The importance of thorough, accurate and cost-effective screening for coronary artery disease (CAD) among prospective and active fire fighters is well recognized, but presents numerous medical and financial challenges. Ultimately, many potentially catastrophic cardiac events are prevented by early diagnosis and treatment, and the consequences of indeterminate medical findings, prolonged absence from work, and overwhelming follow-up costs are reluctantly accepted.
The following pilot program was established by the County of Los Angeles Fire Department and the St. John’s Cardiovascular Research Center to address these challenges. This study, “Staying Alive: Fire Fighter Cardiovascular Screening and Heart Disease Prevention,” was presented at the 2005 Redmond Symposium by George Cruz, Wellness-Fitness Coordinator for the Los Angeles County Fire Department, Dr. Franklin Pratt, Medical Director for the Los Angeles County Fire Department and Dr. Matthew Budoff, Associate Professor of Medicine for Harbor UCLA Medical Center. (Please click on the links below to view the PowerPoint presentation and testimonies from a few fire fighters.)
From November 1, 2003 to September 19, 2005, 3,413 Wellness/Fitness medical exams were performed at six
contracted clinics. As part of this exam, employees received a resting ECG, cardiac auscultation, and a maximal effort stress test using the Gerkin treadmill protocol. As a result, 184 (5.4%) cases were suspected to be positive and referred to a cardiology consultation service for evaluation. Thirty-eight of these “suspected positive” cases were determined to be within normal limits after the initial cardiologist’s evaluation, and these employees resumed full duty immediately. The remaining 146 referrals were confirmed as positive tests and 145 EBCT scans were performed to determine the presence of coronary calcium and extent of CAD. (One case required an arrhythmia evaluation.)
The absence of coronary calcium ruled out significant CAD in 110 of the EBCT scans and these employees returned to full duty immediately. 35 EBCT scans revealed the presence of coronary calcium and EBA scanning was performed to evaluate the extent of coronary artery occlusion and stenosis. Twelve EBA scans found no significant occlusive disease and these employees returned to full duty immediately. One EBA found no CAD, but an arrhythmia required the employee to be returned to work on light duty status.
 The presence of mild or moderate CAD was confirmed in the remaining 22 EBA scans. Fifteen of these employees were able to return to full duty without restrictions, and 7 employees were restricted to light duty. The total of 8 employees placed on light duty equals 0.23% of the entire 3,413 employees receiving their Wellness/Fitness medical exam.
An analysis was made comparing this pilot program with the costs that would likely have occurred under the prior system of evaluating potential CAD cases. Estimates of the cost of evaluating the 184 referrals under the former program range from $285,000 to $774,000 for the 22.5 months. This estimated range would expand to $425,000 to $1,155,000 in savings if there was 100% compliance with the mandatory Wellness/Fitness medical exam. Furthermore, it is estimated that at least 11 additional cases of significant CAD would be diagnosed.
The cost of the pilot program for the cardiology services to be provided was $43,500 annually ($81,562 for the recording period) and was based on the anticipated projected usage. A comparison with the former follow-up evaluation program is shown in Table 1.
Table 1. Cost Comparison of two programs to evaluate suspected positive exercise ECGs.
| |
Pilot Program |
Former Program |
| Total Cost |
$81,562 |
estimated $285,000 - 774,000 |
| Cost per referral |
$443 |
estimated $1,548 - 4,206 |
| Cost per medical exam |
$24 |
estimated $84 - 227 |
Departments establishing new programs to screen for CAD need to prepare thoroughly for the medical and financial responsibilities of the outcome. The data from this program indicate that follow-up analysis will be common. An additional $83-$226 cost per employee screened can be anticipated when a traditional follow-up program is used. This pilot program has proven to be effective in dramatically reducing these costs by minimizing time lost from work, reducing worker’s compensation claims, and avoiding additional medical tests.
Future considerations include the addition of individuals with elevated coronary heart disease factors for EBCT even if they have had a normal exercise ECG. It is hoped that this will be an effective method to discover cases of heart disease at its earliest stages and in cases where exercise testing has been falsely negative.
Click here to view PowerPoint presentation
Click here to watch testimonies (part 1)
Click here to watch testimonies (part 2)
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