There are a few fairly long-standing myths about cardiac CT angiography (CTA). The top two emphasize its exploding use and high costs. Yet, several studies published in this month's American Journal of Roentgenology attempted to put those myths to bed.
David C. Levin, MD, of the Center for Research on the Utilization of Imaging Services at Thomas Jefferson University Hospital and Jefferson Medical College in Philadelphia, and colleagues focused on the myth of exploding use. Indeed, after scouring years of Medicare Part B Physician/Supplier Procedure Summary Master Files of CTA and SPECT imaging, the authors revealed that CTA is underutilized.
In fact, the data surprised Levin, who found that CTA use actually dipped in 2008. Meanwhile, SPECT imaging was performed 44 times as often as CTA.
Alexander Goehler, MD, of the Institute for Technology Assessment at Massachusetts General Hospital in Boston, and colleagues took a different approach, constructing a simulation model of 1,000 low-to-intermediate risk chest pain patients who presented to the ED with chest pain.
The researchers assessed CTA, SPECT and stress echocardiography and demonstrated that CTA reduced initial and 30-day costs, cut the number of invasive catheterizations and improved survival.
These findings were echoed this week at the annual meeting of the American College of Cardiology (ACC) in New Orleans, where Michael Poon, MD, director of advanced cardiac imaging at The Heart Center at Stony Brook University Medical Center in Stony Brook, N.Y., shared compelling findings about cardiac CTA in the ED.
According to Poon, Stony Brook saved $1.5 million by employing 320-slice CT in the evaluation of patients who presented to the ED with acute chest pain. That’s because the center slashed its admit rate for these patients from nearly 50 percent to under 15 percent. Plus, the model cut the number of repeat offenders. That is, patients with a normal CTA are not returning to the ED time and time again.
What’s holding up the diffusion of CTA? It can take a decade or longer to change practice patterns. Plus, cardiologists are invested in SPECT imaging; there is a large inventory of in-office nuclear cameras. CTA reimbursement is less than favorable. And then, there is the tricky question of outcomes. Do patients really do better?
Poon and colleagues hope to answer the latter questions with additional papers in the future. Other comparative effectiveness studies tackling this issue include RESCUE, ACRIN PA 4005 and ROMICAT II.
It seems that the tide is turning as data demonstrating the clinical and economic value of CTA are accruing. As always, we welcome your insights.
Lisa Fratt Editor of Health Imaging & IT
Comparative-effectiveness research has become the platform for several organizations, including the Institute for Clinical and Economic Review (ICER). Based at the Institute for Technology Assessment at Massachusetts General Hospital in Boston, ICER’s mission is to lead comparative-effectiveness–research innovation through methods that the organization says integrate considerations of clinical benefit and economic value through a unique collaboration with patients, clinicians, manufacturers, insurers, and other health-care stakeholders.
William T. Thorwarth Jr, MD, of Catawba Radiological Associates (Hickory, North Carolina), is current chair of the CPT® editorial panel of the AMA, former president of the ACR®, and former chair of the ACR Economics Commission, was recently chosen to represent the ACR as a member of ICER’s advisory board. Thorwarth discussed ICER and the role of comparative-effectiveness research in the radiology sector with ImagingBiz.
ImagingBiz.com: You sit on the ICER advisory board with a number of health-policy experts from various specialties, as well as with health-care stakeholders. Tell us a bit about the composition of the board and how members are chosen.
Thorwarth: The advisory board is made up of 20 members who represent institutions that provide ICER with financial and operational support, as well as at-large representatives from key clinical, policy, and advocacy stakeholder organizations. It comprises a very balanced cadre of health-care providers, payors, purchasers, pharmaceutical companies, and vendors.
The advisory board was created to provide strategic guidance to our organization and, as such, it must look at issues from every angle. This is something that cannot be accomplished without the involvement of representatives from all contingents, and members are chosen with a major focus on maintaining such a mix.
Experience and qualifications come into play, but if, for example, a provider representative drops out, he or she will be replaced by a provider representative; if a payor representative leaves the group, another one—rather than a qualified individual from another category—will be asked to step in for him or her.
ImagingBiz.com: You are the first radiologist to serve on the board. Why do you think the board sought a representative from this specialty?
Thorwarth: ICER approached the ACR about adding a radiologist to the board. I believe much of this had to do with balance, as well as with the fact that radiology is edgy, just like many of the areas in which comparative-effectiveness research is being conducted. I think the fact that I currently chair the AMA’s CPT panel was one of the reasons that I, specifically, was asked to join the board. My work on the panel allows me to give ICER a good perspective on whether appraising a given treatment procedure is worthwhile.
ImagingBiz.com: It is no secret that radiology reimbursement has been a target for reductions. Is there a role for comparative-effectiveness research in demonstrating the ability of radiology to reduce downstream costs?
Thorwarth: Absolutely. Comparative-effectiveness research can confirm the appropriateness of modalities, as opposed to more expensive procedures—and, therefore, radiology’s role in cost reduction. Our recent comparative-effectiveness–research initiative on the use of coronary CT angiography (CCTA) for patients with suspected coronary-artery disease is a perfect example.
While comparative-effectiveness research revealed only limited evidence to determine CCTA’s effectiveness in supporting clinical decision making or improving patient outcomes in the outpatient setting, it did show that the modality is comparable to other noninvasive diagnostic techniques in ruling out coronary-artery disease as the cause of chest pain, when used in the emergency department. It also confirmed the high diagnostic accuracy of CCTA compared with invasive coronary angiography, which is the standard of care.
