Carotid CTA image from the Siemens 64-slice Somatom Sensation CT scanner.

As the population ages and studies prove CT is the right exam for more indications, volume is growing. While there are some factors to consider when launching CT in an outpatient imaging center, the modality lends itself well to the setting. Many industry watchers feel that CT scanning volume will only continue to move to outpatient centers.

CT is the ideal modality for the outpatient-based center, says Mark Winkler, MD, of Steinberg Diagnostic Medical Imaging Centers in Las Vegas. “You can do almost everything on an outpatient basis that you can do as inpatient.” For example, his group routinely performs CT-directed biopsies. “There is no reason to have someone go to the hospital to get a CT scan,” Winkler says.


No longer a hesitance

Since virtually every radiologist is trained to do and read CT, Winkler says, centers only need a CT technologist with a modest level of experience to start offering the procedure. The practice has four offices with a fifth under construction. They use scanners—one 64-slice, two 16-slice and four 4-slice—from Toshiba America Medical Systems. The planned fifth office is designed to manage the growing population in the Las Vegas Valley. Along with population growth, study volume is increasing. “I think that there are more and more indications for CT as prices [of systems and procedures] have dropped dramatically,” says Winkler. “So there’s no longer a hesitance to use the technology. A decade ago people were reluctant to refer a patient for a scan.”

It’s very easy to set up CT in an outpatient office, he says. Steinberg has a PACS and the CT scanner is plug-and-play right into that system. “It’s not that complicated. Everything is on standardized interfaces at this point, so it’s relatively easy to get into PACS.”

Patients too find the outpatient environment more pleasant, Winkler says. Outpatient centers are more likely to stay on schedule, while patients at a hospital are often bumped by emergency patients.

Along with a drop in equipment price, the cost of a CT scan has dropped by more than half, Winkler says. That makes physicians more willing to order CTs. “CT often provides a definitive answer that other modalities sometimes don’t.” If a scan can diagnose appendicitis, it’s better patient management than keeping the patient overnight in the hospital and running a battery of tests to determine the problem. Plus, CT can better evaluate the extent of sinus disease than x-ray can, cancer patients are routinely staged and restaged with CT, and 64-slice CT angiography for stenosis and peripheral artery disease is so good that CT is replacing much of conventional angiography.


A huge difference

Although the price of equipment is right, Comprehensive Cardiovascular Care Group in Milwaukee, Wis., has faced some struggles to get going with CT. The practice took delivery of the GE Healthcare LightSpeed VCT with SnapShot Pulse in May.

The practice merged with another and doubled in size. “We took on a cardiology group,” explains Port. “Because they had been ordering so many studies at the hospital, we knew that volume would translate over to the practice.” Plus, the practice has a significant number of patients who already are being studied at other locations and will continue to get studied. “That allowed us to purchase the equipment,” he says.

“It’s a huge difference for us. As a cardiovascular disease group, we’re used to doing ultrasound and single photon nuclear medicine work in the office,” Port explains. The group does certain kinds of ECG recordings, Holter monitors and other work that does not require much in the way of patient monitoring. Before CT, they didn’t have to worry much about drugs or renal function. “Now you’re in a contrast business, and that’s a whole different ballgame.”

Port says that adjusting the practice to giving patients contrast was a big change. Each patient requires a blood test for renal function and he or she is sent to a lab for kidney function evaluation. These and other steps significantly altered the group’s patient approach. In the hospital setting, “all of these mechanisms seem to happen for you. Skilled nurses take information from patients, check creatinine levels, and call if something is wrong. So much is getting done for you routinely [in a hospital setting] and it’s all happening in the background. Now it’s you and your people that have to make the whole thing flow properly. It’s a quantum leap to get used to that.”

To get everyone on the same page, Port had training sessions for the staff. New requisition sheets were created. A CT technologist and CT nurse came on board a month before exams started on the system so they could develop clinical protocols. “You have to put processes in place,” he says. “It doesn’t become automatic right away.”

Another change is taking on some level of financial conversations with patients. A lot of people in Wisconsin are still paying out of pocket, at least for coronary studies. The fee at Port’s practice is $600, an expensive study for any patient. When a doctor suggests this study to a patient, Port says, they have to have a real financial conversation to explain why the test is recommended and the benefits it brings.

