creating a successful program

Every program needs to take stock and decide are they on the right track or are they barking up the wrong tree. You also need to look at your "competitors" and see if they are doing something different from you and either directly compete with them or change the game and work around them. The first place to start is to look at the purpose of the organization. For corporations, the goal is simple - make money for shareholders and increase shareholder value. Given that we are a 501(c)(3) the goal is a little different. We do not have shareholders. We are not publicly traded. We do have a board of directors who give guidance but they look to each other and those running the organization to provide direction. For Cypress ECG we have come up with a simple goal statement

Provide low cost cardiac screening and increased awareness to reduce the incident of sudden cardiac death in teens. 

I hate it when people dissect sentences but I am going to do this. I think that it is important to talk about different ways of achieving this goal. There are basically three parts to this sentence.

1. Provide low cost cardiac screening
2. Provide increased awareness [of cardiac issues]
3. Reduce the incident of sudden cardiac death

"in teens"

All of these are related to teens and not adults or infants. Let's start with the easy question. Why teens? Why not infants? Pediatric Cardiologists are already focused on newborns and infants. There is a need for us to focus on anyone under the age of 11. There is adequate coverage with Pediatricians and Pediatric Cardiologists on this age group. Most kids under the age of 11 are not highly competitive and will stop participating when things get too difficult or things start to hurt. They are not as competitive and push their bodies harder than their systems can handle.

Why not adults? There are a large number of Cardiologists that handle this field. True that the age of most of their patients are older and typically in advanced stages of disease. We rely upon these Cardiologists to provide secondary screening and follow up visits. Unfortunately, most Adult Cardiologists are prohibited from seeing anyone under the age of 18 due to their malpractice insurance. There are ways around it but it requires the Cardiologists taking additional courses and notifying their insurance that they are planning on seeing patients under the age of 18. 

This leaves a gap of ages 11-18. This is the age where competition gets more difficult. Aggression gets higher with increased hormones. The heart changes from a pediatric heart to an adult heart. If genetics dictate a problem it will be manifested at this time. Unfortunately, this creates a double trouble situation. What was a healthy heart becomes sick due to physical changes. Competition gets more difficult resulting in additional stress on the heart. The symptoms of risk are sweating, being tired, dizziness, nausea, and shortness of breath and in extreme cases chest pain. With the exception of pain, these are also symptoms of heat exhaustion, dehydration, or being out of shape. Not only is there a need but there is a lack of coverage and available resources that can provide medical care to this age group.

"reduce the incident of sudden cardiac death"

This statement is a simple statement but spurs significant debate in the medical and athletic community. The first discussion is what is sudden cardiac death. We define it as anything resulting in death or near death caused by a cardiac related medical problem. Sudden cardiac death is differentiated from things like heart attack, injuries that cause cardiac issues, or diseases that lead to death through cardiac failure. Sudden cardiac death is called sudden because it is something unexpected that was not previously diagnosed. The typical causes that are related are hypertrophic cardiomyopathy, long Qt, Atrial Abnormalities, Axis problems, Conduction delay issues, Wolfe Parkinsons White Syndrome, and Ventricular problems. 

The word reduce is an inflammatory word as well. There is significant discussion on the incident of disease and how many deaths happen based on cardiac issues. We try not to take too strong a stand on this other than to say that the Texas UIL website is significantly on the high side stating that the risk is 1:300,000. Given that there are about 1.7 million high school students in Texas there should be five deaths per year across the state. Given that about 40-50% participate in athletics and that there were 8 deaths in 2010, the rate that is realistic based on recorded deaths is 1:85,000. Publications have honed these numbers down even more and stated that specific sports have a higher risk profile. Golf, for example, is the lowest risk sport. Other sports like cross country, swimming, and basketball have a higher risk profile of 1:3000 to 1:8000 because the heart is pushed harder and longer for these sports. 

Our goal is to see if we can screen all student athletes who are at elevated risk and reduce the number from 5-8 to 0-1. We realize that reducing the number to zero is difficult but a goal worth achieving. Given that we have found on average one student per year that has required surgery and one coach/adult every other year has had surgery we feel like we have reduced our target by at least one per year. 

The next controversial area is "low cost screening". When we analyze what is the highest cost in screening students, the doctor is the highest expense. A doctor can make $400-$500 per hour in their office or at the hospital. Having a doctor on site performing screenings takes on average 4-5 minutes per student. This means that one doctor can see about 20 students per hour if we assume 5 minutes. At $500 each screening would cost $25. If we add travel time we would triple or quadruple this number to $75 or $100 to cover just the time to travel to the remote location. The approach that we take is not to have the doctor on site but to reduce the time required by the doctor to apply their expertise. If we could get the time down to one minute per student then we can drop the cost to below $9 for a screening. If we can drop the time to below 30 seconds the cost drops below $5. 

The second controversy is the amount of testing that needs to be done. The absolute test that will show issues would be a transesophegual exam. Given that this is an $8,000 procedure and requires a trained Cardiologist to perform in a hospital environment, it is a bit impractical. The next level would be a genetic test which ranges from $100-$1000. This is also impractical. Both of these tests are typically used as a final test and not an initial test to examine risk and extent of cardiac issues. 

The two tests that can be performed are the ECG and the Echo. The ECG is an electrical test that can be done with volunteers or athletic trainers/nurses. The ECG machine cost $3000-$30,000 and has a consumable cost of $0.35 per screening. One machine can easily screen tens to hundreds of thousands of students so the cost can be amortized over the number of students screened. An Echo machine cost about 2 to 3 times the cost of an ECG machine. Given that we are doing resting ECGs and Echos we do not need the top end systems. An Echo machine needs a slightly higher trained user. Your typical nurse or Athletic Trainer can not perform a limited Echo. An Echotech is required. The cost of the Echotech is the largest cost in the equation. A typical ECG takes about 3-4 minutes to perform but an Echo takes 15-20 minutes. If we assume 15 minutes that means that someone getting paid $40 per hour can do four Echos at about $10 each. There really is not an easy way to reduce this cost because you can not screen any faster.

