Though expertise and reimbursement lag, many radiology practices gear up to perform their share of a potential 20 million procedures a year The potential market for coronary CT angiography (CCTA) continues to grow as new CT scanners offer improved visualization of the coronary arteries and reduced radiation exposure. At the same time, the obstacles have proven stubborn. While radiologists in academic centers, hospitals, and private practice prepare to use the technology to image the vessels of the heart, they are frustrated by barriers to reimbursement and stymied by turf disputes. Mass-media attention to the controversial practice of self-referral by cardiologists ordering CCTA has also brought to light the need to balance the benefits of advancing technology with rising health care costs. Some radiologists believe that until these issues are resolved, CCTA will not fulfill its potential to improve the medical management of cardiac disease—and, ultimately, patient outcomes. Potential Market Analysis Jack M. Ziffer, MD, PhD, is director of cardiac imaging, Miami Vascular Institute at Baptist Health, Miami, and chair, Radiology Associates of South Florida. He estimates that the potential for CCTA in US market is 10 to 20 million examinations per year. He bases this estimate on the current number of nuclear cardiology studies done per year: 10 million. “A substantial number of those patients would be well served by CCTA as the first type of evaluation,” he says, adding that the potential number of CCTA exams doubles, given the availability of better imaging and reduced radiation dose made possible with newer scanners. Ziffer notes that a preponderance of clinical evidence supports the use of CCTA to diagnose and manage coronary disease. In addition, the new generation of technology will help evaluate a growing population of aging patients with asymptomatic heart disease, diabetes, or siblings with premature heart disease or sudden death. “It can establish whether they have coronary disease or not, and more aggressive management could take place,” he emphasizes. “Data need to be developed to evaluate whether imaging of these high-risk, asymptomatic patients is, in fact, beneficial.”

"We have a tremendous opportunity; it is the beginning of a potential major shift in how patients are evaluated, with nuclear scans currently being the mainstay. It is an incredibly exciting time to be part of the field." -Jack M. Ziffer, MD, PhD Miami Vascular Institute/Radiology Associates of South Florida

He adds, “We have a tremendous opportunity; it is the beginning of a potential major shift in how patients are evaluated, with nuclear scans currently being the mainstay. It is an incredibly exciting time to be part of field,” he says, particularly as it develops the right approaches and avoids applying others where there is no benefit. David Dowe, MD, of Atlantic Medical Imaging in Galloway, NJ, agrees that there is huge potential for CCTA. “The potential is equal to the number of stress tests that are done,” he says. “CCTA is proving to be an equal test, or superior to stress tests, for detecting stenotic disease.” Ethan J. Halpern, MD, MS, professor of radiology and urology at Thomas Jefferson University, Philadelphia, concurs that the number of patients for whom CCTA is appropriate is increasing as the technology improves. “We can get better resolutions on patients who have higher heart rates and higher arrhythmias,” he notes. With the new technology, radiation dose is coming down dramatically, lowering barriers to the use of CCTA to provide the same information gained from a nuclear stress test. In fact, the emergency department (ED) at Jefferson employs a triple rule-out protocol. Halpern cites a recent study on the practice, published in Radiology, that describes the outcomes of 200 patients, presenting in the ED with symptoms suggesting acute coronary syndrome, who underwent CCTA. Takakuwa and Halpern¹ found that 76% of the patients were discharged from the ED after the study. “These are people who otherwise would probably have had a nuclear study,” he emphasizes. Another benefit was that, for a population with an intermediate risk for acute coronary syndrome, the test found extracardiac anomalies in 11% of the patients that might not have been picked up on other tests. This is a patient population in which CCTA has a role in finding an anomaly more quickly, and it can be done without having to control heart rate (thus avoiding the associated risks), Halpern reports. Halpern also sees a potential market in the evaluation of chest pain in low-risk to moderate-risk patients. He agrees that, in many cases, CCTA can be a replacement for stress tests. Specifically, there is a population of patients who have negative stress tests with chest pain—or have positive stress tests and doctors who do not believe the test results. There also are those with false-positive or equivocal stress tests who could benefit from CCTA, he adds. “In patients who have a specific issue with chest pain, if you think they are going to be negative, CCTA is a better way to go.” Another potential application for CCTA is its use in preoperative patients scheduled for ablations and aortic-valve replacement, Halpern says. He also believes that CCTA can have a better prognostic value than cholesterol levels and blood pressure, and whether a patient smokes or has diabetes. Here, the test can be a strong predictor of future coronary events. When clinicians question the clinical status of risk factors, perhaps hesitating to prescribe risk-lowering medications because of their side effects, coronary calcium scoring is very appropriate to ascertain whether the patient’s disease needs to be managed more aggressively.

"One major job is expanding coverage of the ED to lead to improved care for the patients. It's an important expansion." -Ethan J. Halpern, MD, MS Thomas Jefferson University, Philadelphia

