Editorials

AMA Policy Statement on Cardiovascular Screening of Student Athletes

JAMES M. LYZNICKI, M.S., M.P.H.
Council on Scientific Affairs
Chicago, Illinois

NANCY H. NIELSEN, M.D., PH.D.
State University of New York at Buffalo
Buffalo, New York

JOHN F. SCHNEIDER, M.D., PH.D.
University of Chicago Hospitals
Chicago, Illinois

See article in this issue.

In December 1999, the American Medical Association (AMA) Council on Scientific Affairs issued a report on cardiovascular screening of student athletes. This report adds to the American Heart Association's (AHA's) 1996 consensus recommendations for the cardiovascular component of the preparticipation examination of students,¹ and the 1997 guide, "The Preparticipation Physical Evaluation,"² sponsored by several major medical organizations, including the American Academy of Family Physicians (AAFP).

The background article for the current AMA report, "Cardiovascular Screening of Student Athletes," is featured in this issue of American Family Physician.³ The following statements, recommended by the Council on Scientific Affairs, were adopted as AMA policy in December 1999:

1. To promote the health and safety of adolescents, the AMA recommends that state medical societies work with appropriate state and local agencies to promote the following: (A) The development of standards for preparticipation physical examinations (PPEs) that are consistent with consensus recommendations of the AAFP, American Academy of Pediatrics (AAP), American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine and American Osteopathic Academy of Sports Medicine; (B) Only licensed physicians who hold M.D. and D.O. degrees and licensed physician extenders practicing under the supervision of such physicians perform preparticipation examinations; (C) The decision as to whether or not an adolescent is healthy and physically mature enough to participate in a particular sport is made by a qualified physician; (D) The decision as to when an injured athlete resumes participation is made by a qualified physician; and (E) The most current guidelines established by the AAP, American College of Cardiology (ACC), American College of Sports Medicine (ACSM) and other appropriate medical specialty societies are used to determine eligibility for sports participation.

2. The AMA will work with appropriate medical specialty societies to increase awareness among physicians, state and local medical societies, parent-teacher organizations, state legislatures, athletic associations, school administrators and school boards of the availability of consensus medical guidelines and recommendations for sports PPEs.

3. The AMA will submit this report to the Preparticipation Physical Evaluation Task Force requesting that AHA recommendations for (A) family history of heart disease; (B) a specific item for recognition of a heart murmur in the physical examination; and (C) a specific item for recognition of the physical stigmata of Marfan syndrome be considered in future iterations of the PPE form.

James M. Lyznicki, M.S., M.P.H., is a senior scientist in the American Medical Association (AMA) Group on Science, Technology, and Public Health, and assistant secretary to the AMA Council on Scientific Affairs.

Nancy H. Nielsen, M.D., PH.D., serves as clinical faculty at the State University of New York at Buffalo School of Medicine and Biomedical Sciences.

John F. Schneider, M.D., PH.D., is in practice at the University of Chicago Hospitals and professor of clinical medicine in the Division of Biological Sciences at the University of Chicago Pritzker School of Medicine.

Address correspondence to Barry Dickinson, Ph.D., Secretary to the Council on Scientific Affairs, American Medical Association, 515 N. State St., Chicago, IL 60610. E-mail address: barry_dickinson@ama-assn.org.

REFERENCES

1. Maron BJ, Thompson PD, Puffer JC, McGrew CA, Strong WB, Douglas PS, et al. Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee and Congenital Cardiac Defects Committee, American Heart Association. Circulation 1996;94:850-6 [Addendum appears in Circulation 1998;97:2294].
2. Smith DM, American Academy of Family Physicians, Preparticipation Physical Evaluation Task Force. Preparticipation physical evaluation. 2d ed. Minneapolis: Physician and Sportsmedicine, 1997.
3. Lyznicki JM, Nielsen NH, Schneider JF. Cardiovascular screening of student athletes. Am Fam Physician 2000;62:765-74.

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Maternal Serum Triple Analyte Screening in Pregnancy

SARA CATE, M.D.
Central Washington Family Medicine
Yakima, Washington

See article in this issue.

Genetic screening is a burgeoning field of medicine, and family physicians will be instrumental in translating this new science to patients. Dr. Newberger's article¹ in this issue of American Family Physician reviews the importance of screening for Down syndrome. The article is timely and the issues of sensitivity, specificity and cost-effectiveness--common to all screening tests--are reviewed.