We have developed a program where we take ECG equipment to schools and have either trained full time staff perform the screenings or utilize the Nurses and Athletic Trainers to screen students. We ship the ECGs to our Cardiology staff and have them interpret the results. The full time staff communicates with the schools the interpretations to reduce the time needed by the doctors. We have elected to offer Echos as a second stage or optional part of screening. Using this methodology that we have submitted a patent on, we can charge $10-$15 for ECG screening and $25 for a combined ECG/Echo screening. 

Cypress ECG is in a position to provide low cost screening to any school in the state of Texas and is looking at expanding to other cities. In the next blog entry we will look at the way other organizations reduce the cost and provide screenings.

good week

August is a good time to screen students. Most schools in Texas start two-a-days and the new format this year lends itself well to screening students. We are about a third of the way into the month and have screened over 600 students for the month. We have screened at over twelve high schools this month and have been able to turn around most screenings in 48 hours. Many schools are using the "rest day" of two-a-days to have students come back up for screening in the afternoon since they can not practice the second afternoon. This is a good format. Most students are ready to get started and this gets volleyball and football players screened during one of their rest periods. It also gives the coaches a chance to talk to the kids and make sure that they hydrate the second day while standing in line waiting to get screened.

We are seeing tracking of about 4.5% of students needing a follow up and one in two thousand coming back as high risk. This basically means that 95% of students are cleared to participate. Having read all of the literature on screening and watching mass physicals this summer I can attest that the Washington University study stating that 87% of doctors do not ask students the required cardiac health and physical questions and many do not know how to hear a heart murmur. Having a cardiac screening to back up these programs gives parents and coaches a higher confidence level that the students are healthy enough for the rigors of two-a-days in the summer heat. True there might be some angst when they get a follow up request. Yes there is stress when a diagnosis comes back as high risk. What is the alternative? Do you really want someone on the field when they are high risk? If you know they are high risk would you let them participate? For the 4.5% that come back as a follow up request, about 20% come back as elevated risk but not high risk. About 5% come back as high risk of the follow up students. About 80% come back as something unusual but not high risk.

If you are not screening students this August or did not before the end of the school year ask yourself why not. If you are using an Orthopedist to do cardiac screening as part of your physicals you should use screening. If you are using an Nurse Practitioner or Chiropractor to perform physicals you should use screening. There is not cost to the school or athletic department to offer this service prior to participation. Cypress ECG offers the service to parents and comes to your facilities to screen. We typically see about 20% the first year if the screening program is supported and advertised by the coaching staff and administration. We have seen as high as 95% participation when it becomes an annual part of you physical process.

down the rabbit hole part 3

The bills are starting to trickle in. I am amazed by the cost of surgery and all of the procedures associated with it. To summarize for those just joining the discussion, I had a routine doctor visit last month and part of the visit was a routine ECG. The ECG showed classic atrial flutter and was confirmed with an ultrasound. When doing a stress ECG I actually went into Ventricle Tacacardyia  for a few heart beats as my heart raced to 300 beats per minute.

The initial doctor visit - $190 + $40 for ECG.
Secondary doctor visit - $190 + $400 for Echo and $400 for stress ECG
week 1 total - $1220.00

Visit with Electrophysiologist - $190 + $40 for ECG
Transesophageal echocardiogram (TEE) - $8000
week 2 total - $8320

Cardiac Ablation - $101,000
week 3 total - $101,000

month total - $110,540

Of this, the insurance company agreed to pay the hospital a pre-negotiated amount near $67,000 and asked me to pay about $4,000.

Let's put this in perspective. If I were part of a pre-participation screening program I would have gone to my school and had an ECG done for $15. If nothing were found, I would be done until four years later given that you only need to screen middle school and high school students once every four years. The alternative was to go to a doctor and get a routine physical which probably would not include and ECG. The doctor would have missed the atrial flutter because it sounds like a regular fast heart beat to someone not trained to listen for atrial flutter. The cost of the doctor visit would have been $75-$100 with a $25 copay. My out of pocket expense would have been $25 and I would continue participating and in all likelihood have collapsed on the field from dizziness or heart failure.

If something were found on the ECG, as it was in my case, I would have been labeled as follow up or high risk. In my case I would have been labeled as high risk. I would have gone to the Cardiologist and paid the $190 + $400 for the Echo and $400 for the stress ECG. This would have cost $15 for the screening ECG and $990 for the follow up exam. With the follow up exam, I would have paid my $25 co-pay and insurance would have picked up the rest. My out of pocket would be $40 to get screened in as a heart risk or screened out as clear to participate. Given that there was something there, I would have had the TEE performed as well as the Ablation at the same cost. As an aside, the TEE is a fascinating process. The doctor slips a small ultrasound machine down your throat and images your heart from inside your ribs. The pictures are much more accurate and can pick up blood clots and potential issues that could effect an ablation. I understand why this is not done as a screening protocol and requires a Cardiologist but the fact that they can slip an ultrasound machine inside the body and image the heart is interesting.

The alternative to screening was an ambulance/life flight ride, an emergency room visit, and emergency surgery. I don't know the cost of this option but my gut tells me that it is more expensive than just outpatient surgery that we scheduled ahead of time.

Given that we are three weeks after the surgery and I have started a routine of working out and loosing weight, I am glad that we performed the initial screening. I doubt that I would have been able to get back to bike riding, woodworking, and racket ball post emergency room visit as soon as I did with outpatient surgery.

Yes it was scary for my whole family that I had something wrong with my heart. Yes we started looking at things differently. Yes I am glad that I not only had the screening done but that we are providing it as a service for other people around the state.

pat

SWATA and Sudden Death

On July 19th I attended the Southwest Athletic Trainers Association annual conference. I was excited to attend because two of the talks were about sudden death and how to prepare/prevent it. This sounds like something that Cypress ECG would be interested in following and helping with.

