Fire Fighter Cardiovascular Screening Fire Fighter Cardiovascular Screening and Heart Disease Prevention Programand Heart Disease Prevention Program

Franklin D. Pratt, M.D.Franklin D. Pratt, M.D.Matthew Budoff, M.D.Matthew Budoff, M.D.

Fire Captain George A. CruzFire Captain George A. CruzRobert Karwasky, M.S.Robert Karwasky, M.S.

History of LA County Wellness/Fitness History of LA County Wellness/Fitness ProgramProgram

Administered by LA County Occupational Health Administered by LA County Occupational Health ServiceService

40,000 + exercise tests administered 1970-1992.40,000 + exercise tests administered 1970-1992. Several landmark research papers published.Several landmark research papers published.

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

3400 FFs followed for 4.8 years found 36 MI.3400 FFs followed for 4.8 years found 36 MI. 1970- mandatory pre-employment and 1970- mandatory pre-employment and

periodic medical exams for all LA county periodic medical exams for all LA county safety personnelsafety personnel Risk associated with low physical work capacity Risk associated with low physical work capacity

evident primarily in subjects with other risk evident primarily in subjects with other risk factors. factors.

History of LA County Wellness/Fitness History of LA County Wellness/Fitness ProgramProgram

1998- LA County joins 9 other FDs to form 1998- LA County joins 9 other FDs to form IAFF/IAFC Wellness/Fitness IAFF/IAFC Wellness/Fitness

InitiativeInitiative

2000- Medical Exams resume at 6 2000- Medical Exams resume at 6 contracted clinicscontracted clinics

2000-2005 Approx 2000 Medical exams/ 2000-2005 Approx 2000 Medical exams/ yearyearDisappointing ~70% complianceDisappointing ~70% compliance..

Cost Components for Follow-up of Cost Components for Follow-up of Abnormal Stress TestsAbnormal Stress Tests

Initial Cardiologist’ Consult (~$150)Initial Cardiologist’ Consult (~$150)

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

Salary of employee and replacementSalary of employee and replacement

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

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

Salary for additional time off pending clearanceSalary for additional time off pending clearance

Final Cardiologist Consultation (~$250)Final Cardiologist Consultation (~$250)

Potential cost of 184 follow-ups = Potential cost of 184 follow-ups = $275,000 to $775,000$275,000 to $775,000

Cost Components for Follow-up of Cost Components for Follow-up of Abnormal Stress TestsAbnormal Stress Tests

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

Staying AliveStaying Alive

Why is this Why is this soooo….soooo….

IMPORTANT???IMPORTANT???

Firefighter Cardiovascular Firefighter Cardiovascular Disease Screening and Disease Screening and

Heart Disease PreventionHeart Disease Prevention

The history of our Program The history of our Program The mechanics of ProgramThe mechanics of Program The science and medicine of our The science and medicine of our

programprogram

Origins of this Origins of this partnershippartnership

Disagreement between Labor and Disagreement between Labor and Management on financial Management on financial responsibility for evaluation after responsibility for evaluation after Wellness-Fitness ExamWellness-Fitness Exam

– When did W/F exam end and “private When did W/F exam end and “private medical care” begin?medical care” begin?

Origins of this Origins of this partnershippartnership

Too much time lapsed between Too much time lapsed between abnormalities discovered at abnormalities discovered at Wellness-Fitness Exam and further Wellness-Fitness Exam and further evaluationevaluation– Firefighter anxiousFirefighter anxious– Mediocre medical care on occasionMediocre medical care on occasion

Los Angeles County Fire Los Angeles County Fire Department and Harbor-Department and Harbor-

UCLA Medical CenterUCLA Medical Center

Worked together to provide quicker, Worked together to provide quicker, better screeningbetter screening

Working toward a future of all Working toward a future of all inclusive prevention and screening inclusive prevention and screening strategiesstrategies

Origins of this Origins of this partnershippartnership

Availability of cutting edge diagnostic Availability of cutting edge diagnostic tools in a major medical centertools in a major medical center

Academic facility with interest in Academic facility with interest in firefighter healthfirefighter health

Product of the Product of the PartnershipPartnership

Electron Beam Cardiac Scanning for Electron Beam Cardiac Scanning for early diagnosisearly diagnosis

