Challenges to implementing clinical guidelines for preparticipation physical evaluations in youth sports

In most regions in the USA, young athletes interested in participating in organized sports are mandated by law to undergo a preparticipation physical evaluation (PPE) [1,]. According to the PPE Task Force, which was formed in the early 1990s by the American Academy of Pediatrics, American Academy of Family Physicians, and several leading sports medicine organizations, the main goal of the PPE is to promote athlete health and safety [2]. Although PPE stands for preparticipation “physical” evaluation, prior studies suggest that most medical conditions can be detected by history alone [3, 4,]. Thus, the PPE Task Force emphasizes the history as the most relevant aspect of the PPE [2,]. Clinical guidelines for evaluating athletes’ medical history were developed by the PPE Task Force, and their recommendations are summarized in the PPE Monograph, now in its 5th edition (PPE-5), published in 2019 [2]. Although the PPE Monograph describes the standard of care for PPEs, prior literature reveals substantial variation in the implementation of the previous, 4th edition of the PPE Monograph (PPE-4) [1, 5]. It has been nearly 5 years since the PPE-5 was published; still, there is scarce research evaluating adherence to the updated recommendations. We therefore conducted a study at an urban academic health system in California to evaluate the frequency at which clinicians have been implementing standard history elements as recommended by the PPE-5. Of the 365 PPEs we reviewed, only about one-third (28.6%, SE = 0.74) of history elements recommended by the PPE-5 were documented across all patients. While cardiac-related history is emphasized in medical training due to the devastating consequences of missing cardiac conditions that can lead to sudden cardiac death, these symptoms were documented in less than half of the PPEs we reviewed. Though alarming, this finding was not unexpected, given similar findings from a recent study by Miliaresis et al., evaluating adherence to documentation of the American Heart Association’s 14‐point screening questionnaire (AHA-14) in pediatrics. The study found that clinicians were documenting, on average, only about 3.5 out of the possible total of 14 cardiovascular screening elements [6]. To identify barriers affecting adherence to the PPE-5’s recommendations, we distributed an anonymous survey to pediatricians and family medicine physicians at clinics affiliated with an urban academic health center in California. We found that only 41% of the 73 respondents were aware of the PPE-5. The most frequently reported reason for not utilizing the PPE-5’s medical history form was lack of awareness. Prior literature has similarly revealed a lack of familiarity with PPEs among primary care physicians. In a 2012 telephone and web-based survey analyzing utilization of the PPE-4, only 37% of pediatric and family medicine physicians reported an awareness of the PPE-4 [5,]. In a survey of pediatricians in the lower Hudson Valley of New York State conducted in 2013, only 34% of respondents reported being familiar with the PPE, despite 91% of respondents routinely performing sports physicals [6]. That only 41% of pediatric and family medicine physicians at our institution reported being aware of the PPE-5, suggests that awareness of the PPE Monograph’s recommendations has remained largely unchanged over the past decade and highlights the importance of clinician education in delivery of PPEs consistent with clinical guidelines. Interestingly, prior literature has demonstrated that PPEs do not reduce morbidity and mortality associated with sports participation [7]. The PPE Monograph itself states that “there is no solid evidence that a screening PPE will reliably identify important, but clinically silent, conditions” [2]. This poses an important question: is this because the medical histories being obtained by clinicians are often inconsistent with the PPE Monograph’s recommendations, or, does the PPE Monograph’s medical history form inherently have poor sensitivity and specificity for detecting dangerous or life-threatening conditions? Despite this ambiguity, given that the leading cause of mortality among athletes during sports is sudden cardiac death, identifying cardiac conditions associated with sudden cardiac death should be prioritized as part of the PPE. Similar to the AHA-14, the PPE-5’s medical history form contains consensus-derived questions based on expert opinion. A 2019 study published by Williams et al. found that the AHA-14 performed poorly compared to electrocardiograms for cardiovascular screening of high school athletes, highlighting the limitations to routine use of consensus-derived, history‐based questionnaires as the principal tool for preparticipation cardiovascular screening of young athletes [8]. Although performing electrocardiographic (ECG) screenings as part of the PPE is not currently standard practice, prior research has demonstrated that ECGs have a low false-positive rate and superior accuracy compared to a standardized history for detecting life-threatening cardiac conditions [9]. Although the upfront cost of performing ECG screenings as part of the PPE may be slightly higher than that of obtaining a cardiac history alone, prior literature demonstrates that addition of an ECG actually improves cost efficiency per diagnosis by 5-fold [10]. Thus, we believe that ECG screenings are valuable adjuncts to the standardized cardiac history and advocate for evolving current PPE guidelines to include ECG screenings as standard practice. Future research should involve outcome-based research to evaluate how the PPE can be refined to better identify athletes at risk of life-threatening or disabling conditions. More research is needed to determine whether variations in the implementation of PPEs, such as the setting in which they are performed (e.g. medical home, urgent care, or school-based event) influence its efficacy. Finally, while international consensus statements have been developed for certain sports-related medical conditions such as concussion, there is no such standardized guideline for PPEs at the international level, highlighting an opportunity for sports organizations and governing bodies around the world to collaborate on developing uniform clinical practice guidelines globally to reduce practice variation in identifying life-threatening cardiac conditions in youth athletes. None declared.