Why hasn’t coronary CT angiography (CCTA) really taken off as a chest pain triage strategy? Or, as a final stage, pre-cath noninvasive screening tool for certain patient populations? The potential benefits and cost savings associated with CCTA have been recognized and well documented. Clinical studies and research papers continue to tout its cost effectiveness and clinical efficacy. Yet since the advent of the ultrafast, 64-slice CT era began, its increased use has been slow – painfully so to those who promoted its use only a few years ago.
A perceptive article appeared in the November 2010 issue of Diagnostic Imaging. Dr. David A. Dowe, medical director of the coronary CTA program at Atlantic Medical Imaging in Galloway, New Jersey, an early proponent of CCTA, offered his thoughts in an opinion piece entitled, “Coronary CTA really works, but why isn’t its use soaring?” In an accompanying editorial entitled, “The deck is stacked against coronary CTA: why it matters,” the journal’s editor, John C. Hayes, weighs in support of Dr. Dowe.
Dr. Dowe proposes that despite all of the positive attributes of CCTA, the following factors have negatively impacted its use:
- The Radiation Dosage Scare – The uproar over radiation exposure from medical imaging tests kicked off a national debate over dosage that spilled out into CT. CT volumes dropped up to 20% in the outpatient setting. CCTA, which in original form exceeded the radiation doses commonly quoted for catheter-based angiography, was affected even more as it became a political football by those who wished to maintain the status quo.
- Radiology Business Management Companies and Insurance – The explosion in medical imaging volume and costs is well known. For real or perceived reasons, this has put imaging in the crosshairs of the insurance industry, which moved aggressively to confront the problem. Insurance companies contracted with Radiology Business Management Companies (RBMs) to pre approve all imaging scans. RMBs have not accepted CCTA as cost effective given underlying competing economic motives. RMBs may be reimbursed by how well they decrease utilization, or participate in risk contracts where their fee is determined by how far they drive down prices. In addition, the shift of copayments from employers to employees has caused some patient copayments for advanced imaging such as CCTA to soar.
- The Radiology-Cardiology Turf War – There exists an ongoing dispute between radiology and cardiology over the ownership and use of CCTA that has resulted in disagreements over ownership, control, training, certification and usage. Additionally, there is some level of disagreement among cardiologists over the appropriate usage and cost effectiveness of CCTA. To quote Dr. Dowe, “It is an internal conflict, which mixes both medical and economic considerations that are seized upon by the insurance/RBM industry as a reason for not approving any utilization of CCTA. They have a ‘Call me when you agree’ attitude.” Various regulatory and payment mechanisms have continued to address physician self-referral, which impacts cardiologists owning CCTA and supports radiologists grabbing CCTA market share (but then is a disincentive for cardiologists to refer patients to radiology for the test rather than use alternative testing which they themselves control).
Dr. Dowe concludes that it is not clinical efficacy that is the problem with CCTA usage, but rather a host of outside factors that have embroiled and sidelined it, and the result has been less effective care. It will be interesting to see how this issue plays out over time and whether or not health care reform has any impact.
As always, CFA invites your comments, suggestions and questions.