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EBCT Scan Justification
 

EBCT Scan Justification

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    EBCT Scan Justification EBCT Scan Justification Presentation Transcript

    • 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…….
      Priceless!!
    •  
    • 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 – no significant disease 15 - mild Or moderate Disease 7 with significant Disease 3 required Angioplasty or Bypass 4 treated medically
    • 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)
    •