The talk was moderated by Kenny Boyd of The University of Texas at Austin and keynote presenter was Katie Walsh of East Carolina University. Overall the talk was good but lacked emphasis where I feel it needed to be. The top eight causes of death listed are

1. Asthma
2. Concussions/Brain Injury
3. Spinal Injury
4. Diabetes
5. Heat Stroke
6. Sickle Cell reaction
7. Lightning
8. Sudden Cardiac Death

Given that Dr. Walsh is the US expert on lightning, the majority of the talk centered on detection, process and procedures, and the cost of monitoring. What was troubling was that Sudden Cardiac Death was not mentioned in the afternoon session and presented briefly in the morning session. 

Let's put things in perspective.

Asthma - about 8% of the population has asthma at all ages. Rates are higher for children below 18 with 9.5%. This means that one in ten kids statistically has asthma. Based on the CDC numbers about 90% of people diagnosed with asthma see a doctor for medication, 10% visit an emergency room on an annual basis, two percent are hospitalized, and less than one third of one percent die from the disease. The death rate for asthma is 0.15 per 1000 with the majority of those being in the 65 and older age group. For under 18 the rate is 0.09 per 1000 of those with the disease. This correlated to about one in 100,000 at risk for the under 18 age group.

Given that the equipment cost for Asthma is a Spirometer and medication that the student brings, schools can easily prepare for this but do need to perform baseline exams and record this information on the annual physicals. Many doctors will do this as part of the physical and if not athletic trainers or the school nurse can perform the screening for less than $200.

Concussion/Brain Injury/Spinal Injury - This is a topic that has had much discussion in the past two years and we don't need to go much more in depth here. The equipment for screening and testing of this is less than $1000 and is mandated by the state of Texas. 

Diabetes - About 10% of the population has diabetes. The number drops to less than 4% when you talk about under the age of 18. It is difficult to site death rates because diabetes causes other diseases like kidney failure, heart disease and stroke, and is the seventh leading cause of death in the US. Prevention and treatment is typically a glucose meter or something to measure blood sugar and does not exceed a few hundred dollars.

Heat stroke is another cause of death. Between 1999 and 2003 there were 3442 deaths, about 228 or 7% were under 15.  This puts the death rate at less than one per 100,000 in the general population and one per 1,000,000 in the under 18 age group. Treatment is simple if diagnosed early and properly. Most trainers know how to deal with this problem but it has been in the new lately as this has been a hot summer.

Sickle Cell is a genetic blood disorder that effects 50,000 US citizens annually. The disease is typically caught early and treated before the age of 3. Mortality rates in the US have dropped to less than one per 100,000 for this disease. The disease is significant in other countries and specific racial groups but a student in middle school or high school should know ahead of time if they have the disease and alert the medical and training staff prior to participation. No testing or screening equipment should be needed by schools, only treatment plans if a student has the genetic disorder.

Lightning is something that schools in Florida and Texas need to be wary of. During the thirteen year period from 1990-2003, 52 people died in Texas from lightning strikes putting the annual number of deaths in the general population at 4. The chances of death from lighting is one in 1,000,000. Schools in Texas are investing $6-$7K in early lightning detection systems to keep students safe. Events are delayed or cancelled. Participants and spectators are encouraged to seek shelter. Schools must develop an action plan because lightning will happen at some time while students are practicing, participating, or playing outside.

Sudden Cardiac Death is something that schools need to prepare for as well. In 2010 there were eight deaths from SCD in Texas. Given that there is no reporting mechanism by the state or the UIL it is difficult to track exact numbers.

Let's put things in perspective. Teen deaths are less than 1% of all deaths in the US. If a teen is going to die, the leading causes are

1. Auto accident (48% of all deaths)
2. Homicide (13%)
3. Suicide (11%)
4. Cancer (6%)
5. Heart Disease (3%)

From 1999-2006 there were 49.5 deaths per 100,000. This puts heart disease at 1.5 per 100,000 using the Center for Disease Control data. There are just over two million teenagers in Texas which means that there should be an average of 6 deaths per year in the teen population from heart disease.

I guess what I am getting at is that the SWATA Conference this year, the UIL Medical Advisory board for the past two years, the Texas Legislature, and the Texas Coaches Association have focused on the wrong things. Coaches have been focused on concussion screening since it was mandated by the Texas Legislature for most of 2011 and 2012 (relative risk 1:1,000,000). The UIL Medical board spent more time talking about restricting summer practices to avoid heat stroke (relative risk 1:1,000,000). SWATA invited in the leading expert on lighting and athletics to talk about planning and the value of a $7K warning system (relative risk 1:1,000,000). Nothing has been done or suggested by any of these organizations to help reduce the fifth leading cause of death, heart disease, for the school age population.

If schools are going to spend thousands of dollars on lightning warning systems, hundreds to thousands of dollars on baseline concussion screening, and hundreds to thousands of dollars to upgrade helmets and pads to reduce injury for one sport, spending $15-$25/student or asking parents to spend $15-$25/student for cardiac screening once while the student is in middle school and once while in high school should not be that much to ask. Event if money is the key issue, discussing the fact that current screenings with semi-annual physical questions, which are not used or wrong 87% of the time according to the University of Washington, warrants discussion by each of these groups. 

