The CFA Perspective

Cardiovascular CT in the ED – The CT-STAT Trial

Posted by Peter Rastello

2/19/10 5:07 PM

If a blog is an electronic soap box, then CFA can be accused of standing on one and shouting about the continuing positive evidence of the utility of cardiac CT angiography in cardiovascular diagnoses. The reported results of the CT-STAT (Coronary Computed Tomography for Systematic Triage of Acute Chest Pain Patients to Treatment) Trial presented at the AHA meeting in November, 2009, gives positive results for the use of coronary CT angiography on chest pain patients in hospital emergency departments. Previous studies have produced similar results, but they tended to be small and single facility-based trials.

We all realize what a challenge the ED has in the diagnosis of chest pain patients. Six million chest pain patients present to ED's in U.S. hospitals each year. Of these, 75% are found to have non-ischemic or non-cardiac etiologies for their chest pain. The diagnostic cost of diagnosing these patients is estimated at $12 to $14 billion a year. About 2% to 4% of acute coronary syndromes are missed and inappropriately discharged. This leads to an estimated 20% of malpractice costs being assigned to missed diagnosis of chest pain in the ED each year. The standard-of-care testing (rest and stress imaging after serial electrocardiograph and cardiac enzyme tests) for chest pain patients is time consuming and resource intensive, with results that are not always definitive.

In the study 750 low-risk chest pain patients were randomized in 16 hospital sites to receive either CT angiography or standard-of-care workups in an attempt to produce a diagnosis. The results of the trial were striking:

  • The use of CT resulted in a mean diagnosis time of 2.9 hours, compared to 6.2 hours for the standard of care.
  • Use of CT decreased the overall radiation exposure from about 15 mSv for the standard of care to 10.8 mSv for CT angiography.
  • Use of CT decreased overall costs for patients from a mean of $3,458 for standard of care to $2,137 for CT angiography.

In summary, the trial concludes that the use of CT angiography was safe, faster, and cheaper than the standard of care. CFA encourages all hospitals with emergency departments and cardiac CT technology to evaluate chest pain strategies based on cardiac CT angiography, but cautions that there are many factors that must be considered with implementation. Including:

  • Availability of CT (specifically technical staff and interpreting physicians) within the hospital, particularly beyond daytime hours.
  • Interpretation by qualified physicians. After hours coverage is particularly problematic and may require the use of a night read services, which increases costs.
  • Development of protocols that highlight the indications and contraindications for the test, importance of heart rate control, administration of beta blockers and the like to obtain appropriate and assessable studies. Not every patient is a candidate for coronary CT. 
  • Continuing quality audits that track the quality of the studies and pinpoint non-assessable studies, and continuous review of CT cases as part of appropriate monthly multi-disciplinary conferences.
  • Often problematic reimbursement.

For further information on CT-STAT, CFA refers you to http://directnews.americanheart.org/extras/sessions2009/slides/159_sslides.pdf


Topics: CCTA, CT-STAT, Cardiovascular imaging

Advanced Cardiovascular Imaging (CCTA) – A Critical Technology?

Posted by Peter Rastello

12/18/09 6:41 PM

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.

 

Topics: CCTA, Cardiovascular imaging, 3-D imaging