Spiral CT for PE: New Gold Standard?

Spiral CT is reliable and accurate enough for diagnosing pulmonary embolism (PE) that other procedures do not need to be used, concluded an article recently published in the Journal of the American Medical Association .

The study’s lead author, U. Joseph Schoepf, MD, an associate professor of radiology at the Medical University of South Carolina, believes the use of a negative spiral CT scan to rule out suspected PE will reduce radiation exposure, avoid an invasive procedure, and reduce health care costs. “We did this particular study because CT is being used throughout the country and increasingly so as the first line imaging test in patients for pulmonary embolism,” Schoepf says. “We believe it’s accurate enough to rule out pulmonary embolism, but we needed to prove that.”

To arrive at this conclusion, Schoepf et al reviewed the results of previously published studies with a minimum 3-month follow-up to assess the rate of subsequent venous thromboembolic events (VTEs) following a negative CT that resulted in the withholding of anticoagulant therapy.

CT for pulmonary embolism has garnered some criticism from doctors, he says, because previous studies using single-slice spiral CT had determined it was not accurate enough for detection of embolism in the peripheral pulmonary arteries. As a result, patients have been subjected to additional tests to rule out pulmonary embolism, including angiography and ventilation perfusion scintigraphy.

“Our study is aimed at determining the accuracy overall, including all the modalities that are out there,” he says. “It actually just so happens that in those 15 studies that were included in our analysis, 13 used good ol’ single-slice spiral CT.”

According to the study, the negative likelihood ratio of VTE after a negative scan on a single-slice spiral CT for pulmonary embolism was 0.07 and the negative predictive value was 99.1%. The authors found no difference based on the slice count of the scanner used.

Acknowledging that the principal limitation of CT is considered to be the inaccurate detection of peripheral pulmonary embolism, a shortcoming that has been minimized with improved CT technology, the authors assumed that a significant number of patients enrolled in the reviewed studies had undetected peripheral embolism.

REIMBURSEMENT

Aetna Covers CAD. On April 1, 2005, Aetna began reimbursing for computer-aided detection (CAD) for mammography and will also reimburse for the continuing medical physics consultation service, CPT® code 77336, the American College of Radiology announced. Aetna’s medical policy for CAD for mammography previously classified the service as “a quality adjunct to mammography,” “an integral part of a radiology center’s quality improvement program” that was not reimbursed separately.

PET Cancer Coverage Clarified. On April 4, 2005, the Centers for Medicare and Medicaid Services (CMS) issued changes to the National Coverage Determination (NCD) on PET for brain, cervical, ovarian, pancreatic, small cell lung, and testicular cancers.

CMS expanded PET coverage for all oncology indications with a requirement that physicians and patients are enrolled in an approved clinical trial or registry. In the PET NCD update, CMS clarifies the types of cancers that are covered with and without the clinical trials/registry enrollment requirement. Effective April 18, 2005, physician offices can begin billing for these services.

“However, the low incidences of VTEs during follow-up across all studies show that even if peripheral emboli were missed and subsequently not treated based on a negative CT scan, the patient outcome was not adversely affected,” the authors wrote.

“What we tried with our paper was to show them that CT is accurate enough to reliably rule out the presence of pulmonary embolism so they don’t need additional tests,” Schoepf says. “[We’re] basically telling them that they’re doing the right thing and they should feel good about it.”

What many physicians still consider the gold standard—pulmonary angiography—is rarely used today. “It doesn’t help to have a gold standard that nobody uses,” he says. “So that’s another item on our agenda—to nix that notion that you still need pulmonary angiography as the gold standard.”

CT should become the gold standard for diagnosis, he says, and angiography should be reserved for interventional treatment, for instance, if the CT reveals that there are huge clots exerting pressure on the heart and the patient is in immediate danger of dying.

“So one goal that we pursued with that paper was to really educate people on the clinical value of computed tomography and how that has impacted the accuracy with which we can now exclude meaningful pulmonary embolism in those patients,” he says.

With spiral CT as the sole diagnosis for pulmonary embolism, the cost of diagnosis will drop, he says. “We expect it will have a fairly good impact on the cost-effectiveness of this test simply because it obviates the need for performing additional tests for reliability for excluding the presence of pulmonary embolism,” he says. “There is no need for that patient to undergo additional tests, which would drive up the costs for evaluating those folks. So overall, we’re driving down costs.”