Intravenous coronary artery imagingIntravenous coronary artery imaging

Integration of diagnosis and Integration of diagnosis and treatment with prevention, risk factor treatment with prevention, risk factor modificationmodification

Purpose of ProgramPurpose of Program

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

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

36 of the 38 claims were false-positive ECG 36 of the 38 claims were false-positive ECG tracestraces

Purpose of programPurpose of program

Prior to Cardiology programPrior to Cardiology program January 1 - December 31, 2001, 19 cardiac claims were January 1 - December 31, 2001, 19 cardiac claims were

filed as a result of a wellness exam.filed as a result of a wellness exam. January 1 - December 31, 2002, 18 cardiac claims were January 1 - December 31, 2002, 18 cardiac claims were

filed as a result of a wellness exam.filed as a result of a wellness exam.

Implementation of Cardiology Implementation of Cardiology programprogram January 1 - December 31, 2003, 8 cardiac claims were January 1 - December 31, 2003, 8 cardiac claims were

filed as a result of a wellness exam.filed as a result of a wellness exam. January 1 - September 30, 2004, 6 cardiac claims were January 1 - September 30, 2004, 6 cardiac claims were

filed as a result of a wellness examfiled as a result of a wellness exam

Program OverviewProgram Overview

Program implemented in 11/01/03.Program implemented in 11/01/03. Data captured from 11/01/03 to 09/19/05Data captured from 11/01/03 to 09/19/05 3413 Annual medical exams conducted3413 Annual medical exams conducted 6 contracted medical facilities conduct 6 contracted medical facilities conduct

annual medical and fitness exams in the annual medical and fitness exams in the AM hours.AM hours.

During the fitness exam a Maximal During the fitness exam a Maximal exercise test is conductedexercise test is conducted

Rationale for Maximal EffortRationale for Maximal EffortMedical ScreeningMedical Screening

♥ FF tasks or fitness testing commonly elicit sustained HRs FF tasks or fitness testing commonly elicit sustained HRs exceeding 85% of predicted maximum exceeding 85% of predicted maximum ♥ LA County Recruits HR exceed age-predicted max HR by LA County Recruits HR exceed age-predicted max HR by

~4 bpm during 1.5 mile run~4 bpm during 1.5 mile run♥ 39% of first abnormalities would have been 39% of first abnormalities would have been

missed if test terminated at 85% predicted missed if test terminated at 85% predicted Max. HR*Max. HR*

♥ A maximal effort test ensures an accurate measure of A maximal effort test ensures an accurate measure of Cardiovascular fitnessCardiovascular fitness

♥ Doing a Max test and measuring fitness periodically is Doing a Max test and measuring fitness periodically is MOTIVATIONALMOTIVATIONAL♥ Dr. Robert Bruce….63% of men having an exercise test changed Dr. Robert Bruce….63% of men having an exercise test changed

at least one other risk factorat least one other risk factor

* * Based on 552 abnormal tests on men at the Cooper ClinicBased on 552 abnormal tests on men at the Cooper Clinic

Program ComponentsProgram Components If a undetermined ECG trace is discovered If a undetermined ECG trace is discovered

then Fire Fighter is advised of the volunteer then Fire Fighter is advised of the volunteer cardiology program cardiology program

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

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

Step 3: Electron Beam Coronary AngiographyStep 3: Electron Beam Coronary Angiography

3413 Wellness/Fitness 3413 Wellness/Fitness Medical ExamsMedical Exams

184 (5%)

3229 (95%)

SuspectedPos.NormalECG

Note:11/01/03 to 09/19/05 n=3413

184 Suspected Positive 184 Suspected Positive ECG’s ECG’s

Step1: ECG Re-readStep1: ECG Re-read

38 (21%)146 (79%) 38 (21%)

146ConfirmedPos.38 ECG'sNegative

146 146 confirmeconfirmed positived positive

38 ECG’s 38 ECG’s were were negative negative and RTWand RTW

146 Confirmed positive 146 Confirmed positive ECG’sECG’s

Step 2: EBCTStep 2: EBCT

146 (79%)

38 (38%)

ConfirmPositive

RTW

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

1 case required 1 case required an arrhythmia an arrhythmia evaluation evaluation

145 EBCT conducted 145 EBCT conducted

110 (76%)110 (76%)

35 (24%)

Calciumdetected,CAD?

