Recent trends in utilization of cardiovascular imaging: how important are they for radiology?

Challenges and opportunities to delivering cardiac imaging training: a national survey by the Italian college of cardiac radiology

BACKGROUND

Delivering consistent levels of training in cardiac imaging to radiologist is of pivotal importance because of the increasing clinical indications to coronary computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR). Our study sought to capture the heterogeneity of cardiac imaging training programs and to explore residents' vision on cardiac imaging both in the present and in the future.

METHODS

Two web-based surveys were created. The first was administered to all chief residents from the 42 University Hospitals within Italy, aiming to explore the local educational offer in cardiac imaging. The second was administered via social media to all Italian residents, including questions about their overall vision regarding cardiac imaging.

RESULTS

42/42 University Hospitals responded to the first survey and 235 residents to the second. There was at least a 64-slice CT scanner and a 1.5 T MR scanner per center. In the majority of sites, the weekly routine consisted of more than 10 CCTA and more than 5 CMR. Approximately, half of the centers used advanced CCTA and CMR techniques. The majority of the interviewed resident (94%) perceived cardiac imaging training to be moderately to very important, while requirement for external educational resources was advocated in 25% of the cases.

CONCLUSION

Our survey highlighted a significant awareness of radiology residents regarding the importance of cardiac imaging in their training curriculum. All centers met the technical requirements for cardiac imaging, limiting its use to basic applications in around half of cases. Implementation of an educational network might be the key for supporting the growth of this subspecialty field.

Cardiac-CT and cardiac-MR cost-effectiveness: a literature review

Cardiovascular diseases are still among the first causes of death worldwide with a huge impact on healthcare systems. Within these conditions, the correct diagnosis of coronary artery disease with the most appropriate imaging-based evaluations is of utmost importance. The sustainability of the healthcare systems, considering the high economic burden of modern cardiac imaging equipments, makes cost-effective analysis an important tool, currently used for weighing different costs and health outcomes, when policy makers have to allocate funds and to prioritize interventions, getting the most out of their financial resources. This review aims at evaluating cost-effective analysis in the more recent literature, focused on the role of Calcium Score, coronary computed tomography angiography and cardiac magnetic resonance.

The cardiac conundrum: a systematic review and bibliometric analysis of authorship in cardiac magnetic resonance imaging studies

PURPOSE

We aimed to assess the role of radiologists, cardiologists, and other medical and non-medical figures in cardiac magnetic resonance imaging (MRI) research in the last 34 years, focusing on first and last authorship, number of published studies, and journal impact factors (IF).

METHODS

Articles in the field of cardiac MRI were considered in this systematic review and retrospective bibliometric analysis. For included studies, the first and last authors were categorized as cardiologists, radiologists/nuclear medicine physicians, medical doctors (MD) with specialties in both cardiology and radiology/nuclear medicine, and other MD and non-MD. Differences in the number of papers published overall and by year and institution location for the first and last author category were assessed. Mean IF differences between author categories were also investigated.

RESULTS

A total of 2053 articles were included in the final analysis. For the first authors (n = 2011), 52% were cardiologists, 22% radiologists/nuclear medicine physicians, 16% other MD, 10% other non-MD, and 1% both cardiologists and radiologists/nuclear medicine physicians. Similarly, the last authors (n = 2029) resulted 54% cardiologists, 22% radiologists/nuclear medicine physicians, 15% other MD, 8% other non-MD, and 2% both cardiologists and radiologists/nuclear medicine physicians. No significant differences due to institution location in the first and last authorship proportions were found. Average journal IF was significantly higher for cardiologist first and last authors when compared to that of radiologists/nuclear medicine physicians (both p < 0.0001).

CONCLUSION

Over 50% of studies in the field of cardiac MRI published in the last 34 years are conducted by cardiologists.

Outpatient echocardiography in the evaluation of innocent murmurs in children: utilisation benchmarking

OBJECTIVES

We sought to benchmark the utilisation of echocardiography in the outpatient evaluation of heart murmurs by evaluating two large paediatric cardiology centres.

BACKGROUND

Although criteria exist for appropriate use of echocardiography, there are no benchmarking data demonstrating its utilisation.

METHODS

We performed a retrospective cohort study of outpatients aged between 0 and 18 years at the Sibley Heart Center Cardiology and the Children's Hospital of Philadelphia Division of Cardiology, given a sole diagnosis of "innocent murmur" from 1 July, 2007 to 31 October, 2010. Using internal claims data, we compared the utilisation of echocardiography according to centre, patient age, and physician years of service.