On the surface, triple analyte screening for Down syndrome seems like a good idea. It is a blood test that can lead to prenatal detection of Down syndrome. But, like all screening tests, it has its drawbacks. Triple analyte screening has limited sensitivity, with an overall rate of 60 percent and an overall specificity of 93 percent, although these percentages vary according to the age of the patient being screened. A positive test result may need to be confirmed with amniocentesis. Following amniocentesis, a small number of fetuses with false-positive triple-analyte test results will be miscarried.

The limitations of this test highlight the importance of informed consent. The more complex the screening test with respect to potential adverse outcomes, the greater the physician's responsibility to discuss the alternatives, risks and benefits, including assessing each patient's understanding and preferences.² Some patients want to know whether their infant has Down syndrome in order to emotionally prepare for the birth of that child. Other patients may want the option of termination, while still others are not interested in screening if the confirmatory test is associated with any risk of fetal loss. Shared decision-making ensures that the patient is invested in the decision to screen, regardless of the outcome.

While the potential benefits of better patient-physician communication in this litigious society are great, the burden of informed consent rests heavily on physicians. Can we provide this discussion to all pregnant patients? What are the practical considerations of time and financial reimbursement? How do we weigh the costs and benefits of screening for Down syndrome?

In 1996, the American College of Obstetricians and Gynecologists (ACOG) recommended triple analyte screening for all pregnant women less than 35 years of age and amniocentesis for all pregnant women 35 years or older; the U.S. Preventive Services Task Force (USPSTF) recommends triple analyte screening for all pregnant women. The USPSTF recommends offering the triple screen and amniocentesis to women 35 years or older.^3,4 Decision analysis incorporates all potential benefits and costs. It has shown that implementation of the ACOG guideline is associated with the highest number of pregnancy losses associated with amniocentesis and the highest cost per case detected. Screening all women first with the triple analyte test has a 20 percent lower cost and almost one half the number of pregnancy losses associated with amniocentesis.⁵ This analysis suggests that the USPSTF recommendation would be more cost effective.

In addition, the detection rate of the triple analyte test is strongly age-dependent. Older patients accrue the greatest benefits of screening. There are low benefits or even negative effects associated with screening in younger patients. Decision analysis suggests that limiting screening to older women (e.g., those more than 30 years of age) would limit the number of women who need pretest counseling and the number of amniocentesis-related fetal losses, and would lower screening program costs.^6,7

In the future, ultrasonography may be used to reduce the positive screening rate by a "genetic sonogram." Differences in technical accuracy limit the widespread use of this type of ultrasonography.

With the proliferation of new genetic tests that detect carriers of genes that cause and predispose to disease, genetic testing will likely become a much bigger part of primary care practice. The impact on our practices may be profound. Family physicians must play a leadership role in the creation of guidelines for genetic testing that take into account all costs and benefits and in the promotion of skills that enhance communication and shared decision-making with our patients.

REFERENCES

1. Newberger DS. Down syndrome: prenatal risk assessment and diagnosis. Am Fam Physician 2000;62:825-32,837-8.
2. Braddock CT, Edwards KA, Hasenberg NH, et al. Informed decision making in outpatient practice. JAMA 1999;282:2313-20.
3. American College of Obstetricians and Gynecologists. Down syndrome screening. Maternal serum screening. In: ACOG Educational Bulletin. No. 228. Washington, D.C.: American College of Obstetricians and Gynecologists, 1999.
4. Screening for Down syndrome. In: Guide to clinical preventive services: report of the US Preventive Services Task Force. Baltimore: Williams & Wilkins, 1996;449-65.
5. Cusick W, Vintzileos AM. Fetal Down syndrome screening: a cost effectiveness analysis of alternative screening programs. J Matern Fetal Med 1999; 8(6):243-8.
6. Fletcher J, Hicks NR, Kay JD, Boyd PA. Using decision analysis to compare policies for antenatal screening for Down's syndrome. BMJ 1995; 311:351-6.
7. Beazoglou T, Heffley D, Kyriopoulos J, et al. Economic evaluation of prenatal screening for Down syndrome in the U.S.A. Prenat Diagn 1998; 18(12):1241-52.

Sara Cate, M.D., M.P.H., is a faculty member in the residency program at Central Washington Family Medicine, Yakima, and a clinical assistant professor in the University of Washington School of Medicine Department of Family Medicine, Seattle.

Address correspondence to Sara Cate, M.D., Residency Program, Central Washington Family Medicine, 1806 W. Lincoln Ave., Yakima, WA 98902.

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