I guess that I am too passionate about this subject and am not seeing things clearly. If someone told me that there was a cheap and effective way to save five kids lives per year in Texas I would want to at least talk about it. 

down the rabbit hole part 2

Yesterday was an interesting day. I interviewed about 12 students who are about to finish their Echocardiography program at Lone Star College. We are expanding our services to include Echo exams because many schools are fine with ECG screening but others want Echo included. We recently purchased some portable Echo machines and need someone to operate them. It is relatively easy to train someone how to perform an ECG. Where to put the electrodes is the most difficult part but once you do a few hundred you get what is important and what is not. While I was on the operating table last week being hooked up for multiple ECGs, I talked to the nurse about placement of the electrodes. It turns out that their placement is critical and they need to think of things like having monitors for one doctor, monitors for another doctor, and a potential third for emergency situations. We had a long discussion on the placement of the V1 and V2 electrodes. It turns out that the placement of V3-V6 is not as critical as long as you get separation and coverage of the heart. The V1 and V2 placement is a little more critical when a metal object will be inserted into the heart from a vein in the groin area.

When I tried to engage the Echo students about ECG placement, many of them had no clue because they have seen the procedure done but have never done it themselves. It made me realize how specialized we are all becoming and don't understand the basic concepts of everything. I understand a little more about IV placement and why you don't want to re-insert an IV into the same area the next day. I had trouble talking the students lingo when describing the views that we are looking for and realized that I know the term injection fraction but don't know how to measure it. I was able to explain that we are primarily looking for wall thickness and valve structure with an Echo. I could also explain that the medical industry is significantly divided when it comes to what diseases you can find with ECG and what you can find with Echo. What most doctors agree on is that you can catch cardiac disease with screening. Most agree that ECG is a good tool for looking at LongQT and arrhythmias. Echo is the tool to look at wall thickness. Both are good at looking at Brugada Syndrome.

What surprised me most about having an ablation done is how easy the recovery time was. I had the surgery on Friday and Sunday morning I was walking the neighborhood. I went for a bike ride on Tuesday (just to the store to see how it felt) and am ready for a more challenging ride. I now understand why an athlete is ready to get back into the game and start training for the next event. The surgery is complex but low impact on the body. There wasn't a large scar that I had to put a new bandage on every day. I can barely find there the incision was and do not have lingering effects of muscle ache from the surgery. I do have two large bruises that I got from injections of blood thinner but these will go away in time.

I am convinced that screening is something that everyone should do. Early detection is the key to simple treatment. I keep playing different scenarios in my head about alternative outcomes and early screening with preventative surgery is the best case option I can think of. I will summarize the cost of screening and treatment in later weeks as bills come in and help me document my experience.

Our next screening events are at the end of July as football players start returning to campus for summer workouts. As my son starts swimming for his new school I will as a parent pressure the coaches to screen their students. Given that swimming is one of the high risk sports I will work to educate the coaches on the risks and how easy it is to screen to avoid them. My advice is to call your athletic director or head coach and ask why they are not offering screening to their students and parents. It does not cost the district anything and parents can choose to participate or not. Not offering it is admitting that it is not something important and the medical community admits that it is something worthy of looking for but disagrees on the cost of looking and what tests are needed.

from the other side of the looking glass

When I started working at a computer company, I read everything, build my own computers, took extra computer classes, and did what I could to become an expert on the topic of computers. I wanted to make sure that I knew everything about computers and how they worked before getting too far along. When I started working on the ECG project, I did not think that it was possible to figure out everything about the technology, how the heart works, what different diseases are, and surgical processes to correct cardiac issues. I dove into accounting, starting a business, writing a business plan, interviewing techniques, and details about becoming a 501(c)(3) company. Little did I know that I would be looking at cardiac screening with the same zeal and interest as I did computers.

Two weeks ago I scheduled an annual cardiology exam because I was thinking of going to summer camp with the Boy Scouts like I have for the past ten years. Little did I know that something as simple as an ECG would show that I had an irregular heart beat, specifically atrial flutter. The phrase from the hair club for men immediately came to mind, "I'm not just the president, I am a member". For two years we have been traveling the state performing ECGs on students looking for the one in two thousand that would be at risk, talking of warning signs, lobbying on what should be done, and talking to Cardiologists around the state to schedule follow up limited Echos. Not wanting to be a hypochondriac, I dismissed the symptoms because I was talking about it so much. Dizziness while exercising. Tightness in the chest that could be mistaken for muscle fatigue. Shortness of breath. I attributed all of these to being overweight and out of shape. I was exercising to get back in shape and thought that it was just a little more difficult this time since I was getting older.

Good thing that I scheduled a checkup.

Phase two of screening after an abnormal ECG is an Echo. My condition would have been labeled as follow up but can continue to participate with a limited Echo. Given that I work with a Cardiologist and am not a teenager, the diagnosis was not a limited Echo but a stress Echo with a treadmill and all the fun associated with that. After four hours reading various web sites and publications on what a flutter actually is I think that I understand it as well as the potential causes for it at my age. I thought that I was ready for the treadmill and a stress echo. I had done one fifteen years ago and was not looking forward to running as fast as I can to drive my heart rate up to 170 beats per minute. Fifteen years ago I was a marathon runner and needed to run much faster than I wanted to for the heart rate target. This time I was at 170 and climbing within four minutes and I was just starting to walk fast.

Good thing that I schedule a checkup.

Having done miserably on the stress Echo I learned phrases like ventricular tachycardia and arrhythmia from a different perspective. They were no longer wiggles on a trace. They were no longer a diagnosis that a doctor wrote down and I translated this to a student at a school in another city. It was not something that I had to explain to a trainer and tell them look out for excessive sweating, dizziness, and fatigue. It was something that I had to explain to my wife and kids. I started thinking things like is my insurance up to date, can I take a few days off for doctor visits, when can I get surgery scheduled.

Good thing that I schedule a checkup.

For the next week I will get to experience an ablation from the patient side. I will understand what a catheterization means and what it takes to recover from one. I will see things from the other side of the looking glass. I would much rather deal with secondary exams, talking to doctors about procedures, and taking a few days off for a day surgery. Yes, I am a little scare that a doctor will be opening up a vein in my leg and inserting a medical device into my heart while it is beating and short circuit a signal that is causing an extra heart beat in the top half of my heart. Yes, I am nervous about recovery time and limitations placed on me while I recover. Yes, I realize how lucky I am that a simple ECG kept me from going into cardiac arrest and getting to experience an emergency room for the first time. This is something that I hope to avoid for another quarter century or more.

