RSNA: Cardiac CT programs better diagnose acute chest pain, slash costs
Each year, there are an estimated eight to 10 million patients who present to the emergency department (ED) for chest pain, and up to 5 percent of cases may have a missed diagnosis, said Lit.
Setting up a coronary CT program at a hospital is beneficial and can be helpful in the reduction of repeat ED visits and readmissions for the condition, but many factors must be taken into consideration in order to have a successful agenda.
For a chest pain evaluation, Lit said that it is important to first draw an ECG, perform a risk assessment and then determine the proper clinical pathway decisions such as: admittance to the hospital, performing 24-hour observations and determining the best possible discharge pathways.
Comparing the use of cardiac stress testing versus a cardiac catheterization, Lit compared patients who came to the ER with chest pain to those who had a negative stress test and those who had no stress testing. Within both groups they will have the same hospital admission rate, and have the same number of readmissions. A previous negative stress test did not change the rates of 30-day adverse event rates. However, compared with catheter angiography, a previous negative cath had fewer ED visits, hospitalization and greater physician satisfaction
“So where is CT’s role?” asked Lit. He offered that previous single-center trials have shown that cardiac CT is a safe and efficient exam that reduces the number of repeat ED visits and hospital readmissions, while at the same time reducing costs by $250 to $2,500 per patient.
In addition, Lit offered that cardiac CT is endorsed by most payers, including the CMS. He said that CT works because “it acts as a surrogate for catheterization, and ED physicians and patients believe the results.”
At UPenn Lit and colleagues compared the costs and outcomes of immediate CT versus usual care, finding that the costs for immediate CT exam was significantly lower than usual care, $1,240 versus $2,913.
But when implementing a program such as this, what are the upfront decisions that must be made?
Lit said that physicians must decipher what patient populations will be evaluated: only those with MI or only those discharged directly from the ED, for example. In addition, facility stakeholders and personnel must determine the hours of coverage for technicians and other staff.
Who is necessary to make a successful cardiac CT program and what do you need? Lit said that emergency medicine physicians must drive the program at your facility, along with nurses and nurse practitioners. In addition, CT technicians should be available to perform and read CT exams, while radiologists and cardiologists should be included to interpret studies.
Lastly, hospital administrators should be included on the team to oversee reimbursement issues and additional staffing.Most importantly is the inclusion of a protocol, which will outline: which patients receive the test, what staff is responsible for performing it and what constitutes a positive or a negative result.
Lit said that at UPenn a total of six cardiac studies are performed per day. However, the facility performs calcium scoring first. Prospective gating technique is used only on patients with a heart rate under 65 beats per minute and a 100 kVp is used on more than 60 percent of all scans with a dose of 5 to 8 mSv.
He added that it is imperative to involve both ED physicians and cardiologists in planning for your ED cardiac CT services. In addition, he said that you must have a plan and system in place for patient follow-up.
"Don't waffle in your reports, because ER doctors hate that. The key is to have high quality studies. If you have good quality studies, you are going to have good quality reports," he concluded.