectively focused on details of the history and physical examination.

In the short term, standard PPE forms should be supplemented with new information as it becomes available. The longer-term objectives, however, are to develop a PPE process that meets the goals of being health-referenced and sport-referenced,¹⁶ to be highly sensitive for detecting disease and injury, and to reduce the time and resources required.