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  • 1. Exercise Treadmill Testing Part I
    • Eugene Orientale, Jr., MD
    • Associate Professor, Family Medicine
    • University of Connecticut School of Medicine
  • 2. ETT Workshop Format
    • Introduction
    • Feasibility / Equipment
    • ETT basics
    • Other diagnostic tests...
    • Clinical Cases / Discussion
  • 3. OBJECTIVES
    • To improve the current office screening practice of patients with possible coronary artery disease.
    • To facilitate greater understanding amongst faculty and residents of the use of diagnostic office ETT.
    • To augment the diagnostic capabilities of a Family Medicine office practice.
    • To further educate and validate the need for resident education in the use of electrocardiography and ACLS.
  • 4. ETT by Family Physicians ?
    • A random sample of 211 practicing members of the Nebraska AFP found that 58% performed Exercise Stress Testing
    Goeschel DP et al, J Fam Pract 1994; 38:132
  • 5. ETT by Family Physicians ?
    • 92 % of Family Practice Residency Program Directors surveyed believed that FPs should be taught this skill...
    Jurica,JW et al. Graded Exercise Stress Testing in Family Practice and Internal Medicine Residencies . J Fam Pract 1989; 29: 537-41
  • 6. Why ETT?
    • Clinically, inclusion of Exercise Testing in a Family Physicians array of diagnostic procedures increases physician confidence and security in evaluating and managing the overwhelming majority of patients who are seen in the office for chest pain.
    • - Ken Grauer, MD
  • 7. Why ETT?
    • Even if there were enough cardiologists in the country to perform exercise testing on all persons with potentially valid indications for the test, the fact remains that patients with minimal or no symptoms do not routinely present to a cardiologists office with these concerns in mind. - Ken Grauer
  • 8. Why ETT by Family Physicians?
    • Patient Care
    • Cost Containment
    • Comprehensive Care
    • Financial Considerations
  • 9. Reasons cited by FPs not performing ETT:
    • Never had training
    • No time in practice to perform procedure
    • Cannot afford to purchase the unit
    • No access to a treadmill unit
    • Lack of hospital privileges
    • No interest in the procedure
    • Inadequate reimbursement
    J Fam Pract 1994 ; 38 (2) : 135
  • 10. Conclusion
    • Whether family physicians should be doing Exercise Stress Testing is academic. Family physicians will continue to perform the test because demographics and public awareness and expectations will require it. We need to recognize this reality and focus our efforts toward providing competent and well-trained physicians to serve the needs of the public.
    Goeschel, DP et al. Geographic Variation in Exercise Testing by Family Physicians. J Fam Pract 1994; 38 (2):132-137
  • 11. Feasibility
    • Current UConn Family Practice referral rate for ETT
    • is 5--6 / month.
    • This amounts to 60-72 referrals per year.
    • Yearly revenue lost (assuming $250 / test) is:
        • 60 tests: $15,000
        • 72 tests: $18,000
    • CPT code for ETT/Interpretation is 93015
    • Medicare reimbursement: $126 - 200
    • Common office charge: $229 - 285
    • UConn Family Medicine ETT charge: $250
  • 12. Clinical Competence in ETT: ACP / ACC / AHA Task Force, 1990
    • Some Internal Medicine residency programs provide training in exercise testing, often as an elective. A minimum of 4 weeks should be devoted to this training to achieve competence... The number of procedures necessary to insure competence has not been established by objective criteria... The majority opinion of this committee and its consultants is that the trainee should participate in at least 50 exercise procedures during training... However, it is recoqnized that not all training or practice environments are the same and a greater or smaller number of procedures may be deemed appropriate.
  • 13. Maintenance of Competence: ACP / ACC / AHA Task Force, 1990
    • Twenty five tests per year are suggested as the minimum number the physician should perform to maintain clinical competence. Successful completion of a course in ACLS and renewal on a regular basis is necessary.
  • 14. ACC / AHA Task Force, 1997
    • Exercise testing should be supervised by an appropriately trained physician exercise testing in selected patients can be safely performed by properly trained nurses, exercise physiologists, physical therapists, or medical technicians working directly under the supervision of a physician, who should be in the immediate vicinity and available for emergencies.
  • 15. Treadmill Systems Evaluated Spacelabs / Burdick Quest Stress System
    • Marquette
      • Max-1 Stress System
      • Case 8000 Stress System
    • Quinton
      • Q4500 Stress Test System
      • Q Stress System
  • 16. Treadmill Systems
    • Quinton Q Stress System
      • - durable treadmill construction
      • - powerful motor (3HP)
      • - programming ease
      • - stores numerous testing protocols
      • - software upgradeable
      • - ease-of-use
      • - filter technology for cleaner tracings
      • - design your own display format
      • - longest treadmill available (for athletic training / testing)
      • - Q-care service contract
  • 17. ETT System Layout Treadmill BP Cuff Recorder Monitor Controller Crash Cart
  • 18. Treadmill System
    • Treadmill
      • slope 0 - 25 degrees
      • speed 1 - 15 mph
    • Monitor
      • displays 3 or 12 leads
      • computerized (digital) technology
    • Recorder
      • prints reports
      • includes customized summary report
  • 19. Patient Selection Criteria
    • Always have a purpose in mind when selecting patients for Exercise Treadmill Testing...
  • 20. Chest Pain...
    • Atypical Chest Pain
    • Atypical Angina
    • Typical Angina
  • 21. Risk Factors: Coronary Artery Disease
    • Hypertension
    • Hypercholesterolemia
    • Smoking
    • Family History
    • Male >40, Postmenopausal Female
    • Diabetes Mell

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