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  Several landmark research papers published. “ Physical Fitness and Subsequent MI in Healthy Workers”, Peters.RK, et.al., JAMA 1983; 249: FFs followed for 4.8 years found 36 MI.  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. Risk associated with low physical work capacity evident primarily in subjects with other risk factors.

History of LA County Wellness/Fitness Program  LA County joins 9 other FDs to form IAFF/IAFC Wellness/Fitness Initiative Initiative  Medical Exams resume at 6 contracted clinics  Approx 2000 Medical exams/ year  Disappointing ~70% compliance.

Cost Components for Follow-up of Abnormal Stress Tests Initial Cardiologist’ Consult (~$150) Initial Cardiologist’ Consult (~$150) Additional diagnostic tests Additional diagnostic tests –Ex. Echo (~$800), or Thallium (~$1800) Salary of employee and replacement Salary of employee and replacement Administrative costs of Worker’s Comp claim Administrative costs of Worker’s Comp claim –$2300 average for cardiac claim, skewed by a few expensive litigations Additional diagnostic tests Additional diagnostic tests –Cardiac catheterization (~$5000) –Electrophysiological Studies Salary for additional time off pending clearance Salary for additional time off pending clearance Final Cardiologist Consultation (~$250) Final Cardiologist Consultation (~$250) Potential cost of 184 follow-ups = $275,000 to $775,000 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……. 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 history of our Program The mechanics of Program The mechanics of Program The science and medicine of our 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 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 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 Worked together to provide quicker, better screening Working toward a future of all inclusive prevention and screening strategies 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 Availability of cutting edge diagnostic tools in a major medical center Academic facility with interest in firefighter health Academic facility with interest in firefighter health

Product of the Partnership Electron Beam Cardiac Scanning for early diagnosis Electron Beam Cardiac Scanning for early diagnosis Intravenous coronary artery imaging Intravenous coronary artery imaging Integration of diagnosis and treatment with prevention, risk factor modification 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. 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. As a result of the 38 claims filed, the Department Medical cost amounted to $96, of the 38 claims were false-positive ECG traces 36 of the 38 claims were false-positive ECG traces

Purpose of program Prior to Cardiology 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 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. Program implemented in 11/01/03. Data captured from 11/01/03 to 09/19/05 Data captured from 11/01/03 to 09/19/ Annual medical exams conducted 3413 Annual medical exams conducted 6 contracted medical facilities conduct annual medical and fitness exams in the AM hours. 6 contracted medical facilities conduct annual medical and fitness exams in the AM hours. During the fitness exam a Maximal exercise test is conducted 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 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 1: Re-read of ECG by a Board Certified cardiologist within one hour. Step 2: Electron Beam Coronary Calcium Tomography (EBCT) Step 2: Electron Beam Coronary Calcium Tomography (EBCT) Step 3: Electron Beam Coronary Angiography 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 146 confirmed positive 38 ECG’s were negative and RTW 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. 145 EBCT Scans were performed to determine the presence of coronary calcium and extent of CAD. 1 case required an arrhythmia evaluation 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 Cooper Clinic – 170,000 tests since Complications 11 Complications 1 Death, 1 death 10 days later 1 Death, 1 death 10 days later Rate= 0.65 Complications/ 10,000 tests Rate= 0.65 Complications/ 10,000 tests ACSM and ACC Guidelines for Exercise Testing strictly adhered to ! ACSM and ACC Guidelines for Exercise Testing strictly adhered to !

Cost Components for Follow-up of Abnormal Stress Tests Initial Cardiologist’ Consult (~$150) Initial Cardiologist’ Consult (~$150) Additional diagnostic tests Additional diagnostic tests –Ex. Echo (~$800), or Thallium (~$1800) Salary of employee and replacement Salary of employee and replacement Administrative costs of Worker’s Comp claim Administrative costs of Worker’s Comp claim –$2300 average for cardiac claim, skewed by a few expensive litigations Additional diagnostic tests Additional diagnostic tests –Cardiac catheterization (~$5000) –Electrophysiological Studies Salary for additional time off pending clearance Salary for additional time off pending clearance Final Cardiologist Consultation (~$250) Final Cardiologist Consultation (~$250)