- Email: [email protected]
Will robust evidence drive appropriate utilization of CTA?
Journal of Cardiovascular Computed Tomography (2007) 1, 27–28
Editorial
Will robust evidence drive appropriate utilization of CTA? In this issue of the journal, Cole et al1 present a cost analysis of the use of computed tomography angiography (CTA) within the diagnostic paradigm of patients with suspected coronary artery disease. Prior evidence on both the clinical and economic outcomes after use of CTA is limited.2,3 Addressing the cost efficiency of CTA-guided testing can aid in devising adequate payment strategies for clinically appropriate indications. Cole et al1 examined the cost implications of using CTA in 206 patients with mildly abnormal or equivocal myocardial perfusion single-photon emission CT scans. Approximately one third to one half of such patients now proceed directly to coronary angiography.4,5 However, Cole et al1 found only 32% of these patients had potentially obstructed coronary arteries on CTA. Focused referral for invasive angiography resulted in a potential savings of $1454 per patient. Hierarchical strategies have long been used to maximize the yield of diagnostic imaging procedures while minimizing redundancy, reducing radiation exposure, and controlling costs.5,6 Such strategies often use noninvasive imaging as a gatekeeper for more expensive, invasive procedures5 or as a means of limiting hospital admissions to those patients truly at higher risk.2 In prior reports, the use of myocardial perfusion single-photon emission CT in patients with stable chest pain resulted in 30%-40% cost savings when angiography was limited only to patients with inducible ischemia, as compared with direct catheterization approaches.5,6 This report reinforces the need for further concentrated research to develop an adequate body of clinical and economic outcomes evidence for the development and guidance of appropriate payment structures. In this era of cost containment, increased utilization for CTA will not occur because of the high degree of diagnostic accuracy or its excellent negative predictive value.7 In today’s health care market, those working within this field, including the Society for Cardiovascular CT, must devise a dedicated pathway for growing utilization within appropriate indications. The economic evidence must coincide with prognostic data that support the use of CTA as more effective testing strategies when compared with traditional diagnostic imaging approaches. Key in developing evidence supporting appropriate use of CTA is recognition that changes in procedural utilization in the current economic environment must operate within a
“zero sum gain.” Few if any additional funds are available to pay for new imaging modalities, and we are left to shift payment from one test for another. CTA may offer an efficient alternative to x-ray angiography for lower risk patient populations. To that extent, the report by Cole et al1 is an important step in the development of this evidence base. These findings need to be validated and expanded to a larger series of patients in multiple centers to gain critical acceptance by both the medical community and payers. Without this kind of hard evidence of economic value, reimbursement for CTA will remain woefully inadequate, serving as a major impediment to further development of this powerful technique. Cardiovascular magnetic resonance (CMR) imaging has long suffered from inadequate reimbursement, related at least in part to a paucity of evidence for its appropriate and effective utilization in clinical cardiac patient populations. Despite early and widespread clinical adoption of MR technology for noncardiac uses, proliferation of cardiac MR has languished despite impressive scientific advances. Both CTA and CMR share the common characteristic of truly amazing image quality, but image quality alone will not drive procedural utilization despite the intrigue on the part of the cardiovascular community. Showing that new imaging technology can produce images which are superior to previous methods is not enough. The imaging community is now being called on to show that new imaging technology has a positive and direct effect on patient outcomes. Prospective randomized clinical trials, widely used for drug development, are rarely used for diagnostic imaging. Those active within the area of cardiovascular imaging research are slowly devising new evaluative strategies, but we also need to be aware that clinical research support for evidence-based medicine is scanty indeed. Nonetheless, we must live by the ever-changing rules and need to steer the ship of clinical trails into safer waters. The challenge for the field of clinical research with CTA is that additional evidence, such as that reported by Cole et al,1 is desperately needed to guide the development of this exciting, new technology. Samual Wann, MD Wisconsin Heart Hospital Milwaukee, WI
1934-5925/$ -see front matter © 2007 Society of Cardiovascular Computed Tomography. All rights reserved. doi:10.1016/j.jcct.2007.04.009
28
Journal of Cardiovascular Computed Tomography, Vol 1, No 1, July 2007 Leslee J. Shaw, PhD Department of Medicine, Division of Cardiology Emory University School of Medicine EPICORE 1256 Briarcliff Road NE, Suite 1-North Atlanta, GA 30306 E-mail address: [email protected]
References 1. Cole JH, Chunn VM, Morrow JA, Buckley RS, Phillips GM: Cost implications of initial computed tomography angiography as opposed to catheterization in patients with mildly abnormal or equivocal myocardial perfusion scans. J Cardiovasc C T. 2007;1:21– 6. 2. Goldstein JA, Gallagher MJ, O’Neill WW, Ross MA, O’Neil BJ, Raff GL: A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol. 2007;49:863–71.