Yes, I understand the importance of cardiac screening.

Pat Shuff
Chief Operating Officer
Cypress ECG

Legislation around the country

I am amazed by what legislation is being discussed around the nation. Doing a quick search for the word cardiac turns up

• links to Good Samaritan laws for every state
• links to AED legislation for every state
• school usage of AED for every state
• second link for AEDs in schools

It is a little depressing that the bulk of the legislation talks about emergency response and protecting care givers and does not focus on detection or prevention. The only forward looking legislation that I could find is

• New Jersey - A1863 - New Jersey Student Athlete Cardiac Screening Task Force
• New Jersey - S1911 - Children's Sudden Cardiac Events Reporting Act
• Pennsylvania - HB 1610 - Establishes standards for preventing sudden cardiac arrest and death in student athletes

With the passage of the bill in Pennsylvania to define the symptoms of cardiac issues and mandate what coaches and trainers should do when these symptoms appear, there is hope that other states will follow this lead. Texas passed similar laws for concussions last year. Hopefully we can help them pass a similar law for cardiac symptoms.

What should your government do for you

In working with the Texas Legislature and UIL Medical Advisory Board, one question comes to mind... "what should a government do for you". The presidential debate and election coming up clearly presents the question in stark contrast. Should we follow Ron Paul and his strict interpretation of the Constitution? Should we follow Mitt Romney and his cut services because it is not the job of the federal government? Should we follow President Obama and provide services for those that need services? This entry is not intended to be a debate on public policy or presidential politics. It is a discussion about what involvement should be expected and what should be mandated.

Let's put things into context. Cypress ECG works with schools which are government agencies. They are city/county organizations funded by county taxes in our area. Schools are a charter of the school district which are a charter of the Texas Education Department which is a charter of the Department of Education. According to the US Department of Education, about $1.15 trillion is spent nationwide on education at all levels for school year 2011-2012. About 88% of the funds come from non-Federal sources which means that 10.8% is federally subsidized. The Department of Education was created in 1867 to help states establish effective school systems. The Morrill Act in 1890 created a charter for land grant colleges and universities, one of which I attended. Congress has passed multiple acts to expand the role of the Department of Education and promote things like college attendance, vocational education, science, foreign language, equal rights for education, and creation of a Cabinet level post for education.

Education is important to the federal government. If we look at it from a Constitutionalist perspective, the federal government should abolish involvement in education because it is a state initiative. Mitt Romney promoted doing away with the Department of Education in the 90's but in 2007 reversed this opinion and sees it as a tool that can control teachers unions and elevate the interests of kids and parents. President Obama wants to expand the role of the federal government in education.

Education is important to the state of Texas. According to the TEA website, "the mission of the Texas Education Agency is to provide leadership, guidance and resources to help schools meet the education needs of all students". The responsibilities include text book selection, development of a statewide curriculum, administer statewide assessment, collect data on students, staff, and finances, rate schools, monitor compliance with federal guidelines, and serve as a fiscal agent for the distribution of state and federal funds.

Notice that at the state level the guidelines and objectives are a little better defined and mandated. The Texas Constitution in Article 7 mandates the support and maintenance of a system of public free schools. It established a permanent school fund, defines funding, formation of school districts, and creation of a state board of education. Education is the mandate of the state of Texas.

In 1910, the University Interscholastic League was created by the University of Texas to govern debating contests and govern athletic contests across the state. The League is a loose federation of schools that agree to accept and observe the terms of participation in the contests as set forth in the constitution and contest rules defined by the governing body. The UIL is governed by a Legislative Council composed of 28 public school administrators. The council acts on proposed amendments and requires approval of the Commissioner of Eduction before they are implemented. Senate Bill 82 of the 80th Legislative Session gives the UIL the right and authority to administer who can participate in extracurricular athletic activity and the admission of a pre participation physical evaluation. This guideline gives the UIL the authority to define what a physical consists of and who can administer the exam.

Senat Bill 82 states

"An individual answering in the affirmative to
	any question relating to a possible cardiovascular
	health issue, as identified on the form, should be
	restricted from further participation until the
	individual is examined and cleared by a physician,
	physician assistant, chiropractor, or nurse
	practitioner. Ultimately, the individual may need to
	be evaluated by a cardiologist and/or undergo cardiac
	testing (including an echocardiogram and/or other
	heart-related examination) based on the assessment by
	the primary care provider."

The bill was submitted by Senator Van de Putte of San Antonio and Senator Royce West in Dallas County.

I realize that I meandered a long way to get to legislation relating to cardiac testing of students. I personally think that it is important to see what people are requested to do, what they are required to do, and what they are mandated to do. If we are going to effect change in our government, knowing who is responsible for the change is the first step in making the change. Complaining about what the President is or is not doing with education will not effect an issue that is important to me, cardiac health. The agent of change for student health is the UIL who mandates what coaches and trainers are required to do.

actual vs theoretical

This month has been a very interesting month that has centered around theoretical vs actual. The month started with budget estimates and how many students we can screen. The discussion degenerated into how much theoretically can you do and how much do you expect to do. Theoretically we can do a significant number of ECGs. Our average tech can perform one screening every three to five minutes. If we assume five minutes we can do twenty ECGs per hour. Given that there are about five hours per day that we can screen during the school day and two after hours, one person can screen 140 students per day. Granted, that is a long day of standing and screening students. We usually being more people and machines to reduce the wait time and compress the screening into shorter hours. Given that we have about 20 machines our theoretical limit would be 2800 students per day. This brings us back to theoretical and actual. The largest screening we had in one day was 350. We had six machines and screeners for six hours. Even though we can do about 3000 per day, 300 is a more realistic number. If we look at it closer we didn't do that many more than a handful of times throughout the year. A number closer to 100-200 per day is a typical day. Given that we have about 180 days that kids are in school we should be able to screen 504,000. Again, that isn't practical. If we want to target screening 20,000 students and assume that we can screen about every other day on average we need to screen about 220 students at an average screening and do that about 100 times a year. Not only is this number practical but it is realistic. We can fill in some Saturdays or after school as well as extend into late summer during pre-season. Screening 20,000 students is not only theoretically possible but is in line with numbers we have generated in the past and maintained over longer periods.

