Cardiovascular Business - May/June 2008 - (Page 9)

Coronary CTA Data Registry Shows Appropriate Use CTA as stand alone test CTA after an inconclusive SPECT CTA first, then cath inconclusive CTA, then SPECT CTA as layered test a registry of more than 25,000 cases indicates that less than 1 percent of coronary CTa exams are being ordered inappropriately as layered tests. (source: Timothy attebery, CVi3) CTA, they then sometimes have to call the RBM to get approval for the test. If the RBM doesn’t agree the test is necessary, a game of tag ensues where the physician from the practice and the physician from the RBM try to have a peer-to-peer review. And even if the provider is granted a radiology quality initiative (RQI) number to go ahead with the exam, it still might be denied later, Biga says. Dollars and sense A concern of payors is that cardiac CT, particularly coronary CTA, will be used indiscriminately along with other well-established imaging tests. The evidence, however, doesn’t bear that out. Analysis of a coronary CTA registry containing data for more than 25,000 patients found that less than 1 percent of exams were used as a layered test, meaning inappropriately ordered on top of other tests. The majority of the coronary CTA exams in the registry were used appropriately: ■ CTA was performed as a stand-alone test in 69 percent of patients; ■ CTA was performed after an inconclusive SPECT exam, essentially as a cath substitute, in 16 percent of patients; ■ CTA was performed as a first test, then cath, essentially acting as a SPECT substitute, in 9 percent of patients; and ■ CTA was performed first with inconclusive results, followed by a SPECT exam in 5 percent of patients. “The average savings per diagnostic episode was $442,” says Timothy Attebery, who is involved with the CCTA Registry and is president and CEO of CVI3, a firm that provides training and education for cardiovascular CT. The impact coronary CTA has on a cardiology practice can be gauged by the percentage of normal caths. If coronary CTA is used successfully to triage low- to intermediate-risk patients away from catheter angiography, the number of normal diagnostic caths should be reduced. Figures from the CCTA Registry show a 6 percent decline in normal caths, while therapeutic caths increased 13 percent. But how does coronary CTA compare with the gold standard? In the first prospective, multicenter study comparing 64-slice coronary CTA with quantitative coronary angiography, reported at the ACC meeting, researchers found that CTA consistently demonstrated high accuracy to detect stenosis (>50 percent and >70 percent) in chest pain patients being referred for invasive coronary angiography. The study, which enrolled 232 patients from 16 academic and private practice sites, did not exclude any patients based on high heart rate, high baseline calcium score or high body mass index. Additionally, researchers included all vessel segments in the analysis irrespective of size, says James K. Min, MD, a cardiologist at Weill Cornell Medical College in New York and lead author of the study. “We’ve established CTA’s diagnostic accuracy and now we need to prove that it’s clinically useful,” Min says. That can be done in three ways. First, prove it’s more cost-effective to use CTA as a first line test. Second, demonstrate that the findings on coronary CTA have prognostic value. And third, conduct prospective randomized trials comparing CT with the standard of care. Min and colleagues presented another study at the ACC meeting where they found that patients with no known coronary artery disease who undergo coronary CTA as a first-line test incur lower costs compared to CAD-naïve patients who undergo SPECT imaging initially. In contrast, patients with known CAD › Advanced CT Technology Keeps Radiation Dose Low While radiation dose of coronary CTA is a concern, retrospective ECG-gating with dose modulation and prospective ECG-gating with step-and-shoot protocols have reduced dose to as low as 3 to 5 mSv—that’s lower than most catheter angiography procedures. Even the latest slice iteration—the 320-detector row scanner from Toshiba America Medical Systems—can feasibly deliver an effective dose of 4 mSv, according to a study by Frank Rybicki, MD, PhD, director of the applied imaging science laboratory, and colleagues at Brigham and Women’s Hospital (Int J Cardiovasc Imaging 2008;online:Mar 27). CardiovascularBusiness.com Cardiovascular Business 9 http://CardiovascularBusiness.com

Table of Contents Feed for the Digital Edition of Cardiovascular Business - May/June 2008

Cardiovascular Business - May/June 2008 Contents First Word Cover Story - Coronary CTA: Drafting the Strategic Plan Financing New Technologies: Early Adopters, Lease vs. Purchase, and Joint Ventures Clinical Study Digest: ACE or ARB: It's Your Choice Can Off-Hour D2B Times Be Reduced Without Breaking the Bank? Digital Image Management Primer: Integrating Echo SPECT/CT for Cardiac Disease Detection: An Economic Conundrum Integrating the Healthcare Enterprise Connects IT Systems News & Views Calendar Reader's Resources The Back Page

Cardiovascular Business - May/June 2008

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