Fire Fighter Cardiovascular Screening Fire Fighter Cardiovascular Screening and Heart Disease Prevention Program and 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. Fire Captain George A. Cruz Cruz Robert Karwasky, M.S. Robert Karwasky, M.S.
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Fire Fighter Cardiovascular Screening and Heart Disease Prevention Program Franklin D. Pratt, M.D. Matthew Budoff, M.D. Fire Captain George A. Cruz Robert.
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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
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
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
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
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
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
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