Inside the Transition to Flow-Based Patient Care

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 - Ochsner Health System
Ochsner Health System, New Orleans, La.

The nuclear cardiology department at Ochsner Health System, a New Orleans-based multi-hospital organization with facilities peppered throughout southern Louisiana, is revising its cardiac imaging model and implementing a flow-based imaging program. Leveraging the Positron Attrius cardiac PET system, the new model is characterized by highly accurate patient diagnosis and treatment and judicious use of healthcare resources. It's a win-win proposition, says Robert Bober, MD, director of nuclear cardiology.

"The traditional methods of treating coronary disease have not led to better outcomes," says Bober, an affirmed evidence-based practitioner, who refers to the COURAGE and FAME trials as strong rationales for a flow-based approach to revascularization. The FAME trial, in particular, demonstrated that FFR-guided percutaneous coronary interventions produced improved clinical outcomes compared with angiography-guided stent placement.

Setting the stage

Prior to 2010, the nuclear imaging infrastructure at Ochsner was fairly slim. The hospital had purchased a SPECT camera in 2005, which was moved to a satellite clinic after Hurricane Katrina that same year. Stress echocardiography played a dominant role in imaging. Bober employed a two-pronged approach to coronary imaging, focusing on educating providers about appropriate roles and candidates for stress echo and perfusion imaging, while also trying to boost volume.

By early 2010, it became clear that the health system needed another coronary imaging option to supplement the offsite SPECT camera. Committed to making a sound clinical and economic investment, Bober and colleagues surveyed the market, considering PET/CT, SPECT and PET.

"It was clear that PET represented the future of cardiac perfusion imaging," he says. "The cardiology community is moving to a flow-based approach to coronary imaging, and PET is the right tool to do that.

"At this time, we can't non-invasively evaluate flow data with any other modality," Bober shares. "PET provides the ability to quantify absolute myocardial perfusion at rest and stress. With PET and FDA-approved flow quantification software that provides flow and flow reserve, it fundamentally changes which patients you send for revascularization and which patients are not referred."

Other imaging options do not match the capabilities of cardiac PET. Newer CZT-SPECT systems may be approaching flow capabilities, however, this technology is in its infancy with regards to flow, Bober notes. The decision-making team also considered the economic implications of investing in a hybrid PET/CT system. However, the numbers didn't add up, he confides. CT added hundreds of thousands of dollars in costs to the system, and CT angiography volume at Ochsner did not justify the additional expense.

In contrast to other options, Positron's Attrius cardiac PET system provides the right mix of diagnostic capabilities and value for Ochsner Health System. "The primary drivers have been the clinical application of the technology and what it brings to the practice in terms of diagnostic differentiation. It is cutting-edge technology in cardiology," explains Mark A. French, vice president of operations, surgical services and cardiology at Ochsner. The Attrius effectively weds cutting edge with cost-effectiveness. "We want to make sure our investments are sound," continues French. The economic case for the Attrius was crystal clear for Ochsner decision-makers. A pro forma calculated at six studies a day indicated return on investment (ROI) in six to eight months, shares Bober, and the hospital hit a breakeven point at three studies daily.   

Establishing a new standard

The flow-based cardiac PET model represents a stark contrast to the conventional approach, notes Bober. "The standard now is to do a stress test and if abnormal, then do an angiogram and hopefully the two correlate. If they don't, the angiographer puts in stents based on what the angiogram shows and calls the stress results wrong. What we should do is use more FFR in the cardiac cath lab, making sure that what we see is actually flow-limiting and then revascularizing the flow-limiting lesions. FFR is very objective and reproducible."

The Attrius facilitates the flow-guided model and reinvents patient care. Take for example the not atypical case of a large-breasted woman who presented with angina prior to Ochsner's cardiac PET deployment. The stress echo showed multiple abnormalities that confounded the interpretation