American College of Radiology blog

ACR, Patient Groups, Industry Make Case for CTC Coverage

Despite significant evidence of CT colonography’s effectiveness as a screening tool for colorectal cancer, on Feb. 11, the Centers for Medicare and Medicaid Services (CMS) announced a proposed decision not to cover the exam, stating that the evidence was inadequate to conclude that CTC would provide health benefits to the average Medicare beneficiary.

In the CMS proposed decision memo, opponents to coverage cited unknown effects from radiation exposure associated with the exam, questions as to the amount of training necessary to properly read the exam, and concern that it would be difficult to generalize the results of the ACRIN CT Colonography Trial to the average practice setting and specifically to the Medicare population.

The ACR and other societies have been working together to reverse CMS’s proposal by educating members of Congress that using CTC as a screening method for colorectal cancer will help more people to get screened, aid in early detection and ultimately help save lives.

At a Capitol Hill briefing last Monday, Elizabeth McFarland, M.D., chair of the ACR Colon Cancer Committee, made a presentation to congressional and regulatory staff members on behalf of the College as to the effectiveness and importance of this exam. In response to these efforts, several lawmakers have signed on to letters written to CMS urging them to cover CTC.

In a letter to the editor published in Saturday’s New York Times, Andrew R. Spiegel, chief executive of the Colon Cancer Alliance, Ilyse Schuman, managing director of the Medical Imaging and Technology Alliance, and myself, reinforced the proven cost-effectiveness of CTC as well as its “potential to enhance colon cancer screening compliance.”

The 30-day public comment period for the proposal ended on Friday, CMS is expected to make a final (at least for the immediate future) decision on coverage by May 12.

For those of you who currently offer/perform CTC:

• Has your practice seen an increase in CTC volume since the results of the ACRIN study were published in the New England Journal of Medicine last fall or a decrease since CMS proposed not to cover the exam?

And if you do not currently offer/perform CTC:

• Will Medicare’s final coverage decision determine whether or not you add this exam to your practice or seek out training?
  
  

I look forward to your thoughts.

Savings Through Spending: Obama’s Budget Announced

On Thursday, President Obama announced his $3.6 trillion budget plan for the 2010 fiscal year. The plan would create a “health care reserve” costing $634 billion over 10 years, in an effort to provide universal health coverage. Tax increases and cuts to Medicare and Medicaid would fund the reserve.

According to the plan, increased spending on insuring all Americans upfront will save money in the long run, because patients will seek out care and engage in preventative measures to reduce the occurrence of chronic (and often costly) diseases.

The proposed plan would seek to control imaging costs through the use of radiology benefit management companies in the Medicare program. The ACR, however, has argued that the use of Appropriateness Criteria in an order entry system is a better way to monitor imaging, and ensures that patients receive the best study for their condition in a timely manner.

Other health care measures in the plan include:

• $1 billion to the FDA to improve food safety
• $6 billion for cancer research
• $76.8 billion toward EMR adoption and medical treatment comparison
• $330 million toward addressing doctor and nurse shortages

What do you think about the budget plan in terms of health care reform?

What do you think are the strengths and shortcomings of the plan?

I look forward to your comments.

Good, Better and Best Practices

My column in this month’s ACR Bulletin focuses on how collaborating with others on best practices can lead to quality improvement and overall patient satisfaction. Focusing on improvement doesn’t necessarily mean that your practice is sub-par or not meeting certain standards of care; it simply means that we as physicians recognize that in this ever-changing health care arena, there are bound to be new ideas or solutions for things we do every day.

This being said, I’d like to hear what best practices you’ve adopted and made part of your daily routine. How did you identify the need for a change? What has worked and what hasn’t? Perhaps it was as simple as providing patients with educational materials before an exam. Or, maybe you invested in new imaging equipment, or learned a cutting-edge technique. Feel free to leave details in the comments section to share with other members.

I’m looking forward to your responses. And, be sure to read the articles in this month’s Bulletin for more ideas, tips, and testimonials from your colleagues on implementing best practices.

Unnecessary Invasive Breast Biopsies

In case you missed it, CBS News recently aired a story regarding a study which showed that approximately 600,000 women each year receive invasive breast biopsies performed by surgeons when referring them to a radiologist for a needle/stereotactic biopsy would be just as effective at confirming or ruling out cancer, would be less costly, less invasive, and would leave the patient with a far smaller scar.

If you are having trouble viewing the video below, it can also be viewed on the CBS Web site (a short commercial will air before the segment begins).

