ACCA: Before jumping on the cardiac CT bandwagon, consider this
CHICAGO—The importance of including cardiac CT into a cardiovascular program was addressed by several speakers at the annual meetings of the American College of Cardiovascular Administrators (ACCA) and the Alliance of Cardiovascular Professionals (ACVP), both held here last week.

“It’s a very strategic decision,” said Susan Heck, a vice president with Corazon, a Pittsburgh, Penn.-based consulting firm that specializes in cardiovascular program development, at the ACCA meeting. “Many programs with CT scanners have had to go back to the basics because they didn’t pay attention to some critical details before the purchase.”

Some aspects to consider are:
  • Where will the scanner be located?
  • Who will buy it?
  • Who will read the exams?
  • What competency and credentialing criteria will be used?
Cardiac CT has proven valuable to triage low- to intermediate-risk patients with acute chest pain. Should the scanner be located in or close to the emergency room? CT has also excelled in pre- and post-operative evaluation of patients undergoing percutaneous or conventional heart surgery. Should the scanner sit within the cardiology department?

Generally, cardiology can’t keep a CT scanner busy on a daily basis and must augment cardiac-based studies with general exams. Should the scanner be located in radiology? Will it be used in the outpatient setting? What are future plans for the hospital and the technology?

“It’s more than a simple equipment purchase,” Heck said, echoing a common refrain in regards to cardiac CT.

With stiff competition, personnel shortages, overworked staff and decreased reimbursement, cardiovascular programs can maintain an edge by incorporating cardiac CT, said Ross Swanson, director of consulting services at Corazon, at the ACVP meeting.

“If you are not developing a business plan for cardiac CT implementation, then you’ve already fallen behind,” Swanson said.

CT has moved rapidly into the full continuum of pre- and post-operative care and is now used as a strategy to capture market presence for the entire CV business, he said. Many hospitals advertise their use of 64-slice CT or dual-source CT on their web sites as differentiators.

A CT scan of the coronary arteries also captures most of the chest and the upper abdomen. Physicians are responsible for reading every part of the exam. A model of cooperation that has evolved is for cardiologists to read the heart and radiologists to read the rest. But any reading arrangement must be worked out prior to purchasing the scanner, because even vascular surgeons might want a piece of the action, said Heck. 

What do the data say about cardiac CT’s efficacy and utilization? Tim Attebery, president and CEO of CVI3, based in Tennessee, has been involved in a coronary CTA registry for a number of years. The data on more than 25,000 patients indicates that CTA is being ordered appropriately, he said at the ACCA meeting.

An analysis of the registry showed that:
  • 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;
  • CTA was performed first with inconclusive results, followed by a SPECT exam in 5 percent of patients; and
  • CTA was used as a layered test (inappropriately) in less than 1 percent of patients.
The data show that therapeutic caths were up 13 percent, normal caths down 6 percent, and nuclear volume down 8 percent. The average savings per diagnostic episode was $442, Attebery reported.

Medicare pays between $600 and $700 per coronary CTA, while commercial payers dole out $1200. Global Medicare reimbursement for an outpatient cardiac cath is $2000, and commercial reimbursement is $3000.

CT has a nearly 100 percent negative predictive value, Attebery said, particularly for patients with low- to intermediate-risk factors. If a patient has a high pre-test probability for coronary artery disease, he should not receive a CT scan.

An advantage of CT is its reproducibility, unlike cardiac MRI. It also is readily available in most hospital settings.

Physician payment is an issue, especially if it has to be split between cardiologists and radiologists. Medicare can only make one payment. The easiest thing is for the hospital to bill for the global fee and distribute the money, Heck said. Physicians are often reluctant to have hospitals in that mix. It’s prudent to negotiate a deal before the purchase of the scanner.

Attebery predicted that:
  • Coronary CTA will continue to grow.
  • Calcium scoring will become more prevalent.
  • SPECT utilization will remain flat and be subject to increased scrutiny.
  • Echo, the stethoscope of the 21st century, is solidly entrenched and will remain a good value.
  • PET/CT will make its way into more than a few advanced, high-volume settings, and will work in collaboration with oncology; and
  • Cardiac MRI will emerge as the superior functional and physiologic modality.