A recent article in the American Heart Circulation (May 29, 2012, Volume 125, Issue 21) also generated significant discussion earlier this month. The article from Tufts University talks about the cost effectiveness of screening high school students using simulation models and assumptions drawn from existing literature. The simulation shows that the cost per life-year saved ranges from $91,000 to $204,000. Given that we screen students and follow what actually happens to them we decided to compare the theoretical against actual. We have screened just over 20,000 students and cleared 95% of them with an ECG test that we charge $15 per student. If you assume that a follow up exam is $300 for a doctor visit and limited echo and $900 for someone flagged as high risk, the cost of screening comes out to $300K for healthy patients, $268K for follow up patients and $39.6K for high risk patients. If you further assume that 80% of all high risk and follow up patients are cleared and can be treated with medication, the remaining 20% represent an additional cost of $357K of treatment with continued care and long term medication and $352K for surgical correction (9 students at $40K per surgery). Two of the high risk students had heart transplants at a cost of $1.5M each.

Our actual numbers show that screening 20,000 students cost $300K with the burden being on the parents who wanted screening. The remaining $268K and $39.6K was split by the insurance companies and the parents. For the 18 students that have heart issues that do not require surgery but have heart issues the $107K cost is split by the insurance companies and parents. For the 11 students that had corrective surgery the $352K for minor surgeries and $3M for heart transplants were effectively paid for by insurance.

If we include the two students that had heart transplants the cost per life saved for the program is $388K. If we assume that the 11 that had surgery would have died before they were 30 and they will now live to be 75, the cost per life-year saved is $8,600 (dividing 388K by 45 years of additional life). If we drop out the two heart transplants the cost per life saved is $150K or $3.3K per life-year saved assuming that the 9 students live an additional 45 years due to the surgery. If we assume that the student lives an additional ten years this still results in $38K per life-year saved and $15K per life-year saved without the heart transplants.

Actual vs theoretical is a good discussion. When we are talking about actual lives saved and actual screening of students, simulations and extrapolations are not good enough. Having 11 kids that have gone through surgery, two major and nine minor, and 179 that have heart issues that are being treated early in their lives can not be ignored. Ask any of these 190 students if they think that screening is worthwhile and I think that every one of them and their parents will say yes. We can talk about life years saved and was a life saved or did we just postpone something but improving the lives of these 190 students is significant. Confirming that the remaining 19,810 students don't have heart problems is equally significant. Our stance is that affordable screening works. Eight years of screening with confirmation from multiple Cardiologists that the 190 students that have gone through this program and been identified as someone with a heart issue that needs treatment can not be discounted despite what a simulator or extrapolation from other publications tells you.

One person can make a difference

There are some days when the alarm goes off and all you want to do is pull the covers over your head. Other days it is easy to get out of bed and make a difference to someone. When I worked in the corporate world it was easy to say it can wait or we can get to it tomorrow. Working with people who want things to happen and are excited to make a difference becomes infectious.

I have been working with a couple of people who do make a difference and have infected me with their drive and determination. The first is Dr. Thomas DeBauche. I met him just over twenty years ago a few weeks after meeting his oldest daughter. I was hesitant to meet him because it was a dinner and the purpose was to tell him that my intentions were to marry his daughter. Over the years I have seen what he does and how he works with patients and the community that he lives in. I have seen him get numerous community awards for service and giving to the local schools. About two years ago he convinced me to leave a perfectly stable job and help him start a small company that wants to screen high school athletes. Eighteen months later we are almost profitable and have expanded to three states and about 4% of all athletes in the state of Texas. His excitement for the company has helped me be creative and grow the company in ways that I would not have thought of. Our plans are to expand into one or two other states next year and triple the number of students that we screen next year.

The second person that I think makes a difference is Marcia Niles. I have never personally met Marcia but have talked to her on the phone and helped her with one of her projects. About three years ago her granddaughter passed away from sudden cardiac death. Marcia's daughter called me and asked how we could help start a program in Phoenix to prevent this from happening to other kids and parents. She was able to partner with the Anthony Bates Foundation and get screening started at area schools and continues to screen students in Arizona. Marcia started a screening program in Lincoln County Washington at one school last year and has expanded to most of the schools in the county this year. We donated one of our machines to her this year so that she can expand her screening and cover more schools.

It is easy to wake up and hit the snooze button. It is easy to let someone else take care of things and do the hard work before you get there. I find it rewarding to get up and work with the people who make a difference in the lives of others. They encourage me to try and make a difference as well. This morning I took my youngest son to his first high school swim practice. I introduced myself to the swim coach and told him that I wanted to screen all of his swimmers before the start of school. I have already cleared it with the athletic director for the district but it is important to me that all the kids that my son will be swimming with gets screened. He looked a little shocked by my determination but said that he will work with his trainers and athletic director to lock down a date. He thinks that screening is a good idea and wants to make sure all his kids are safe as well.

One person can make a difference.

is it better to find something or nothing

I have been helping with cardiac screenings for the past two years and as a company we have screened for eight. Last year it was rare to screen over twenty students and have all of them come back as low risk in medical terms or healthy in lay terms. We can't say words like "strong hearts", "good hearts", "happy and healthy", or "no problems". We have to use terms like low risk and high risk. The strongest thing that we can say is that someone has a normal ECG but that typically does not mean anything because our Cardiologists typically come back and correct what the machine says. We turn off the auto-interpretation because it is inaccurate and misleading to people we screen.

