Inter-Rater Reliability and Downstream Financial Implications of Electrocardiography Screening in Young Athletes

Harshil Dhutia, Aneil Malhotra, Tee Joo Yeo, Irina Chis Ster, Vincent Gabus, Alexandros Steriotis, Helder Dores, Greg Mellor, Carmen García-Corrales, Bode Ensam, Viknesh Jayalapan, Vivienne Anne Ezzat, Gherardo Finocchiaro, Sabiha Gati, Michael Papadakis, Maria Tome-Esteban, Sanjay Sharma

Research output: Contribution to journalArticlepeer-review


BACKGROUND: Preparticipation screening for cardiovascular disease in young athletes with electrocardiography is endorsed by the European Society of Cardiology and several major sporting organizations. One of the concerns of the ECG as a screening test in young athletes relates to the potential for variation in interpretation. We investigated the degree of variation in ECG interpretation in athletes and its financial impact among cardiologists of differing experience.

METHODS AND RESULTS: Eight cardiologists (4 with experience in screening athletes) each reported 400 ECGs of consecutively screened young athletes according to the 2010 European Society of Cardiology recommendations, Seattle criteria, and refined criteria. Cohen κ coefficient was used to calculate interobserver reliability. Cardiologists proposed secondary investigations after ECG interpretation, the costs of which were based on the UK National Health Service tariffs. Inexperienced cardiologists were more likely to classify an ECG as abnormal compared with experienced cardiologists (odds ratio, 1.44; 95% confidence interval, 1.03-2.02). Modification of ECG interpretation criteria improved interobserver reliability for categorizing an ECG as abnormal from poor (2010 European Society of Cardiology recommendations; κ=0.15) to moderate (refined criteria; κ=0.41) among inexperienced cardiologists; however, interobserver reliability was moderate for all 3 criteria among experienced cardiologists (κ=0.40-0.53). Inexperienced cardiologists were more likely to refer athletes for further evaluation compared with experienced cardiologists (odds ratio, 4.74; 95% confidence interval, 3.50-6.43) with poorer interobserver reliability (κ=0.22 versus κ=0.47). Interobserver reliability for secondary investigations after ECG interpretation ranged from poor to fair among inexperienced cardiologists (κ=0.15-0.30) and fair to moderate among experienced cardiologists (κ=0.21-0.46). The cost of cardiovascular evaluation per athlete was $175 (95% confidence interval, $142-$228) and $101 (95% confidence interval, $83-$131) for inexperienced and experienced cardiologists, respectively.

CONCLUSIONS: Interpretation of the ECG in athletes and the resultant cascade of investigations are highly physician dependent even in experienced hands with important downstream financial implications, emphasizing the need for formal training and standardized diagnostic pathways.

Original languageEnglish
Pages (from-to)e003306
JournalCirculation: Cardiovascular Quality and Outcomes
Issue number8
Early online date14 Aug 2017
Publication statusPublished - Aug 2017


  • Adolescent
  • Adult
  • Age Factors
  • Arrhythmias, Cardiac/complications
  • Athletes
  • Clinical Competence
  • Cost-Benefit Analysis
  • Death, Sudden, Cardiac/etiology
  • Electrocardiography/economics
  • Female
  • Health Care Costs
  • Humans
  • Logistic Models
  • Male
  • Multivariate Analysis
  • Observer Variation
  • Odds Ratio
  • Predictive Value of Tests
  • Prognosis
  • Reproducibility of Results
  • Risk Assessment
  • Risk Factors
  • Young Adult


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