ImagingBiz.com: What are some of the projects that you expect to work on this year?
Thorwarth: The big push for 2011 is treatment for low-back disorders and the proposed patient categories and treatments for comparison. It is a very important project, when one considers not only that low-back disorders are an exceedingly common complaint, with a lifetime prevalence ranging from 54% to 80%, but that chronic low-back pain might be seen in 25% to 60% of patients one year or more after an initial episode.
The economic impact of low-back pain is incredibly substantial: It is the fifth most common reason for all physician visits in the United States, and it is responsible for direct medical costs that approach $30 billion annually. In addition, low-back pain is a major cause of lost productivity; it is estimated that 2% of the US work force is compensated for back pain or injury each year. Our appraisal will evaluate evidence on the comparative risks, benefits, and cost effectiveness of multiple management strategies for patients with chronic low-back pain. Pain in this category is of more than four weeks’ duration—without evidence of systemic disease or significant neurological findings.
ImagingBiz.com: What is the ideal role of comparative-effectiveness research in the wake of health-care reform?
Thorwarth: While innovation remains the name of the game, health-care decision makers are demanding increasingly comprehensive and solid evidence that new drugs, devices, procedures, and biologics bring true value to the table. Policymakers and those pushing for health-care reform continue to argue the point that simultaneously meeting the goals of innovation, cost control, and improved quality of care within the health-care system necessitates more explicit appraisal of the clinical effectiveness and comparative value of new interventions.
Their requirements for existing interventions are identical. Conducting the necessary appraisals and, consequently, filling the evidence gap, as we call it, constitutes the ideal role for comparative-effectiveness research in the wake of health-care reform, now and going forward.
ImagingBiz.com: Comparative-effectiveness research has been the target of outlandish accusations, with charges related to death panels being the most notorious. What should physicians and others in the health-care community be doing to depoliticize the subject?
Thorwarth: The average physician is not going to become an activist. The best approach that can be taken is for medical societies to educate their constituents on the value and importance of comparative-effectiveness research in improving our health-care system, so as to put it in a better light for accusers.
Julie Ritzer Ross is a contributing writer for ImagingBiz.com.
(Ivanhoe Newswire) -- Women who received one of three treatments for uterine fibroids at Brigham and Women's Hospital in Boston said their symptoms diminished and their quality of life significantly increased, according to this study.
Uterine fibroids are benign pelvic tumors that occur in as many as one in five women during their childbearing years. Although not all fibroids cause symptoms, some women experience heavy bleeding, pain and infertility. Treatment options include hysterectomy, minimally invasive uterine artery embolization (UAE) and a noninvasive MR-guided focused ultrasound (MRgFUS) procedure.
"When discussing treatment options for women with uterine fibroids, the pros and cons of each treatment option need to be outlined," the study's lead author, Fiona M. Fennessy, M.D., Ph.D., assistant professor of radiology at Harvard Medical School, was quoted as saying. "But until now, we haven't been able to evaluate all of the options with health-related quality-of-life measures, assessing symptom relief as well as the pain, anxiety or recovery time associated with the treatment itself."
In the study, researchers surveyed a total of 197 women who underwent hysterectomy (62), UAE (74) and MRgFUS (61) for symptomatic uterine fibroids between 2004 and 2006. The mean ages of the women in three groups were 47, 44 and 47, respectively.
A utility weight (a single unit of measure that encompasses all the different quality-of-life benefits from a health care intervention) was obtained for each of the fibroid treatment options. Comparisons of quality of life were made before and after treatment.
In addition, short-term utility weights for the actual treatments the women underwent were compared, allowing comparison of the actual treatment experiences among the options. To do this, the researchers used the waiting trade-off (WTO) method, which is based on the fact that people tend to wait longer to avoid unpleasant tests or procedures. Analysis by the WTO method provides short-term quality-of-life tolls in terms of quality-adjusted life-weeks.
"Quality of life significantly increased following each of the fibroid treatment options," Dr. Fennessy said. "But patients rated the non- or minimally invasive treatments –UAE and MRgFUS – more favorably."
Patients who underwent a hysterectomy reported that they would wait 21 weeks in order to avoid the procedure, while patients in the other two groups said they would put off their procedures by only 14 weeks.
The minimally invasive UAE procedure, which is increasingly used as an alternative to the surgical removal of the uterus (hysterectomy), requires only a small nick in the skin, through which a catheter is inserted to deliver particles that block blood flow to the fibroids. UAE may be associated with a number of days of pain and cramping. The MRgFUS procedure, which was approved by the U.S. Food and Drug Administration in 2004 as a treatment option for uterine fibroids, is noninvasive: it uses ultrasound energy to ablate the fibroids. MRgFUS is quick and painless for many, and symptom relief has been shown to occur by 12 weeks.
"In order to be widely adopted, MRgFUS must be deemed as beneficial as the established alternatives," Dr. Fennessy said. "Our study not only provides measures to aid in future cost-utility analysis of uterine fibroid treatments, but it may be helpful to patient and physician decision-making with regard to treatment options."
*** SOURCE "Quality-of-Life Assessment of Fibroid Treatment Options and Outcomes." Collaborating with Dr. Fennessy were Chung Yin Kong, Ph.D., Clare M. Tempany, M.D., and J. Shannon Swan, M.D. Radiology, published March 1, 2011.