SPECT/CT Roundtable: Experts Speak Out about Quality, Efficiency and Technology

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Advanced SPECT imaging hardware and software, as well as quantitative processing techniques, will ensure the modality remains a major clinical workhorse. Source: David Wolinsky, MD, Albany Associates in Cardiology, Albany, N.Y.

Moderator:  C.P. Kaiser, Editor, Cardiovascular Business

Cardiovascular Business invited four luminaries in the field of nuclear cardiology to discuss SPECT and SPECT/CT, including advanced technology, utilization in hospital- and office-based settings and reimbursement challenges. Participants in the roundtable discussion are:

Daniel S. Berman, MD, chief of cardiac imaging and nuclear cardiology at the S. Mark Taper Foundation Imaging Center at Cedars-Sinai Medical Center and a professor of medicine at the David Geffen School of Medicine at UCLA in California.

Gary V. Heller, MD, PhD, a professor of medicine and nuclear medicine at the University of Connecticut School of Medicine and associate director of the division of cardiology and director of the nuclear cardiology laboratory at Hartford Hospital, Harford, Conn.

Terrence D. Ruddy, MD, head of the division of cardiology, director of nuclear cardiology and a professor of medicine and radiology at the University of Ottawa Heart Institute and head of nuclear medicine at The Ottawa Hospital, Canada.

Leslee J. Shaw, PhD, an outcomes research scientist and a professor of medicine at Emory University School of Medicine, Atlanta, and program chair for the 2009 American Society of Nuclear Cardiology meeting.

How do the financial considerations differ for providing hospital- or office-based SPECT imaging?

Gary V. Heller, MD, PhD: The main consideration for the hospital-based setting is that if the test is ordered, we must image those patients. The reimbursement is extremely different from the office-based setting depending on DRGs, insurance companies, etc. The challenges for an imaging laboratory in the hospital are quite enormous, leading to hospitals trying to be as efficient as possible.

Terrence D. Ruddy, MD:
In Canada, we have the same reimbursement for clinics outside the hospital as for patients done in the hospital. But an outside clinic pays rent and buys its own equipment. They tend to have older cameras and run simple, inexpensive tests to save money. In the hospital, we have access to more capital and tend to have state-of-the-art equipment. In fact, when my academic center buys a new camera, we typically sell the old one to the outside clinic.

Dr. Shaw, is there any research to indicate differences in quality between hospital-and office-based settings in the U.S. that would impact financial considerations?

Leslee J. Shaw, PhD: Dr. Ruddy alluded to some of the differences which may occur if there are disparities in the advanced imaging techniques that are available, but there is no hard evidence showing this. At least in the U.S., it appears the quality of the equipment is fairly equivalent between the outpatient and hospital setting.

What can cardiologists do to increase revenues regarding SPECT imaging?

Heller: I am worried about the words “increase revenues.” I think the message should be “increase efficiency and reduce cost.” There is an enormous effort in the field of SPECT imaging to reduce acquisition time and improve image quality.

Daniel S. Berman, MD:
Many vendors are producing new software approaches to reduce acquisition time without losing image quality. They include UltraSPECT, Philips Healthcare (Astonish), Siemens Healthcare (Flash 3D), GE Healthcare (Evolution) and Digirad (nSPEED). There also are advanced cameras with faster acquisition times such as the CardiArc SPECT system and D-SPECT (Spectrum Dynamics). In addition, the PET imaging protocol is extremely efficient, allowing for a rest/stress exam in 30 minutes, compared to two to three hours for conventional rest/stress SPECT.

Is it possible that advanced SPECT technology would close the timing gap with PET?

Ruddy: Attenuation correction works really well with PET, especially in obese patients or women with large breasts. We also use quantitative blood flow analysis with either 13N-ammonia ?or rubidium-82 and find it helpful in patients who have diabetes or multivessel disease. The ischemia is more accurately quantified with PET.

Berman: The absolute flow measurement analysis techniques and looking at coronary flow reserve with PET are likely to become widely disseminated soon. We should acknowledge, though, that SPECT/CT systems are