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.