I am not a breast imager by subspecialty, but would be interested to know whether this is a pattern of referral behavior that you are seeing in your market (without mentioning specific names).

If so — what do you think radiologists can and/or should do to counter this trend?

What would you recommend that patients ask their referring physicians regarding this process?

I look forward to hearing from you.

Scanning for Truth: New Opportunities for fMRI

Recently, the ACR Daily News Scan ran an original article about using MRI as a tool for truth detection.

We are accustomed to using MRI as a screening tool for diagnosing and treating disease — serving as the next-generation polygraph seems a bit far fetched. Or is it?

fMRI truth-testing analyzes blood flow and oxygen changes in the brain, whereas the polygraph focuses on the human stress-response. And, the polygraph is arguably only about 65 percent accurate. One San Diego, Calif.-based firm is currently conducting a large trial set for completion next year, which hopes to achieve upwards of 90 percent accuracy in determining who is telling the truth.

The ACR has not taken a formal position on fMRI for truth detection, nor whether it represents an appropriate use of a diagnostic study for medical-legal purposes. I urge you to read the article in its entirety, as it discusses the medical and legal implications, as well as the opportunities for fMRI use in pre-employment screenings and the criminal justice system.

How do you feel about MRI being used as truth screenings?

Do you think this technology could have real implications on our judicial system?

I look forward to your thoughts.

ACRIN CT Colonography Results Published in NEJM

It has been a while since we last talked about CT Colonography. The results of the American College of Radiology Imaging Network’s (ACRIN) CT Colonography trial — which determined that virtual colonoscopy is comparable to standard colonoscopy in its ability to accurately detect polyps — were published in the Sept. 18 issue of the New England Journal of Medicine.

ACR member, C. Daniel Johnson, M.D., of the Mayo Clinic in Scottsdale, Ariz., was the study’s principal investigator. We expect the results of this trial to make a large impact on the number of patients being screened for colon cancer, increase early detection, and ultimately help save lives.

The preliminary results of this large, multi-center trial were presented at the ACRIN annual meeting last fall. Milestones since the initial presentation have been the adoption of CTC as a recommended screening tool by the ACR, the American Cancer Society, and the U.S. Multi-Society Task Force on Colorectal Cancer, and the initiation of a national coverage analysis (NCA) for the use of screening CT Colonography for colorectal cancer issued by CMS.

Below is a video summarizing the ACRIN CT Colonography trial results. Click on the arrow for the video to begin playing.

It is widely known that screening rates for colorectal cancer are low. How do you think the results of the ACRIN trial will impact you and your practice in terms of screening rates, reimbursement for the exam, and the need to undergo any further educational training?

I look forward to your thoughts.

Would You Let a Ghost Do Your Reporting?

The College recently posted to the Web site an original article, Ghost Reporting: The “Scary” Specter of Rubber-Stamped Reads. The article focused on what ghost reporting is — the practice of a U.S. radiologist signing off on a report that was actually done by someone else — and what can be done to stop it.

I think ghost reporting is unethical as well as a gross disservice to patients. The ghost reader might be a radiologist or another doctor, but it could just as easily be someone who has no medical credentials whatsoever either in this country or in some place halfway around the world. So why would anyone even consider this practice? There is no hard data that even suggests it is being done in the United States. However, with telemedicine as a growing field, with reimbursement declining, and with nonradiologists getting more and more involved with imaging, ghosting could become more of a reality than ever before.

In May 2006, the ACR issued a statement on ghost reporting:

“It is unethical and likely fraudulent for a physician who has not personally interpreted the images obtained in a radiologic examination to sign a report or to take attribution of an interpretation of that examination rendered by another physician in a manner that causes the reader of a report to believe that the signing radiologist was the interpreter. This practice, known as ghost reporting, should be strictly prohibited.”

• What do you think the radiology community needs to do to make sure that this practice is not only discouraged, but prohibited? 
• Or, do you take the position that ghosting by radiologists or nonradiologists is nothing to be concerned about and that we need not bother with worrying? 

I would like to hear your thoughts.

New Technology Puts Care in Patient Hands

Keeping up with advancing information technology and trends in radiology and medicine in general is a full-time job. It seems as though every day new equipment debuts, scientific studies are released and software is redesigned. People are constantly working to advance the field which makes our jobs as physicians ever-changing.

This week, I’ve been particularly aware of technology as it pertains to patients. As reported in last Friday’s Daily News Scan, the Florida Hospital system is introducing kiosks to their radiology department in an effort to speed up the check-in process and will eventually allow patients to make payments on the machines.