So far, Port says “we are thrilled with the equipment.” The SnapShot Pulse software offers a prospective gating technique. That allows the physicians to select small portions of the heart cycle to turn on the radiation. That reduces radiation by a factor of three to four. “It made me uncomfortable to deliver 13 to 15 milliseverts of radiation to the chest,” he says. “We start talking to women about their likelihood of breast cancer as part of whether to do this study at all. Now we can do a CT angiogram at the same or less radiation as catheterization. We still have to think about it when approaching any patient, especially women, but now we’re not talking about major radiation exposure to the chest.”


Staying on the cutting edge

The ability to expand the range of services available to patients and to stand out from the competition is a big draw of CT. “Our MO is to try to stay pretty much cutting edge—at or just below,” says William Muhr, MD, a radiologist at South Jersey Radiology Associates, a group with nine locations in southern New Jersey. To maintain that goal, the practice installed a 64-slice CT scanner from Siemens Medical Solutions last September. “We were interested particularly in coronary CT angiography.”

“Cardiac imaging is the new line of work,” Muhr says. “There has been an overall increase of CT utilization nationwide for a lot of reasons.” For one, the image quality is phenomenal. Also, CT has replaced some other techniques. CT is almost the first line of treatment for general abdominal pain today. There also is work being done on tumor perfusion on CT and assessing tumor response to chemotherapy at a very early stage. These and other applications will continue to drive the increasing use of CT.

To be efficient on high-end scanners, “we need to be able to run a fairly decent schedule but we don’t have a captive audience of inpatients to fill gaps,” Muhr says. So, it’s important to have a very efficient schedule and adhere to it.

Muhr says clinicians have some dependency on CT scanners right now. “They are very efficient and absorb a fair amount of growth.”


The competition crunch

The biggest difference between outpatient imaging centers and hospitals is competition, says Jon Ekstrom, MD, president of Radiology Associates in Eugene, Ore., which covers Oregon Imaging Centers. “You need to win the confidence of referring physicians and the patients themselves” to grow your business. That includes easy scheduling for the referring office staff, as well as a pleasant environment in a convenient location for the patients. “You should have updated equipment that you can push to differentiate yourself.”

There are more issues for outpatient imaging centers to consider in the competitive environment, such as accredited equipment, certified technologists and radiologists who can distinguish themselves as experts. As new, more complicated studies come along, Ekstrom says that specialty and subspecialty physicians can champion those studies and take on the task of educating the community about the studies.

Meanwhile, Ekstrom sees a trend of more and more nonradiology groups bringing imaging in-house. “The specialties that tend to generate a lot of imaging studies are leading the charge,” he says, which includes orthopedists and neurologists. If they have the volume to justify the purchase, the investment probably makes sense for those groups, he says.

The investment makes sense for many practices but Winkler cautions against the pressure to purchase high slice-count multidetector scanners if a facility doesn’t truly need those scanning capabilities. “The new family of scanners is based upon the same detector design,” so providers can hold on to the same system for a longer period of time because they have not become obsolete. “That’s important in this era of [reimbursement cuts due to] the Deficit Reduction Act.” Plus, clinicians can keep using 4-slice scanners for their bread-and-butter work indefinitely because the systems are so reliable and robust.

This also means that unless clinicians are going to do cardiac imaging, they do not need a 64-slice scanner, Winkler says. “People are spending too much on technology when there’s effectively no difference. A high-quality 16-slice machine is more than adequate for everything but cardiac work.”  


On the horizon

In the future, almost all outpatient CTs will be performed in an outpatient environment, says Winkler. “Outpatient centers are aesthetically more attractive. Patients can get in and out much faster.”

Muhr agrees and says the growth in imaging centers and CT in the imaging center marketplace will be “driven by patient desire for comfort and convenience.”

Port says payors will eventually realize that they’ll save money by covering CT scanning in outpatient centers instead of hospitals. “Within the next five years, [cardiac CT studies] will be covered,” he says. “They’re valuable studies. If you look nationwide right now, you can safely say that 20 to 35 percent of catheterization lab volumes represent people with normal coronary arteries.” A percentage on top of that includes people who don’t have bad enough disease to warrant an intervention. The actual volume of patients that need to be in the cath lab for coronary purposes is probably less than half of those patients who walk through the door. “It wouldn’t be unreasonable to say that at least 40 to 50 percent don’t have any coronary disease or don’t have it to the degree that warrants an intervention,” Port says.

Payors are paying more for same-day surgery suites, cath lab room charges and labor than they would for outpatient CT angiography. “If we could make a dent in that difference,” says Port, “we could save payors a huge amount of money. I think the payors are going to wake up to that as long as we deliver.”