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.