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Gold, incentives and meh

Charity requesting GP follow-ups following unapproved heart screening test

A charity is offering patients an unapproved free heart screening service and sending them to GPs with requests for follow-up tests. 

Cardiac Risk in the Young (CRY), in conjunction with St George’s University Hospitals NHS Foundation Trust, offers free ECG screening to anyone aged 14 to 35 through clinics located across the UK.

The screening programme, which is not approved by the National Screening Committee, directs patients to their GP for follow-up tests if the ECG shows any abnormalities.

GPs warned that not only does this increase their workload, but there could be ‘untoward consequences’ as there is not enough evidence that the benefits ‘outweigh the harms and costs’.

The hospital says that a similar scheme in Italy has suggested that screening saves lives.

The charity screens around 30,000 individuals each year with a health questionnaire and ECG, while St George’s collates and interprets the data.

During the screening process, a cardiologist will discuss any abnormalities with the patient, before sending a letter to the patient’s GP - advising further tests that can be conducted locally - or referring them to the cardiovascular unit at St George’s University Hospitals NHS Foundation Trust.

However, this type of screening is not approved by the National Screening Committee.

RCGP overdiagnosis group member and clinical research fellow at the University of Birmingham Dr Samuel Finnikin said: ‘There is no doubt that sudden cardiac death is tragic, and it seems heartless to oppose initiatives that aim to reduce these tragedies. But the National Screening Committee has considered screening such as that currently being undertaken by CRY and St George’s, and found that the was insufficient evidence that it was beneficial.

‘We simply don’t have the evidence that this screening will have benefits that outweigh the harms and costs. And the costs go beyond the act of screenings. CRY may be using charitable money to fund the screening, but the downstream costs will be passed to the NHS.’

He went on to question the other costs to such screening, asking if the tests are ‘good enough to prevent unnecessary worry and harm to those who have false positives’ and whether the interventions make the patients’ lives better.

‘Well-intentioned initiatives like this will always have untoward consequences. Worried parents/patients may well turn up at their practice expecting their GP to offer this screening, or interpret tests done elsewhere. This is extra work for GPs, and extra concern for patients that probably hasn’t been factored in by CRY or anyone promoting this screening,’ Dr Finnikin added.

Professor Sanjay Sharma, professor of inherited diseases and sports cardiology at the St George's, University of London, said: 'The National Screening Committee have not performed a thorough literature review and have focused only on one disease, hypertrophic cardiomyopathy. Based on a recent paper in the NEJM, the death rate in British adolescent soccer players is 1 in 15,000. If we extrapolated this to the young population, this would equate to 1400 deaths per year. We state at least 600 deaths per year at CRY but the NSC says it is 29.

'At CRY we have shown that ECG screening is possible and will identify people with serious disease. We cannot prove whether this saves lives at present, although we may well be in a situation to show this in 5 years’ time. Data from Italy (where screening is mandatory) has suggested that cardiac screening saves lives.

'We are in the process of developing an infrastructure. CRY (and St George’s University) have trained 29 doctors in screening young people and the management of diseases implicated in their deaths. Of these, 14 have become consultants in various parts of the country and could establish clinics to manage young people identified through screening.'

Dr Steven Cox, chief executive of CRY, said: 'The reason why CRY’s screening programme started (in 1993) is because fit and healthy young people die suddenly from undiagnosed cardiac conditions. Usually they will have had no symptoms and the only way to have prevented the death would have been through screening. Undiagnosed cardiac conditions are one of the most common causes of death in young people and the most common cause in young athletes.

'There are many problems with the outdated approach the National Screening Committee (NSC) is taking on this issue, but the most serious of these is the way they have massively underestimated the number of young people who are dying of these conditions. It is also unacceptable how the NSC have incorrectly evaluated the electrocardiogram (ECG) as a diagnostic test.'

Earlier this year, GPs raised concerns over Public Health England's heart age campaign, which asked everyone over 30 to take an online test to find out their ‘heart age’ and directed patients to their GP if their cholesterol level or blood pressure was unknown.

Readers' comments (16)

  • If evidence isn't there - it is called a RESEARCH TRIAL and GPs are paid to recruit and manage patients within these trials.

    If the evidence is there, it is NON-CORE work and GPs need to be paid an enhanced service for carrying this out.

    It's simple really. But I could have put a fiver on Ivan defending screening at all costs - I don't think he attended the medical school lecture on risks and benefits of it.

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  • 2 points

    1) Have the originators of this scheme thought that by forcing young people into appointments they may displace older people with serious pathology.? Have they thought they may actually do population harm ( despite NHSE myth GP appointments are unlimited and free there is very very limited capacity)
    2) even if I was paid for this extra contractual work I would not be getting involved with 14 yr olds ECGs. ( as someone who has studied ECGs extensively). Were the MDOs consulted

    Well meaning amateurs are doing so much harm with this sort of thing.

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  • Guys;

    He does not need evidence

    He does not need research

    He does not need to be reasonable

    He does not need to consider reflect or any other of the things in the med school lectures

    There is no mechanism by which he can be stopped

    There is no-one looking at stopping him

    There is no body with the authority to stop him

    To negotiate a fee we would have to go to war with terrified mothers concerned about the lives of their children.Personally I would duck that one.

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  • you could refer him to me :)

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  • I have enjoyed reading this debate and just wanted to make a few clarifications and provide more information. The views below are my own and do not reflect those of my Trust or University:

    1. CRY is a non profit making organisation.
    2. Our Trust does not receive financial remuneration to conduct screening, however our clinics support further investigations for those referred to us.
    3. Most individuals self-present to CRY screenings because they are worried about potential symptoms and their family history.
    4. Cardiologists working with CRY filter out a large proportion of young people with atypical symptoms by taking a careful history, examining the ECG and performing echocardiography on the day (if necessary); therefore they save workload for GPs and the NHS rather than increase it.
    5. Only 2% of the number screened around the country need further tests to confirm or refute cardiac disease. Based on the numbers screened per year this equates to 600 referrals per year throughout the country. Whereas I agree that this may be considered as extra work in primary care, it is not as onerous as some perceive.

    Important points you may wish to consider in your arguments are as follows:

    1 in 300 young people have a cardiac disorder capable of causing sudden cardiac death.Over 80% of these individuals have no warning symptoms prior to sudden cardiac arrest. Most deaths occur at home and during sleep where timely use of a defibrillator is not possible. Over 60% of young people diagnosed with serious disease receive medical intervention other than life style modification. The cost of identifying 1 person with a serious cardiac disorder based on NHS tariffs in £29k; CRY swallows most of this cost! We are prepared to pay up to £30k for QALY in the UK just imagine how many life years you give back to a 16 year old diagnosed with long QT syndrome by prescribing a beta-blocker (50 years plus!!!!).

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  • Many new screening tools are being developed and require cost-effectiveness analyses to support their value proposition. It is clear that NHS have not done this work yet. Without meaning to impune anyone's good will here, a single issue charity is not always the place to expect the most dispassionate analysis.

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