Since the first of 2012, we have modified what we look for and have refined our categorization of low risk and high risk as well as a follow up request because the ECG does not fit into either profile. A result of this modification has resulted in a larger number of low risk categorizations and a lower number of follow up requests. 

This change has prompted the question; what is better .... coming back with one high risk student from a group or coming back all low risk? We get press and attention when we find someone who no one knew had problems. Everyone wants to talk about a high risk student. Trainers and coaches want to know more information and talk to each other and us about the interpretation. Talk is good. Talk is healthy. It increases the discussion about what to look for. It increases awareness about the risks. It makes the coaches and trainers review their CPR and AED training programs. It brings the risk to their school and make it real for them without having to deal with a tragedy. This excitement crosses over to the parents and booster clubs start talking about making screening mandatory. It makes schools they compete against call us and ask if we can talk about screening at their schools. In my opinion, talk is good because it helps prevent a tragedy and prepares everyone to look for and act if and when something happens.

On the flip side, if we screen fifty seven students, like we did at Clifton High School in north Texas, or thirty five athletes, like we did at New Braunfels, and all come back as low risk there is little talk. In my opinion this is a stronger statement for a community that everyone we screened was healthy. Unfortunately, newspapers don't want to talk about how healthy and good their athletes are. Parents assume that their students will come back low risk so it does not surprise them. In 2011we screened 8,700 students across the state and 8,400 came back as low risk. This is 96.56% which in my opinion is a good thing. We saw 21, or about 0.24%,  categorized as high risk with one going through corrective surgery, two getting implants, three getting recategorized as low risk, and the rest being monitored for early stages of what could potentially become problems as they mature. Of the 278 that were asked to have follow up exams, one was categorized as high risk, twenty are being monitored for early stages of potential problems, and the rest are being asked to get screened again in two years even if they are still in middle school or high school. 

For the first half of this year we have screened 3,100 students, coaches, and teachers. We are seeing a higher percentage categorized as high risk (0.9%) but two thirds of these are coaches. One knew that he had heart problems and the other checked into the hospital after the screening and had surgery that weekend. We are seeing 96.39% cleared as low risk which is tracking with previous years. 

We are expecting to screen about 12,000 more students before the end of the year. This means that 60 students will be classified as high risk and 11,568 will be classified as low risk. What keeps me coming to work each day and shouting from the blogosphere that cardiac screening is a good thing is that each student that we categorize as high risk is a potential life saved. This means that the paper won't be reporting a student collapsed at practice, an ambulance was required at a stadium, an AED was able to shock someone back to life, or a school is mourning the loss of a student. On the flip side it also means that about 14,500 student can push themselves a little harder, dream of getting a college scholarship based on their athletic abilities, and help raise the level of competition in their district. I know that I push myself a little harder when I know that I have laid the proper foundation to take it to the next level. I can't swim a sub minute fifty meters until I break thirty seconds in a twenty five. I can't maintain a seven minute pace for a 10K until I can run a seven minute mile. Having an ECG listing me as low risk is just as important to me as heading to the pool for a morning training swim or an afternoon track workout. 

I will let you answer which is more impressive, finding the one student that potentially could collapse on the field or finding that all of you students are healthy and can take competition to the next level.

Kudos to Pennsylvania General Assembly

It is always heart warming to see government act to serve and protect. Today the Pennsylvania General Assembly passed House Bill 1610 which defines warning signs for sudden cardiac death and details the actions required of coaches and trainers to remove and re-instate players from participation. There is a huge debate across the country on screening procedures, the number of students at risk, the cost and effectiveness of screening. No one disagrees that there is a problem. It is refreshing to see something done about it to positively protect student athletes from the risk of cardiac death.

In Texas legislation was passed last year to protect students from the risk of concussions. The medical advisory board of the UIL admits that screening through history and physicals by physicians, nurse practitioners, and chiropractors is not an optimal solution. The concussion screening protocol was mandated by the State Legislature. Will it take a state law to enforce similar guidelines for cardiac screening?

The Pennsylvania law is simple. If a student exhibits "fainting, difficulty breathing, chest pains, dizziness and

abnormal racing heart rate" then they are prohibited from returning to participation until cleared by a medical professional. This law is less complex than the concussion law passed last year in Texas. In my opinion it should be passed in all fifty states. If we can't get screening a suggested part of pre-participation physicals the least we can do is define a protocol on what to do before the use of an AED is required.

growth vs fiscal responsibility

As I listen to news about the Greek and Spanish Debt Crisis, I wonder at what point should I worry about debt. Running a small business has been interesting this year. We have generated more income in the first half of the year than we did all of last year. I started learning a new accounting system to track income, expenses, profitability, and viability of the company. Last year when I got a check I was excited because I was not spending my own money and not taking personal funds to pay for new equipment. Upon advisement of my board of directors I took on debt in the form of an American Express card. The interest rate wasn't that much but it was more than I had the previous year.

After paying finance charges for a year on about $10K in debt, I question the viability of floating loans. Is it better to conservatively grow and buy equipment when you have cash or should I manage the amount of debt so that we can grow the company. New equipment means more potential for earning money. New equipment also means more debt. The question that I am facing now is how much new equipment follows new expenses? Looking at QuickBooks, I do notice that some of our accounts tend to generate more income than others. Some of our early deals loose us money for each transaction. I think I figured out how to leverage the equipment and have it drop the price of other customers screenings.

As my focus changes from how do I make payroll for a new employee to how do I grow the company fast enough to minimize debt and maintain monthly income and expenses. The fledgling company that we started 18 months ago is almost ready to step out and walk on it's own. We still need a little help when it comes to climbing the stairs and getting out of holes that we fall into but given another 18 months it will be interesting to look back and realize that $10K in debt wasn't much to worry about and ordering two new machines is something that hopefully happens on a regular basis.