3. Pundziute G, Schuijf JD, Jukema JW, Boersma E, de Roos A, van der Wall EE, Bax JJ: Prognostic value of multislice computed tomography coronary angiography in patients with known or suspected coronary artery disease. J Am Coll Cardiol. 2007;49:62–70. 4. Mishra JP, Acio E, Heo J, Narula J, Iskandrian AE: Impact of stress single-photon emission computed tomography perfusion imaging on downstream resource utilization. Am J Cardiol, 1999;83:1401–3. 5. Shaw LJ, Hachamovitch R, Berman DS, Marwick TH, Lauer Ms, Heller GV, Iskandrian AE, Kesler KL, Travin MI, Lewin HC, Hendel RC, Borges-Neto S, Miller DD: The economic consequences of available diagnostic and prognostic strategies for the evaluation of stable angina patients: an observational assessment of the value of precatheterization ischemia. Economics of Noninvasive Diagnosis (END) Multicenter Study Group. J Am Coll Cardiol. 1999:33:661–9. 6. DesPrez RD, Gillespie RL, Jaber WA, Noble GL, Soman P, Wolinsky DG, Williams KA, Shaw LJ: American Society of Nuclear Cardiology Information Statement on the Cost Effectiveness of Myocardial Perfusion Imaging. J Nucl Cardiol. 2005;12:750 –9. 7. Achenbach S: Computed tomography coronary angiography. J Am Coll Cardiol. 2006;48:1919 –28.
Editorial
Will robust evidence drive appropriate utilization of CTA? In this issue of the journal, Cole et al1 present a cost analysis of the use of computed tomography angiography (CTA) within the diagnostic paradigm of patients with suspected coronary artery disease. Prior evidence on both the clinical and economic outcomes after use of CTA is limited.2,3 Addressing the cost efficiency of CTA-guided testing can aid in devising adequate payment strategies for clinically appropriate indications. Cole et al1 examined the cost implications of using CTA in 206 patients with mildly abnormal or equivocal myocardial perfusion single-photon emission CT scans. Approximately one third to one half of such patients now proceed directly to coronary angiography.4,5 However, Cole et al1 found only 32% of these patients had potentially obstructed coronary arteries on CTA. Focused referral for invasive angiography resulted in a potential savings of $1454 per patient. Hierarchical strategies have long been used to maximize the yield of diagnostic imaging procedures while minimizing redundancy, reducing radiation exposure, and controlling costs.5,6 Such strategies often use noninvasive imaging as a gatekeeper for more expensive, invasive procedures5 or as a means of limiting hospital admissions to those patients truly at higher risk.2 In prior reports, the use of myocardial perfusion single-photon emission CT in patients with stable chest pain resulted in 30%-40% cost savings when angiography was limited only to patients with inducible ischemia, as compared with direct catheterization approaches.5,6 This report reinforces the need for further concentrated research to develop an adequate body of clinical and economic outcomes evidence for the development and guidance of appropriate payment structures. In this era of cost containment, increased utilization for CTA will not occur because of the high degree of diagnostic accuracy or its excellent negative predictive value.7 In today’s health care market, those working within this field, including the Society for Cardiovascular CT, must devise a dedicated pathway for growing utilization within appropriate indications. The economic evidence must coincide with prognostic data that support the use of CTA as more effective testing strategies when compared with traditional diagnostic imaging approaches. Key in developing evidence supporting appropriate use of CTA is recognition that changes in procedural utilization in the current economic environment must operate within a