Some physicians are less convinced that patients and referring physicians should necessarily jump aboard the CCTA bandwagon. Jay P. Earls, MD, of Fairfax Radiology Consultants in Fairfax, Va, says that his hospital-based private practice of 76 physicians has had its ups and downs with CCTA and currently does about 2,000 scans per year. All CCTA studies are read at a central location. The Inova Fairfax Hospital has used CCTA in the chest-pain observation unit as an intermediate step. The big problem is reimbursement, but once that is cleared up, CCTA will be more common than it is currently, Earls notes. He adds that it is a common misconception that CCTA will eventually replace angiography. He believes that CCTA is better suited for patients at intermediate risk for disease, while patients at high risk will still go to traditional angiography. Training Hospital-based practices, community private practices, and radiology academic training programs vary by practice and region in their approaches to the level of training used to meet the demand for CCTA. Since the ACR Education Center began offering courses in CCTA in March, with three courses to date, 68 physicians have earned certificates of proficiency in CCTA in accordance with the case requirements specified in the ACR Practice Guideline for the Performance and Interpretation of Cardiac Computed Tomography.² As more centers expand the use of CCTA, greater levels of ACR-approved training are expected. At Fairfax Radiology, eight readers meet ACR guidelines for interpretation of CCTA; five of these physicians meet level-3 guidelines set by the American College of Cardiology (ACC) and the remaining three meet level-2 ACC guidelines. Earls predicts that more radiologists will be trained, if needed. At Baptist Health, Ziffer anticipates that his department will be extending ED coverage to six days per week, and then providing coverage around the clock in the future. This obviously will determine the need to train more radiologists in CCTA. In addition to radiologist training, hospitals must be able to supply CCTA-trained nurses and technologists to provide a quality product. For community-based centers like Modesto Radiology Imaging in Modesto, Calif, the amount of training completed is directly related to anticipated need and reimbursement. Of a total of 15 radiologists at the practice, just a few have been trained in CCTA so far. “We are in the early stages of preparation right now,” cardiovascular and interventional radiologist Richard Haak, MD, reports. At Thomas Jefferson, the focus is on research and on extensive training of residents and fellows in CCTA. Halpern says that as private practices battle reimbursement issues, his department is focusing on finding the best applications for CCTA. “We are going to a 256-slice scanner and plan to expand our practice in the ED to provide more testing of ED patients presenting with chest pain. We want to do a better job of triage for appropriate treatment. One major job is expanding coverage of the ED to lead to improved care for the patients,” he says; residents are being trained to cover CCTA 24/7. “It’s an important expansion.” Halpern emphasizes the importance of training radiologists with an interest in cardiac imaging and is concerned that a five-day course offered at various training facilities may not be enough. “We offer a training course for levels 1 and 2,” Halpern says, “but I don’t see that viewing 150 cases over a week prepares someone adequately for what CCTA is all about. It is about how the technology gives information in certain situations. It has to be incorporated into a broader period of residency training.” Building Alliances Working with referring physicians, hospitals, and cardiologists is crucial to building the CCTA practice. John Schaper, COO, Modesto Radiology Imaging, Calif, reports that his center has initiated a sit-down interactive meeting with a cardiology group to “sort out the turf.” He adds, “CT scan imaging is classically radiologist turf, but cardiologists obviously have a vested interest in coronary angiography, regardless of how it is done.” In fact, at Jefferson University, cardiology fellows train side by side with radiologists to read CCTA. “We have conversations about what is appropriate and what it not appropriate based on patients we see,” Halpern says. “It gives us more time to learn what the most appropriate response is.” Dowe predicts that hospitals will embrace a tremendous explosion in the ED use of CCTA once reimbursement issues are resolved. Then, hospitals will demand 24/7 radiology coverage for CCTA. Already, hospital administrators recognize the worth of CCTA in providing reductions in liability, ED lengths of stay, and cost of care. They also see the ability to market the facility as an elite medical center. “They get it,” he notes. Ziffer predicts that radiologists will continue to develop multidisciplinary credentialing and will create professional and economic partnerships. “It is important that people be paid for doing the appropriate work, creating legal and ethical models to work together,” he says. Some groups are forming a separate business entity—a reading panel that would execute interpretation and oversight of CCTA under a parent organization such as the hospital. Ziffer acknowledges that there are legal ramifications associated with different business models, and he identifies the need to work at the professional-society level to sort out all the issues. Technology and Reimbursement While technology continues to improve, some hospitals, private practices, and even academic institutions are holding back on purchasing new scanners until reimbursement issues are resolved. At Baptist Health, the hospital has three 64-slice scanners; physicians and administrators are evaluating the next generation to provide broader coverage. “We are looking at how can we most effectively get a study in the context of the ED,” Ziffer says. For nonemergency patients, the issues are radiation-dose reduction and improved resolution, he notes. By far, the most important hurdle to be overcome in expanding the use of CCTA is reimbursement, and few predict a positive resolution in the near future. As Ziffer states, however, costs justification of the technology at hospitals goes beyond simple reimbursement to include shorter lengths of stay and more effective diagnosis. “This can have a major impact on net finances in running an ED,” he says. Private practices are principally looking at return on investment as the driving factor on the revenue side. While reimbursement varies by practice and region, it generally lags behind technology. Modesto Imaging has promoted CCTA to referring physicians, but most patients are not willing to pay approximately $800 for the examination if there is no insurance reimbursement. “It remains to be seen how it will play out,” Haak says. “We are a little frustrated; it has its definite uses, and at this point, CCTA is underutilized. Lack of interest and a lagging insurance market have put a damper on things.” Halpern agrees that lack of reimbursement through Medicare is a major roadblock. Clearly, the acceptance levels of CCTA among physicians, patients, and payors are all intertwined. Although CCTA has demonstrated its value to radiologists and cardiologists, many private payors remain reluctant to pay for the test. The lag time between the adoption of preferred technology and payment for its use may continue to dissuade physicians and hospitals from switching to the potentially better method of assessing heart disease. There are hopeful signals on the horizon. Ziffer, who recently returned from a meeting of the Society of Cardiovascular Computed Tomography (SCCT), acknowledges that gaining broader adoption and payment for the technology will be an ongoing process. Layering is a concern, since no one wants to introduce one more test on the way to angiography, but Ziffer cites data becoming available on the role of CCTA in ultimately saving lives and money. There is an ongoing educational effort to ensure that payors and physicians are aware of those benefits. The SCCT, for example, promotes a multidisciplinary approach recognizing roles of both radiology and cardiology in providing CCTA. Additional Reading-Speed and Efficiency Drive CCTA Technique