Barriers prevent wider adoption of cardiac CT
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Guidelines, economics and education are some of the barriers that block a wider adoption of cardiac CT, according to a presentation at the Society of Cardiovascular Computed Tomography Annual Scientific Meeting.
Cardiac CT myths
Several myths exist regarding cardiac CT, one of which is that identifying plaque is not important because most patients already have it, Ron Blankstein, MD, MSCCT, FASNC, FACC, FASPC, director of cardiac computed tomography, associate director of the cardiovascular imaging program and associate physician of preventive cardiology at Brigham and Women’s Hospital, associate professor of medicine and radiology at Harvard Medical School and president of the Society of Cardiovascular Computed Tomography, said during his presentation. In fact, detecting plaque can lead to better medical therapies and improved outcomes.
Some have argued they believe that because cardiac CTA cannot detect ischemia, most patients will require further testing. Patients often have normal or minimal CAD, and it turns out that only approximately 10% to 20% of patients will have lesions that may benefit from further testing. Other myths include that cardiac CTA leads to higher downstream costs, has a high radiation dose and that it does not improve patient outcomes.
“The reality is today in 2020, we know that CT is associated by approximately 30% reduction in the rate of subsequent myocardial infarction,” Blankstein said.
Another barrier preventing wider adoption of cardiac CT is that more physicians must be trained in how to appropriately read it. Blankstein said far more physicians are certified to read nuclear cardiology compared with cardiac CT.
Economics is another barrier regarding cardiac CT. From 2017 to 2020, payment for coronary CTA decreased by 33%, according to the presentation.
“This is, of course, on top of payment that has never really been appropriate,” Blankstein said.
An issue is that the Medicare payment for the technical component of CT in the U.S. is lower than the actual cost of providing the test.
“If you’re a hospital, you may not be trying to make money off of doing tests, but you certainly don’t want to lose money,” Blankstein said. “Whenever you have a test where the payment that you get for it is lower than the cost of providing, that’s certainly a barrier to adoption.”
This is different compared with other countries. Blankstein asked colleagues to find out what is the reimbursement of coronary CTA relative to chest CTA. Compared with the U.S., which gets reimbursed one times as much, other countries get reimbursed more for this, including Brazil (two times), the United Kingdom (three times) and Israel (four times).
“I’m not sure what the right answer is, but I can assure you that it’s not a one-to-one ratio because coronary CT requires a lot more resources than a chest CT,” Blankstein said.
Recently, the European Society of Cardiology updated its guidelines and provided a class 1 recommendation for coronary CTA as a first-line test to evaluate patients with stable chest pain. In the U.S., an updated chest pain guideline is expected to come out within the next year. While such guidelines aid clinicians (and may influence payors), their impact on test selection is often overstated, according to the presentation.
According to Blankstein, guidelines can help guide clinicians, but their local practices and training may be more important in dictating practice patterns than what the guidelines actually state.
Importance of education
Blankstein emphasized the importance of educating the “end users” of cardiac CT, which include referring clinicians and other physicians. They must learn more about when cardiac CT is useful or not useful, and when are other imaging tests preferable. In addition, clinicians must learn how to integrate those test results into managing a patient.
“We need to help clinicians know when is medical management alone sufficient, when is stress testing needed, and when do patients really need to go to invasive angiography,” Blankstein said. “This is important, and I urge everyone ... who may be the local CT champion in their center to be the person who educates everyone in their community how to use the results of cardiac CT.”
An important force related to cardiac CT is de-adoption, which occurs when cardiac CT studies are not useful or inaccurate. Physicians may receive the results, determine that it is not helpful and order another test. To avoid de-adoption, Blankstein suggests avoiding tests when good image quality cannot be obtained.
“Coronary CTA is absolutely a test that’s dependent on the technique and on image quality,” Blankstein said. “If you have a patient with small stents, someone who cannot hold their breath or someone who’s tachycardic that you cannot control that, that might not be a good patient for cardiac CT.”
Training is critical for physicians involved in cardiac CT, with a specific focus on image acquisition and interpretation.
“This is essential for the long-term success of cardiac CT and for improving patient outcomes,” Blankstein said.
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Blankstein R. Cardiovascular CT in 2020: Current Developments, Guidelines and Trials. Presented at: Society of Cardiovascular Computed Tomography Annual Scientific Meeting; July 17-18, 2020 (virtual meeting).
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