Average Pay Down; Workload Up

Working harder, making less? Average payments for a typical service have decreased by as much as 19% over an 8-year period, while the typical workload has increased about 28%, according to a study by Christopher Hogan, PhD, and Jonathan H. Sunshine, PhD, published in the March 2004 issue of Radiology .

The study examined financial benchmarks for radiology practices throughout the nation as well as the corresponding trends in those ratios and payments using data primarily from 1992 to 1999.

Hogan and Sunshine looked at four ratios: gross collection rate (net revenue divided by gross charges); net collection rate (net revenue divided by net charges); net-to-gross charge ratio (ratio of net charges to gross charges); and accounts receivable (AR) turnover (total AR divided by a practice’s daily charges). The information was gathered from two sources: Medicare Physician-Supplier Procedure Summary File and 2001 Medicare claims data.

The authors found a 55% gross collection rate, meaning just over half of the billed charges were being paid in 1999, down from 71% in 1992.

From a regional standpoint, practices in the Northeast had lower gross collection rates than practices in the Midwest and West, excluding California. They also found that radiologists in rural areas were submitting charges 6% lower than those in metropolitan areas, and radiologists in the Northeast and California were charging 10% and 23% higher, respectively, than radiologists in the South. Radiologists in the West, excluding California, were charging 5% less than their counterparts in the South.

From 1992 to 1999, radiologists increased the amount billed per service by 24.5%. The actual payment, however, decreased 19% during that same time period. Net collection rates averaged 78%, down from 86% in 1992.

The average AR turnover was 69 days; in the Midwest it was 80 days.

The authors discovered that a decreased ability to collect money for services accounted for 40% of the decline in the gross collections rate. The rest was due to reductions in insurers’ allowed amounts.

Nonmetropolitan areas collected a higher percentage of the billed amount than metropolitan areas. Hogan and Sunshine hypothesized that rural practices generally have a more difficult time recovering payments for services rendered, partially due to a disproportionate poverty rate. They were “surprised” that rural radiologists fared better than radiologists in other regions in three out of the four financial measures.

They found, however, that despite size, region, payor mix, and other characteristics, “nonmetropolitan radiology practices were paid a substantially higher fraction of their billed charges than other radiology practices, and were paid more quickly than other practices.” The higher payment rate is because of lower charges by the radiology practice, not insurers making higher payments.

Practices in the Northeast region had low gross collection rates, but higher charges and more rapid payment; practices in the Midwest and West, excluding California, showed a higher gross collection rate, but lower gross charges. Researchers said high collection rates appear to be due to a variation in billing charges rather than a variation in insurers’ payments, and concluded that increasing charges to increase revenue has limited effect even though high-billed charges can offset lower gross collection rates if a practice has a significant number of patients who go “out of network” and are responsible for total billed charges.

Brain Injuries Prompt MRI Recommendations from FDA

After receiving several reports of serious injury of patients with implanted neurological stimulators who underwent MRI, the Food and Drug Administration has issued recommendations to help prevent the problem.

The reported injuries—coma and permanent neurological impairment—most likely happened after the electrodes at the end of the leadwires heated, causing damage to surrounding tissue. Although the incidents reported involved deep brain stimulators and vagus nerve stimulators, the FDA says similar injuries can occur with any type of implanted neurological stimulator, including spinal cord, peripheral nerve, and neuromuscular stimulators.

The FDA released the following recommendations to radiologists who use MRI equipment:

  • All patients should be screened for implanted devices, even if they have been turned off. Patients should also be questioned about devices that have been implanted and removed because leads, or portions of leads, can remain in the body, and may act as an antenna and become heated.
  • If the patient does have an implanted device, consider consulting with the referring physician to discuss other imaging options.
  • If an MRI is to be performed, make sure to review the labeling for the specific model implanted in the patient, paying particular attention to warnings and precautions. The monitoring physician may need to be consulted for this information. Any instructions given for MRI that may be in the labeling for the implant should be followed. This information may include types and/or strengths of MRI equipment that may have been tested for interaction with a particular implanted device. This information is available from the device’s manufacturer.

