Three-dimensional imaging diagnostics-in particular, Cardiovascular CT angiography (CCTA)-have been widely touted as the next big thing in the diagnosis of CAD and PAD. Nearly every day a new clinical article related to CCTA shows up in my inbox. What's the current state of 3-D imaging?
While important, this technology has not proliferated as rapidly as many of us thought it would. It is clear that the reason is largely (but not exclusively) economic: the high cost of the equipment (beyond the scanners themselves, the workstations required to post-process and analyze results), the impact of the worldwide recession on capital purchases, lack of technological uniformity, lack of skilled technologists, the cost-related pushback by insurers (including Medicare) due to the proliferation of all types of imaging, fear of a negative impact on cardiac catheterization volumes, the time commitment and cost required for physicians to obtain proficiency, and so on. Overall, reimbursement has been challenging, with ever-changing policies and payment inconsistencies among payers.
Given the current challenges, what trends relative to CCTA does CFA believe will be important for hospital cardiovascular programs in the future?
- If you don't provide access to CCTA, your cardiologists and vascular specialists may be motivated to work with your competition that does. Or possibly to purchase it themselves (if they haven't already) and go into open competition with you (another reason for hospital/physician alignment strategies!). New regulation, including healthcare reform, could mitigate this issue, but it will still exist.
- The use of CT technology will continue to be shared between Radiology, Cardiology and others, except in the largest volume programs that can justify dedicated (and cardiology-controlled) cardiovascular CTA. This situation drives the need for inter-disciplinary collaboration and a cooperative model for sharing access to the equipment and completing comprehensive interpretation of the results.
- ED usage of CCTA for chest pain triple rule-out (because of its diagnostic capability to assess aortic pathology, coronary artery disease, and pulmonary emboli in one scan) may soon become the standard protocol for diagnosis of chest pain.
- As hospitals continue to develop stroke center capabilities, quadruple rule-out examinations, which extend coverage from the skull base through the thorax, may become useful in patients with syncope, transient ischemic attacks, and cerebrovascular accidents resulting from carotid stenoses. The so called "half-body scan" may become more commonplace.
- Automated cardiac CT-analysis software shows promise, has a high negative predictive ability and may facilitate utilization for smaller, community hospitals.
- The recent Texas law requiring insurance companies to pay for CV screening inclusive of non-contrast CT measuring coronary artery calcification (calcium scoring exam) will most likely not soon be replicated in other states.
- Use as a universally accepted (and reimbursed) screening tool for asymptomatic patients is highly unlikely as well.
- Highest and best use may be as a "filter" to avoid invasive angiograms where likelihood of CAD is not very high.
- Over time, CCTA will become part of the diagnostic work flow for many cardiologists, cardiac and vascular surgeons, and become an expected part of their clinical routine.
- As 3-D diagnostic imaging continues to develop, consistent reimbursement is established, drops in cost, and is generally accepted by other specialists (especially for surgical/procedural planning), it will become the standard. Payers will come to see it as possessing real value. The trend to promote all 3-D imaging will help promote CCTA for cardiac and vascular use as well.
The CFA team recommends that those interested in learning more about Cardiovascular CT contact the Society of Cardiovascular Computed Tomography (SCCT) at http://www.scct.org/. This is the leading professional organization dedicated to CCTA and provides its members with regular updates on education and training programs and legislative initiatives. SCCT publishes a journal devoted to the utilization of this technology.