Imaging Hearts & Bones PET/CT Underutilization
In this issue, we address several important issues related to the quality of care and the business of molecular imaging. The recent 99mTc shortage made it clear that long established imaging studies will eventually be replaced by more robust and higher quality alternatives. This will foremost affect two major applications of nuclear medicine, myocardial perfusion and bone imaging.
Cardiac PET/CT imaging with fluorinated perfusion probes, 13N-ammonia or 82Rubidium is an attractive alternative to SPECT perfusion imaging. Based on older studies, the accuracy of PET for detecting coronary artery disease is significantly higher than SPECT. However, the business model for cardiac PET/CT imaging in the community has not been well thought through. Thousands of cardiology offices operate SPECT systems in the U.S. These systems are inexpensive, require little space and are easy to manage. PET/CT systems are expensive, have a large footprint and are less than ideal for office-based cardiac imaging operations. A need exists for small, dedicated cardiac PET systems. The second important aspect is related to the costs of isotopes. 99mTc is inexpensive. Without some new options, cardiac PET will not be successful in the community.
The obvious alternative for conventional bone imaging is PET/CT bone imaging using 18F-sodium fluoride (18F-NaF). To provide CMS with evidence for its effectiveness and accuracy, the NOPR group is establishing a registry that will collect data on impact on management and patient in this outcome. At the same time, the Academy of Molecular Imaging is conducting a randomized multicenter trial to compare the accuracy of 18F-NaF PET/CT to that of conventional bone imaging. It is hoped that these studies will provide the data to support CMS coverage for PET-based bone imaging.
A recent study published in JAMA reported on the contribution of imaging to the cost of cancer care (Dinan et al; Jama 2010; 303: 1625-1631). Using CMS claims data, this analysis revealed that imaging contributes less than 5 percent to the overall costs of cancer. The study also demonstrates that imaging costs increase at a higher pace than overall healthcare cost. Importantly, costs arising from PET/CT imaging accounted for a much smaller fraction. For instance, in 2006, the average patient with lymphoma underwent eight conventional radiographs, six CT scans, one PET scan, one other nuclear medicine test, one MRI, three echocardiograms and three ultrasound exams. I would conclude that PET/CT is dramatically underutilized and the associated costs are overstated. Appropriate management of cancer patients should include FDG PET/CT that has shown to be cost-effective and affects the management of more than 30 percent of cancer patients (NOPR).
Cardiac PET/CT imaging with fluorinated perfusion probes, 13N-ammonia or 82Rubidium is an attractive alternative to SPECT perfusion imaging. Based on older studies, the accuracy of PET for detecting coronary artery disease is significantly higher than SPECT. However, the business model for cardiac PET/CT imaging in the community has not been well thought through. Thousands of cardiology offices operate SPECT systems in the U.S. These systems are inexpensive, require little space and are easy to manage. PET/CT systems are expensive, have a large footprint and are less than ideal for office-based cardiac imaging operations. A need exists for small, dedicated cardiac PET systems. The second important aspect is related to the costs of isotopes. 99mTc is inexpensive. Without some new options, cardiac PET will not be successful in the community.
The obvious alternative for conventional bone imaging is PET/CT bone imaging using 18F-sodium fluoride (18F-NaF). To provide CMS with evidence for its effectiveness and accuracy, the NOPR group is establishing a registry that will collect data on impact on management and patient in this outcome. At the same time, the Academy of Molecular Imaging is conducting a randomized multicenter trial to compare the accuracy of 18F-NaF PET/CT to that of conventional bone imaging. It is hoped that these studies will provide the data to support CMS coverage for PET-based bone imaging.
A recent study published in JAMA reported on the contribution of imaging to the cost of cancer care (Dinan et al; Jama 2010; 303: 1625-1631). Using CMS claims data, this analysis revealed that imaging contributes less than 5 percent to the overall costs of cancer. The study also demonstrates that imaging costs increase at a higher pace than overall healthcare cost. Importantly, costs arising from PET/CT imaging accounted for a much smaller fraction. For instance, in 2006, the average patient with lymphoma underwent eight conventional radiographs, six CT scans, one PET scan, one other nuclear medicine test, one MRI, three echocardiograms and three ultrasound exams. I would conclude that PET/CT is dramatically underutilized and the associated costs are overstated. Appropriate management of cancer patients should include FDG PET/CT that has shown to be cost-effective and affects the management of more than 30 percent of cancer patients (NOPR).