Here’s another example: Patients of the Duke University Health System can now book appointments online — which may save phone calls, waiting room time and possibly frustration for hospital staff and patients.

And take Ohio State University Medical Center. They’re publishing consumer-focused data directly on their Web site to allow patients access to more information and ultimately more control over their health, according to the site. Everything from medical results statistics to patients’ opinions of the quality of service they received is published for the public to see.

Now, these examples are taken from large hospital systems which may or may not apply to your practice; however, I do wonder how powerful allowing patients to access specific information online would impact any radiology experience. On Monday, USA Today reported that doctor-rating Web sites — which are becoming increasing popular (though highly criticized) — have put doctors on the defensive, which I can’t say I believe this is good for medicine.

Recently, Dr. Thrall blogged about the AIM site, which offers estimates of the radiation received from specific imaging procedures. Many of you wrote in expressing your concern and ideas to alter this tool to be of use to patients and referring physicians.

• How has patient access to technology impacted your career; or, how do you see it changing your role as a physician in the future?
• How can we harness in all of the available information and make it relevant and available to our patients?

I understand the convenience and in some cases cost-effectiveness of allowing patients to take charge of their health. But where do we draw the line?

I look forward to your thoughts.

Imaging Safety Concerns Over Online Interactive Tool

Next week’s edition of AMNews features an article criticizing a health-plan owned company for a new interactive tool on their Web site. I visited the American Imaging Management Web site to try this tool out for myself. There is a 3-D image of a woman beside a list of imaging modalities and procedures. If you click on one of the procedures, the woman’s body lights up in the area to be scanned. A summary of common uses for the selected procedure is provided, along with alternatives to the imaging study. The user is also provided a numeric total at the bottom of the screen: exposure in mSv, number of equivalent chest x-rays, and natural equivalent in years. Of course natural background radiation is to the whole body and adding site specific information as is done on this Web site is incorrect and misleading.

While the company contends that the purpose of the tool is to educate patients about the radiation exposure associated with their imaging exam, I have to agree with the AMA, and wonder if there is more to the story. If you didn’t have time to read the article, it clearly states that health plans have acknowledged the increased utilization of imaging over the past several years, and have had to reevaluate their patient access to medical imaging for financial reasons.

Nowhere on the site can you find information about the benefits and cost-effectiveness of early detection through medical imaging, radiation dose variance between patients and machines or the financial interest a health plan-owned company may have in keeping imaging costs down. In Dr. Moore’s column in this month’s ACR Bulletin, he addresses the ACR’s ongoing patient safety efforts — which aim to educate, not confuse patients.

• Would any of you refer your patients to this tool?
• What value could it have for health care?
• What can we, as physicians do to prevent our patients from once again receiving incomplete information that may lead them to question getting necessary examinations?
  

Disruptive Technologies Present Challenges, Opportunities for Radiology

The ACR recently posted to the Web site an original article titled, The Double-Edged Sword of Technology: “Disruptive Technologies” Concerns Radiologic Profession Built on Innovation. The article focused on what it termed “cheap, good-enough scanning technologies that may enable competitors to infiltrate the world of radiology, compete on unequal terms, and redefine the standards of practice.”

There is little doubt that as scanners become smaller and more available to lesser trained personnel, the trend will present challenges to radiologist physicians intending to protect patients from substandard care.

What do you think that the radiology community needs to do to make sure that patients receive the best care possible in the face of advancing technology that could place price, portability, and perceived convenience over quality?

Did the Recent NEJM Article Overstate Any Cancer Risk Associated With CT Scans?

An article titled, Computed Tomography-An Increasing Source of Radiation Exposure, published in the Nov. 29 issue of the New England Journal of Medicine (NEJM) has re-ignited a firestorm in the medical community and created confusion in the minds of many of our patients.

The study claimed that up to 2 percent of all cancers in the United States may be caused by radiation received from CT scans and equates radiation exposure and effects experienced by many atomic bomb survivors in Japan to present day patients who receive computed tomography (CT) scans.

The ACR immediately issued a response in order to allay patient fears engendered by media reports on the study, lay out what the radiology community has been doing to address radiation risk, and help give physicians some guidance on what they might say to their patients. The response was referenced in many newspaper articles nationwide and I was interviewed by several newspapers regarding this issue.

But, I wanted to find out what you think about the utilization of CT and any associated cancer risk. Please write in with your thoughts regarding how CT is being utilized and whether you think the cancer risk was overstated in the NEJM article. I look forward to hearing what you have to say.