We are on our way to screening 20,000 students this year. The spring was an excellent start to this goal but we need to start screening more and more in the fall to make this target.

if I talked to our team doctor

I had a question the other day that I had to pause a second or two and figure out how to answer. The question was "If I talked to our team doctor and asked her what she thinks about your screening process, what would she say". It took me a while to think of an answer.

There were three things that I debated talking about. First, not all doctors are qualified to talk about cardiac screening. Having worked with a group of doctors, each has their own specialty. We go to a Pediatrician but I would not trust her reading an ECG. We go to an Orthopedist but I would not trust him with interpreting an Echocardiogram. I go to a Chiropractor and he was smart enough to say that using a stethoscope is something beyond his abilities. Each of these doctors has a specialty and a focus just like every one else in the world. I don't ask my Cardiologist about a pain in my lower back or an ankle injury. He isn't up to date on childhood diseases and immunizations that are needed for middle school.

My first thought was that the doctor that the school has a relationship with is probably an Orthopedist but I didn't want to jump to conclusions. I assumed that they were qualified on cardiac screening and that led me to the next quandary. If they know anything about cardiac screening there are two camps of thought. One group says that simple screening with an ECG will yield about one in two thousand at risk kids. Given that the school has over 23,000 students, that means that there are about 11 kids are potential sudden cardiac death candidates at one of twenty four schools. There is about a fifty-fifty chance that there is one kid has a serious problem in one of the schools and does not know about it. A screening program for all athletes will pick up five or six of these kids assuming a 40% participation in athletics. A doctor who believes in ECG screening would be behind a $15 screening program that hits 80-90% of all student athletes, band members, and ROTC participants.

On the other hand, the American Heart Association is split on this issue. The doctor could fall into the camp that ECG screening catches the worst cases and produces about 10% false positives. To truly catch disease you would need to include Echo screening and the cost of doing that is really expensive. Once they find out that we charge $25 for ECG and Echo screening combined they might recommend the program but admit that not everyone can afford the $25 screening or the $200 doctor visit if something is found.

Either way, everyone agrees that the standard questions posed by the American Heart Association that has been included in the standard physicals is neither comprehensive, effective, or practical. If you answer that you have a family history of cardiac problems you immediately fail your physical and need to see a family physician for a full workup. If you answer that you have fainted or felt dizzy while running you fail your physical. A University of Washington study last fall showed that the majority of doctors don't ask every student the standard questions that are required and the students don't answer the questions correctly because they don't know or don't want to fail the physical.

I did answer the question after about 20 seconds of hesitation as all of these thoughts went through my head. I said that the doctor will either be 100% behind ECG screening and strongly recommend it or hesitate and say that it should include Echo screening. They will also advise that you need to think about what to do with the 5% of the kids that are not categorized as low risk and need a doctor visit. They might also ask how low income kids are going to come up with $25. They should also ask who you are using for screening and what is their history at screening other schools. Fortunately for us, we have faced these questions from other schools and have recommendations on follow up requests as well as eight years of history screening high school athletes.

Hopefully a study in 2012 will show that ECG screening is either effective, a waste of time, or Echo screening is needed to find the leading indicators resulting in sudden cardiac death. Until then, we will continue to have this discussion as well as offer both services to schools that get recommendations that both are needed.

Doing the right thing and subcommittees

At what point do you stop doing the right thing and start protecting yourself? I have a friend that was elected to the city council of our small town. When re-election came he decided not to run again. His frustration level was so high because the other people on the council didn't want to vote for or against anything controversial or co-sponsor bills because they were afraid of being sued.

We have presented three times to the UIL Medical Advisory board and all three times have gotten the impression that our input is valued but nothing will be done. The board is the same group of people every time with very little change in the membership. They are required to listen to the public twice a year. If you want to say something, you get five minutes. The first time we presented we went with another non-profit organization and had them present the risks of sudden cardiac death and asked that the UIL website be changed because it showed that one in three hundred thousand high school kids are at risk for sudden cardiac death. Recent studies have shown that the number is more like one in three thousand for sports like basketball, cross country, and water polo. Our request was denied because the recent publications focused on NCAA sports and not high school sports in Texas. The doctor that came with me to testify left in anger saying that the board was a waste of her time and she would never return to present. The second time we presented we cited high school deaths in the state and the board questioned our numbers. They don't record or track athlete deaths and wanted to know why we had access to data that they did not. A subcommittee was formed to look into getting the data for the board. The third time that we presented we asked for an update on the subcommittee and presented new data that the history and physicals used to screen athletes are ineffective and generate way too many false results both negative and positive. We got agreement that there was debate over the questions used but our screening results were not 100% so recommending a change was not suggested at this time. They will get back to us in October about the subcommittee because they need to consult with the Attorney General of the state and he had not returned their calls from the previous October.

Here we are 18 months later and nothing has changed. We have concussion screening, which no one has died from, that they are 100% focused on because the state legislature passed this as a requirement. The medical board decided that concussion screening was too controversial and did not need to be done when it reviewed the options. The state legislature mandated it and everyone in the state needs to be screened for concussions prior to participating in athletics.

Our programs growing but not fast enough in my opinion. We cover about 6% of the state. If we had something like a checkbox on the physical form suggesting cardiac screening for those doctors that do not know how to perform screening that number would be significantly higher. If the UIL would acknowledge that a higher number of students are at risk, people would take screening more seriously. I don't understand the reservation in protecting student athletes as more and more die each year from sudden cardiac death. The board is more concerned with not being at risk themselves than adequately protecting students.

I realize that my statements are a bit inflammatory but it is frustrating when a leading Cardiologist who volunteers his time to screen students in a non-profit organization recommends against cardiac screening across the state. I'm not sure if he is against ECG screening, ECG and Echo screening, or screening of any type. We were not recommending any specific type of screening just that something be done. Death of students is something that needs attention. Doing nothing to protect your job is something that does get me angry.