RESULTS

Of 23,114 eligible patients (Sibley Heart Center Cardiology: 12,815, Children's Hospital of Philadelphia Division of Cardiology: 10,299), 43.1% (Sibley Heart Center Cardiology: 45.2%, Children's Hospital of Philadelphia Division of Cardiology: 40.4%; p1-5 years had the lowest utilisation (32.7%).

CONCLUSIONS

In two large paediatric cardiology practices, the overall utilisation of echocardiography by physicians with a sole diagnosis of innocent murmur was similar. There was significant and similar variability in utilisation by provider at both centres. Although these data serve as initial benchmarking, the variability in utilisation highlights the importance of appropriate use criteria.

Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians

BACKGROUND

Cardiac screening in adults with resting or stress electrocardiography, stress echocardiography, or myocardial perfusion imaging can reveal findings associated with increased risk for coronary heart disease events, but inappropriate cardiac testing of low-risk adults has been identified as an important area of overuse by several professional societies.

METHODS

Narrative review based on published systematic reviews; guidelines; and articles on the yield, benefits, and harms of cardiac screening in low-risk adults.

RESULTS

Cardiac screening has not been shown to improve patient outcomes. It is also associated with potential harms due to false-positive results because they can lead to subsequent, potentially unnecessary tests and procedures. Cardiac screening is likely to be particularly inefficient in adults at low risk for coronary heart disease given the low prevalence and predictive values of testing in this population and the low likelihood that positive findings will affect treatment decisions. In this patient population, clinicians should focus on strategies for mitigating cardiovascular risk by treating modifiable risk factors (such as smoking, diabetes, hypertension, hyperlipidemia, and overweight) and encouraging healthy levels of exercise.

HIGH-VALUE CARE ADVICE

Clinicians should not screen for cardiac disease in asymptomatic, low-risk adults with resting or stress electrocardiography, stress echocardiography, or stress myocardial perfusion imaging.

ICMA: an integrated cardiac modeling and analysis platform

Summary: ICMA, a software framework to create 3D finite element models of the left ventricle from cardiac ultrasound or magnetic resonance imaging (MRI) data, has been made available as an open-source code. The framework is hardware vendor independent and uses speckle tracking (endocardial border detection) on ultrasound (MRI) imaging data in the form of DICOM. Standard American Heart Association segment-based strain analysis can be performed using a browser-based interface. The speckle tracking, border detection and model fitting methods are implemented in C++ using open-source tools. They are wrapped as web services and orchestrated via a JBOSS-based application server.

Availability and implementation: The source code for ICMA is freely available under MPL 1.1 or GPL 2.0 or LGPL 2.1 license at https://github.com/ABI-Software-Laboratory/ICMA and a standalone virtual machine at http://goo.gl/M4lJKH for download.

Contact:r.jagir@auckland.ac.nz

Supplementary information:Supplementary materials are available at Bioinformatics online.

The increasing role of nonradiologists in performing ultrasound-guided invasive procedures

PURPOSE

Recent proliferation of mobile diagnostic ultrasound (US) units and improved resolution have allowed for widespread use of US by more providers, both for diagnosis and US-guided procedures (USGP). This study aims to document recent trends in utilization for USGP in the Medicare population.

METHODS

Source data were obtained from the CMS Physician Supplier Procedure Summary Master Files from 2004 to 2010. Allowed billing claims submitted for USGP were extracted and volume was analyzed by provider type and setting. Compound annual growth rates were calculated.

RESULTS

The total utilization rate for all USGP was 2,425 per 100,000 in 2004 and 4,870 in 2010, an increase of 100.8% (+2,445 per 100,000) with a compound annual growth rate of 12.3%. The year 2010 represents the first year that nonradiologists as a group performed more USGP than radiologists, at 922,672 versus 794,497 examinations, respectively. Nonradiologists accounted for 72.2% (599,751 of 830,925) of the USGP volume growth from 2004 to 2010. Most 2010 claims were submitted by radiologists (n = 794,497; 46.3%) and surgeons (n = 332,294; 19.4%). The largest overall volume increases from 2004 to 2010 were observed among radiologists, surgeons, anesthesiologists, rheumatologists, midlevel providers, primary care physicians, nonrheumatologist internal medicine subspecialists, and the aggregate of all other provider types.