“zero sum gain.” Few if any additional funds are available to pay for new imaging modalities, and we are left to shift payment from one test for another. CTA may offer an efficient alternative to x-ray angiography for lower risk patient populations. To that extent, the report by Cole et al1 is an important step in the development of this evidence base. These findings need to be validated and expanded to a larger series of patients in multiple centers to gain critical acceptance by both the medical community and payers. Without this kind of hard evidence of economic value, reimbursement for CTA will remain woefully inadequate, serving as a major impediment to further development of this powerful technique. Cardiovascular magnetic resonance (CMR) imaging has long suffered from inadequate reimbursement, related at least in part to a paucity of evidence for its appropriate and effective utilization in clinical cardiac patient populations. Despite early and widespread clinical adoption of MR technology for noncardiac uses, proliferation of cardiac MR has languished despite impressive scientific advances. Both CTA and CMR share the common characteristic of truly amazing image quality, but image quality alone will not drive procedural utilization despite the intrigue on the part of the cardiovascular community. Showing that new imaging technology can produce images which are superior to previous methods is not enough. The imaging community is now being called on to show that new imaging technology has a positive and direct effect on patient outcomes. Prospective randomized clinical trials, widely used for drug development, are rarely used for diagnostic imaging. Those active within the area of cardiovascular imaging research are slowly devising new evaluative strategies, but we also need to be aware that clinical research support for evidence-based medicine is scanty indeed. Nonetheless, we must live by the ever-changing rules and need to steer the ship of clinical trails into safer waters. The challenge for the field of clinical research with CTA is that additional evidence, such as that reported by Cole et al,1 is desperately needed to guide the development of this exciting, new technology. Samual Wann, MD Wisconsin Heart Hospital Milwaukee, WI
1934-5925/$ -see front matter © 2007 Society of Cardiovascular Computed Tomography. All rights reserved. doi:10.1016/j.jcct.2007.04.009
28
Journal of Cardiovascular Computed Tomography, Vol 1, No 1, July 2007 Leslee J. Shaw, PhD Department of Medicine, Division of Cardiology Emory University School of Medicine EPICORE 1256 Briarcliff Road NE, Suite 1-North Atlanta, GA 30306 E-mail address: [email protected]
References 1. Cole JH, Chunn VM, Morrow JA, Buckley RS, Phillips GM: Cost implications of initial computed tomography angiography as opposed to catheterization in patients with mildly abnormal or equivocal myocardial perfusion scans. J Cardiovasc C T. 2007;1:21– 6. 2. Goldstein JA, Gallagher MJ, O’Neill WW, Ross MA, O’Neil BJ, Raff GL: A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol. 2007;49:863–71.
3. Pundziute G, Schuijf JD, Jukema JW, Boersma E, de Roos A, van der Wall EE, Bax JJ: Prognostic value of multislice computed tomography coronary angiography in patients with known or suspected coronary artery disease. J Am Coll Cardiol. 2007;49:62–70. 4. Mishra JP, Acio E, Heo J, Narula J, Iskandrian AE: Impact of stress single-photon emission computed tomography perfusion imaging on downstream resource utilization. Am J Cardiol, 1999;83:1401–3. 5. Shaw LJ, Hachamovitch R, Berman DS, Marwick TH, Lauer Ms, Heller GV, Iskandrian AE, Kesler KL, Travin MI, Lewin HC, Hendel RC, Borges-Neto S, Miller DD: The economic consequences of available diagnostic and prognostic strategies for the evaluation of stable angina patients: an observational assessment of the value of precatheterization ischemia. Economics of Noninvasive Diagnosis (END) Multicenter Study Group. J Am Coll Cardiol. 1999:33:661–9. 6. DesPrez RD, Gillespie RL, Jaber WA, Noble GL, Soman P, Wolinsky DG, Williams KA, Shaw LJ: American Society of Nuclear Cardiology Information Statement on the Cost Effectiveness of Myocardial Perfusion Imaging. J Nucl Cardiol. 2005;12:750 –9. 7. Achenbach S: Computed tomography coronary angiography. J Am Coll Cardiol. 2006;48:1919 –28.