No Calc. =no sig.CAD,= RTW

Note: 1 Arrhythmia

35 Positive EBCT scans35 Positive EBCT scans

1 (3%)

12 (34%)

22 (63%) Confirmed truepositive, CAD

False Positive, noSig.CAD,RTW

Arrhythmia,noCAD

CAD

No CAD

22 Confirmed True 22 Confirmed True Positives on EBA Indicate Positives on EBA Indicate

Mild to Moderate CADMild to Moderate CAD

7 (32%)15 (68%)

Temporarylight duty

RTW, fullduty

Note:, 1 Arrhythmia, Light duty, 1 Arrhythmia, RTW

Coronary Artery ScanningCoronary Artery Scanning

SEVERE CALCIFICATION

Pathway for Coronary Pathway for Coronary CalciumCalcium

146 Scans35 with Coronary Calcium Present

13 –no significant

disease

15 - mild Or moderate

Disease

7 with significant Disease

3 required Angioplasty

or Bypass

4 treated medically

High Specificity for High Specificity for ObstructionObstruction

Exquisite Detail of Exquisite Detail of AnatomyAnatomy

Lumen + Plaque BurdenLumen + Plaque Burden

CONCLUSIONSCONCLUSIONS

Able to rapidly Able to rapidly screen and screen and triage triage firefighters firefighters (almost always (almost always same day) same day) back to work back to work or light dutyor light duty

Safety of Maximal Exercise TestingSafety of Maximal Exercise Testing

Cooper Clinic – 170,000 tests since 1971Cooper Clinic – 170,000 tests since 1971

11 Complications11 Complications

1 Death, 1 death 10 days later1 Death, 1 death 10 days later

Rate= 0.65 Complications/ 10,000 testsRate= 0.65 Complications/ 10,000 tests

ACSM and ACC Guidelines for Exercise ACSM and ACC Guidelines for Exercise Testing strictly adhered to !Testing strictly adhered to !

* Estimate calculated from average of 151.7 exams/ month from 11/1/03 to 12/31/04, extrapolated to 22.5 months.

Comparison of Present Versus Former Cardiology Follow-up Programs

3413* 100 Maximal Effort treadmill test Clinic MD review

Ex Echo or Thallium. Possible Cath. Off-duty pending eval. Work comp.

Ex Echo? Thallium ? Off-duty pending eval? Work comp?

OHP MD review ( 1 hour-2 weeks), Cardiologist review?

Former Program

Clinic MD review

EP study evaluated. Status determined by OHP MD.

OHP MD (1 hour-2 weeks). Consider EP study

Status pending final review

Status pending final review

Present Program

Card. review within hour, 38 RTW w/o further eval.

EBCT same day, 110 negative and RTW

EBA next day or shift

Final review same day. 12 No sig. CAD -RTW- no time lost

15 RTW w/o restrictions. 7 temporary light duty pending

Cardiologist review within hour. Consider EP study.

EP study evaluated. Status determined by OHP MD.

Procedure

Initial ECG re-read

After ECG re-read, EBCT recommended

After EBCT, EBA recommended

After EBA

After final review

After initial review

After EP study

After final review8

% Total

5.4

4.3

1

0.6

0.2

0.06

0.03

0.23Total Cardiac requiring light duty

N

184

146

35

22

7

2

1

Confirmed CAD

CAD requiring light duty

Arrhythmia requiring evaluation

Arrhythmia requiring light duty

All Exams (11/1/03 to 9/19/05)

Suspected Positive ECG

Conformed Positive ECG

Coronary Calcium present

Cost Components for Follow-up of Cost Components for Follow-up of Abnormal Stress TestsAbnormal Stress Tests

Initial Cardiologist’ Consult (~$150)Initial Cardiologist’ Consult (~$150)

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

Salary of employee and replacementSalary of employee and replacement

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

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

Salary for additional time off pending clearanceSalary for additional time off pending clearance

Final Cardiologist Consultation (~$250)Final Cardiologist Consultation (~$250)