CONCLUSION

The year 2010 represents the first year that nonradiologists performed more USGP than radiologists. From 2004 to 2010, radiologists and surgeons experienced only modest growth in USGP volume, whereas several other provider types experienced more rapid growth. It is likely that many procedures that were previously performed without US guidance are now being performed with US guidance.

Open access integrated therapeutic and diagnostic platforms for personalized cardiovascular medicine

It is undeniable that the increasing costs in healthcare are a concern. Although technological advancements have been made in healthcare systems, the return on investment made by governments and payers has been poor. The current model of care is unsustainable and is due for an upgrade. In developed nations, a law of diminishing returns has been noted in population health standards, whilst in the developing world, westernized chronic illnesses, such as diabetes and cardiovascular disease have become emerging problems. The reasons for these trends are complex, multifactorial and not easily reversed. Personalized medicine has the potential to have a significant impact on these issues, but for it to be truly successful, interdisciplinary mass collaboration is required. We propose here a vision for open-access advanced analytics for personalized cardiac diagnostics using imaging, electrocardiography and genomics.

Development and validation of a predictive screening tool for uninterpretable coronary CT angiography results

BACKGROUND

Coronary CT angiography (CCTA) is an excellent tool for noninvasive assessment of coronary arteries in low- to intermediate-risk individuals. However, the accuracy of CCTA heavily depends on image quality. Our objective was to develop and validate a tool to predict pre-CCTA risk of obtaining an uninterpretable result in symptomatic patients.

METHODS AND RESULTS

Among 8585 symptomatic patients, we identified variables independently associated with the presence of at least 1 uninterpretable major coronary segment to create the uninterpretable risk score (URS). This risk score was developed using both clinical variables and patient variables acquired at the time the CCTA was performed (heart rate and coronary calcium). The URS was then prospectively validated among an additional 915 symptomatic patients. The URS was predictive of uninterpretable results in both the development and the validation cohorts. For every 4-point increase in the URS (range, 0 to 12), the rate of at least 1 uninterpretable coronary segment per 100 CCTA studies increased ≈1.5 fold. Increased heart rate and coronary artery calcium score were predictive of uninterpretable CCTA study results. Uninterpretable results were associated with 3-month outcomes in the development cohort.

CONCLUSIONS

The URS can categorize patients who are likely to have at least 1 uninterpretable major coronary segment on CCTA. This may aid in appropriate patient selection for CCTA and avoiding radiation exposure in those likely to have an uninterpretable study. Clinical Trial Registration- URL: http:///www.clinicaltrials.gov. Unique identifier: NCT00640068.

Assessment of left ventricular function in older Medicare beneficiaries with newly diagnosed heart failure

BACKGROUND

Assessment of left ventricular function is a recommended performance measure for the care of patients with newly diagnosed heart failure. Little is known about the extent to which left ventricular function is assessed in real-world settings.

METHODS AND RESULTS

We analyzed a 5% national sample of data from the Centers for Medicare and Medicaid Services from 1991 through 2008. Patients were 65 years or older, with incident heart failure in 1995, 1999, 2003, or 2007. We searched for evidence of tests of left ventricular function from 30 days before through 60 days after an incident heart failure diagnosis. We used logistic regression to identify patient characteristics associated with assessment of left ventricular function. There were 45 005 patients with incident heart failure in 1995, 38 425 in 1999, 39 529 in 2003, and 32 629 in 2007. Assessment of left ventricular function increased from 46% to 60%, with rest echocardiography being the predominant mode. Patients diagnosed with heart failure during a hospitalization had the highest assessment rates (58% in 1995, 64% in 1999, 69% in 2003, and 73% in 2007). After adjustment for other patient characteristics, odds of assessment were 4 times higher among patients diagnosed in inpatient settings.

CONCLUSIONS

Nearly 40% of Medicare beneficiaries do not undergo assessment of left ventricular function when newly diagnosed with heart failure. Quality-improvement strategies are needed to optimize the care of these patients, especially in outpatient settings.

Cost-effective diagnostic cardiovascular imaging: when does it provide good value for the money?