The Road to Electronic Health Record Adoption

Compared to other industries, the health care industry has been slow in adopting information technology by at least 5-7 years, but perhaps by as much as 10-15 years, according to the Health Information Technology Leadership Panel Final Report, prepared by The Lewin Group Inc, and released March 2005. Citing a study by Anthony G. Bower of the RAND Corporation, the report suggests that health care is midway along an adoption curve for the electronic health record (EHR) of 50 years, which is comparable to new technology adoption cycles in other industries or large-scale relational databases (LSRD). The study indicates that EHR use for inpatients is approaching the midpointabout 23 years since adoption first beganand a current penetration rate of about 20%. The graph indicates the inpatient EHR adoption curve in the United States. According to the report, Rand projects 40% penetration in a few years.

Source: Health Information Technology Leadership Panel Final Report, prepared by The Lewin Group, Inc, released March 2005.

Industry News

GE Healthcare , Waukesha, Wis, has signed a 10-year research agreement with the University of California, San Diego . The research alliance will focus on neuroscience, MR guided focused ultrasound, Alzheimer’s disease, and atherosclerosis…Natick, Mass-based Boston Scientifics’ Liberte heart stent has been approved by federal regulators… The American Society for Therapeutic Radiology and Oncology (ASTRO) public awareness campaign to educate cancer patients on treatment options won an Award of Distinction from The Communicator Awards. ASTRO also received Awards of Distinction for its quarterly magazine, ASTROnews, and Annual Meeting Guide, the magazine’s supplement… American Medical Sales Inc , Hawthorne, Calif, has developed a new partnership with Shimadzu Medical Systems direct operations in Dallas… Merge Technologies Inc , Milwaukee, and Cedara Software Corp , Toronto, are having its shareholders vote on a merger between the two companies. The transaction is expected to be complete the last week in May… FUJIFILM , Stamford, Conn, has renewed its support of the ASRT Education and Research Foundation , Albuquerque, NM, with sponsorship of the Health Care Industry Advisory Council by & Outpatient Imaging Affiliates, LLC (OIA), Nashville, Tenn, announced a joint venture— UT Imaging Houston, LLP—with University of Texas Physicians , a nonprofit corporation and affiliate of the University of Texas Health Science Center, Houston… Quantum Medical Imaging , Long Island, NY, has expanded by relocating to a new facility. The company’s new address is 2002 Orville Drive North, Ronkonkoma, NY 11779… IntrinsiQ Research Inc , Waltham, Mass, will be integrating ScanSoft® Dragon™ NaturallySpeaking® to enable speech recognition within IntelliDose, a medical oncology clinical workflow solution… Florida Medical Consultants Inc , St Cloud, Fla, announced its name change to SonoDepot during the Association for the Advancement of Medical Instrumentation Conference… Philips Medical Systems , Andover, Mass, has published Digital Radiography, An Administrators Guide , a 44-page instruction manual for the transition to filmless radiology. The guide is distributed free to attendees of Digital Solutions for General Radiography Conference, presented by Northwest Imaging Forums , Eugene, Ore, which will be held next October 10-13 in Las Vegas. To register, visit www.nwforums.com… Eastman Kodak Company, Rochester, NY, and The SSI Group Inc (SSI), Mobile, Ala, have signed a co-marketing agreement allowing each company to promote the medical imaging, information, and software products of the other to diagnostic imaging centers in the United States.

People

Monte Clinton, CRA
Makato Kawaguchi

Long-time Decisions in Axis Imaging News board member Monte Clinton , CRA, will retire from his position as administrative director of the Department of Diagnostic Radiology at Dartmouth-Hitchcock Medical Center, Lebanon, NH. He started as a radiologic technologist in 1963 at St Anthony Hospital in Denver. In 1973 he became administrator of the Department of Radiology at Memorial Sloan-Kettering Cancer Center in New York. In 1992 he moved on to become administrative director of the Dartmouth-Hitchcock Medical Center, where he saw the radiology department through a complete digital remodel, the addition of a new doctor’s building, the implementation of the Philips VM digital room, and a PACS implementation…
FUJIFILM Medical Systems USA, Stamford, Conn, has appointed Makoto Kawaguchi as the company’s new president… Dave Armstrong has joined RADinfo SYSTEMS Inc, Dulles, Va, as vice president of sales and marketing…Evolved, Brentwood, Tenn, has named Paul H. Hoyt as chief executive officer…The board of directors at Eastman Kodak Company, Rochester, NY, have named Michael W. Jackman and Michael L. Marsh as vice presidents of the company… Brent Shafer has been appointed as executive vice president and CEO, sales and service region for North America, for Philips Medical Systems.