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EBCT Scan Justification - The IAFF

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EBCT Scan Justification - The IAFF Powered By Docstoc
					Fire Fighter Cardiovascular Screening and
    Heart Disease Prevention Program
              Franklin D. Pratt, M.D.
              Matthew Budoff, M.D.
           Fire Captain George A. Cruz
              Robert Karwasky, M.S.
     History of LA County Wellness/Fitness
                    Program
     Administered by LA County Occupational Health
      Service
     40,000 + exercise tests administered 1970-1992.
     Several landmark research papers published.

    “ Physical Fitness and Subsequent MI in Healthy
      Workers”, Peters.RK, et.al., JAMA 1983; 249:3052-
      3056.

      3400 FFs followed for 4.8 years found 36 MI.
   1970- mandatory pre-employment and periodic
    medical exams for all LA county safety personnel
       Risk associated with low physical work capacity
      evident primarily in subjects with other risk factors.
     History of LA County Wellness/Fitness
                    Program
   1998- LA County joins 9 other FDs to form
    IAFF/IAFC Wellness/Fitness
    Initiative

   2000- Medical Exams resume at 6 contracted
    clinics

   2000-2005 Approx 2000 Medical exams/ year
     Disappointing ~70% compliance.
Cost Components for Follow-up of Abnormal
              Stress Tests
   Initial Cardiologist’ Consult (~$150)

   Additional diagnostic tests
     – Ex. Echo (~$800), or Thallium (~$1800)

   Salary of employee and replacement

   Administrative costs of Worker’s Comp claim
     – $2300 average for cardiac claim, skewed by a few expensive litigations

   Additional diagnostic tests
     – Cardiac catheterization (~$5000)
     – Electrophysiological Studies

   Salary for additional time off pending clearance

   Final Cardiologist Consultation (~$250)

   Potential cost of 184 follow-ups = $275,000 to $775,000
     Cost Components for Follow-up of
           Abnormal Stress Tests



   Cardiac events prevented by early
    diagnosis and treatment of 22 mild or
    moderate CAD cases…….
   Staying Alive


Why is this soooo….
IMPORTANT???
     Firefighter Cardiovascular
    Disease Screening and Heart
         Disease Prevention
 The history of our Program
 The mechanics of Program
 The science and medicine of our program
    Origins of this partnership
   Disagreement between Labor and
    Management on financial responsibility for
    evaluation after Wellness-Fitness Exam

    – When did W/F exam end and “private medical
      care” begin?
    Origins of this partnership
   Too much time lapsed between
    abnormalities discovered at Wellness-
    Fitness Exam and further evaluation
    – Firefighter anxious
    – Mediocre medical care on occasion
      Los Angeles County Fire
    Department and Harbor-UCLA
          Medical Center

 Worked together to provide quicker,
  better screening
 Working toward a future of all inclusive
  prevention and screening strategies
    Origins of this partnership
   Availability of cutting edge diagnostic tools
    in a major medical center

   Academic facility with interest in firefighter
    health
    Product of the Partnership
   Electron Beam Cardiac Scanning for early
    diagnosis

   Intravenous coronary artery imaging

   Integration of diagnosis and treatment
    with prevention, risk factor modification
        Purpose of Program

   May 2000 to October 2001, 38 Workers’ Compensation
    claims were filed for questionable ECG tracings that
    were discovered during a cardiac exercise stress test.

   As a result of the 38 claims filed, the Department
    Medical cost amounted to $96,463.

   36 of the 38 claims were false-positive ECG traces
          Purpose of program
   Prior to Cardiology program
     January 1 - December 31, 2001, 19 cardiac claims were filed as
      a result of a wellness exam.
     January 1 - December 31, 2002, 18 cardiac claims were filed as
      a result of a wellness exam.

   Implementation of Cardiology program
     January 1 - December 31, 2003, 8 cardiac claims were filed as a
      result of a wellness exam.
     January 1 - September 30, 2004, 6 cardiac claims were filed as a
      result of a wellness exam
          Program Overview
   Program implemented in 11/01/03.
   Data captured from 11/01/03 to 09/19/05
   3413 Annual medical exams conducted
   6 contracted medical facilities conduct annual
    medical and fitness exams in the AM hours.
   During the fitness exam a Maximal exercise test
    is conducted
             Rationale for Maximal Effort
                  Medical Screening

♥    FF tasks or fitness testing commonly elicit sustained HRs exceeding
     85% of predicted maximum
      ♥ LA County Recruits HR exceed age-predicted max HR by ~4 bpm
         during 1.5 mile run
♥    39% of first abnormalities would have been
     missed if test terminated at 85% predicted Max.
     HR*
♥    A maximal effort test ensures an accurate measure of
     Cardiovascular fitness
♥    Doing a Max test and measuring fitness periodically is
     MOTIVATIONAL
      ♥ Dr. Robert Bruce….63% of men having an exercise test changed at
        least one other risk factor

*   Based on 552 abnormal tests on men at the Cooper Clinic
        Program Components
   If a undetermined ECG trace is discovered then
    Fire Fighter is advised of the volunteer cardiology
    program

   Step 1: Re-read of ECG by a Board Certified
    cardiologist within one hour.

   Step 2: Electron Beam Coronary Calcium
    Tomography (EBCT)

   Step 3: Electron Beam Coronary Angiography
3413 Wellness/Fitness
   Medical Exams




  Note:11/01/03 to 09/19/05 n=3413
184 Suspected Positive ECG’s
       Step1: ECG Re-read



                               146
                                confirmed
                                positive

                               38 ECG’s
                                were
                                negative
                                and RTW
146 Confirmed positive ECG’s
         Step 2: EBCT

                           145 EBCT Scans
                            were performed to
                            determine the
                            presence of
                            coronary calcium
                            and extent of CAD.

                           1 case required an
                            arrhythmia
                            evaluation
145 EBCT conducted




    Note: 1 Arrhythmia
35 Positive EBCT scans




   CAD


         No
         CAD
22 Confirmed True Positives on
EBA Indicate Mild to Moderate
            CAD




  Note:, 1 Arrhythmia, Light duty, 1 Arrhythmia, RTW
     Coronary Artery Scanning


SEVERE CALCIFICATION
       Pathway for Coronary
            Calcium

                        146 Scans
                    35 with Coronary
                     Calcium Present


     13 –         15 - mild
                                         7 with significant
no significant   Or moderate
                                              Disease
    disease        Disease


                               3 required
                                                              4 treated
                               Angioplasty
                                                              medically
                                    or Bypass
High Specificity for
   Obstruction
Exquisite Detail of Anatomy
Lumen + Plaque Burden
CONCLUSIONS

 Able to rapidly
 screen and
 triage
 firefighters
 (almost always
 same day) back
 to work or light
 duty
Safety of Maximal Exercise Testing

       Cooper Clinic – 170,000 tests since 1971

                        11 Complications

                1 Death, 1 death 10 days later

           Rate= 0.65 Complications/ 10,000 tests

   ACSM and ACC Guidelines for Exercise Testing
               strictly adhered to !
      Cost Components for Follow-up of
            Abnormal Stress Tests
   Initial Cardiologist’ Consult (~$150)

   Additional diagnostic tests
     – Ex. Echo (~$800), or Thallium (~$1800)

   Salary of employee and replacement

   Administrative costs of Worker’s Comp claim
     – $2300 average for cardiac claim, skewed by a few expensive litigations

   Additional diagnostic tests
     – Cardiac catheterization (~$5000)
     – Electrophysiological Studies

   Salary for additional time off pending clearance

   Final Cardiologist Consultation (~$250)

				
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