To summarize the results of all original cost-utility analyses (CUAs) in diagnostic cardiovascular imaging (CVI) and characterize those technologies by estimates of their cost-effectiveness. We systematically searched the literature for original CVI CUAs published between 2000 and 2008. Studies were classified according to several variables including anatomy of interest (e.g. cerebrovascular, aorta, peripheral) and imaging modality under study (e.g. angiography, ultrasound). The results of each study, expressed as cost of the intervention to number of quality-adjusted life years saved ratio (cost/QALY) were additionally classified as favorable or not using $20,000, $50,000, and $100,000 per QALY thresholds. The distribution of results was assessed with Chi Square or Fisher exact test, as indicated. Sixty-nine percent of all cardiovascular imaging CUAs were published between 2000 and 2008. Thirty-two studies reporting 82 cost/QALY ratios were included in the final sample. The most common vascular areas studied were cerebrovascular (n = 9) and cardiac (n = 8). Sixty-six percent (21/32) of studies focused on sonography, followed by conventional angiography and CT (25%, n = 8, each). Twenty-nine (35.4%), 42 (51.2%), and 53 (64.6%) ratios were favorable at WTP $20,000/QALY, $50,000/QALY, and $100,000/QALY, respectively. Thirty (36.6%) ratios compared one imaging test versus medical or surgical interventions; 26 (31.7%) ratios compared imaging to a different imaging test and another 26 (31.7%) to no intervention. Imaging interventions were more likely (P < 0.01) to be favorable when compared to observation, medical treatment or non-intervention than when compared to a different imaging test at WTP $100,000/QALY. The diagnostic cardiovascular imaging literature has growth substantially. The studies available have, in general, favorable cost-effectiveness profiles with major determinants relating to being compared against observation, medical or no intervention instead of other imaging tests.

Cardiac imaging training in radiology residency programs: a survey of radiology chief residents

RATIONALE AND OBJECTIVES

Comprehensive training in cardiac imaging during radiology residency is imperative if radiologists are to maintain a significant role in this rapidly growing field. In this study, radiology chief residents were surveyed to assess the current status of cardiac imaging training in radiology residency programs. The responses to this survey may be helpful in understanding current trends in cardiac imaging training and how such training can be improved in the future.

MATERIALS AND METHODS

Chief residents at accredited radiology residency programs were sent an e-mail with a link to a 17-question Web-based survey. The survey assessed the organization of cardiac imaging training in each residency program, imaging modalities incorporated into cardiac imaging training, the role of residents on cardiac imaging rotations, and attitudes of residents about their cardiac imaging training and the future of cardiac imaging.

RESULTS

Responses were obtained from 52 of 112 (46%) programs. Seventy-one percent had at least one dedicated cardiac imaging rotation during their residencies. Fifty-two percent and 62% of respondents reported <5 hours of cardiac imaging-related case conferences and didactic lectures per year, respectively. Most had cardiac computed tomography or magnetic resonance imaging incorporated into their cardiac imaging training. Although 92% felt that cardiac imaging training is important, only 17% felt that they currently received adequate training in cardiac imaging.

CONCLUSIONS

The majority of residency programs represented in this survey had at least one dedicated cardiac imaging rotation for their residents. Most of these programs had few cardiac imaging-related conferences and lectures per year. Although most chief residents believed that cardiac imaging training is important, only a minority felt that they currently received adequate training in cardiac imaging.

Trends in echocardiography utilization in the Veterans Administration Healthcare System

BACKGROUND

There is growing concern over the impact of accelerating use of diagnostic imaging services on health care spending. Echocardiography is an important cardiovascular imaging procedure, but little is known about trends in its use or utilization. We examine trends in the utilization of echocardiography in a national health care system.

METHODS

We used administrative data from the Veterans Healthcare Administration (VA) from 2000 to 2007 to identify patients receiving regular medical care (VA users) or echocardiograms at the VA. We then examined the number of echocardiograms performed each year within the VA and echocardiogram utilization (rates per 1,000 VA users). We examined changes in echocardiogram use and utilization over time and potential overuse of echocardiography.

RESULTS

The number of echocardiograms increased from 92,269 in 2000 to 195,767 in 2007 (a 112.2% increase). Alternatively, echocardiogram utilization remained relatively stable, increasing from 68.8 per 1,000 VA users in 2000 to 71.5 per 1,000 VA users in 2007 because the number of VA users increased by 104.2% over the study period. The mean number of scans per year in echocardiogram recipients remained constant at 1.1/y, and the proportion of recipients receiving multiple scans remained constant at <10%.

CONCLUSIONS

Use of echocardiography in the VA increased dramatically between 2000 and 2007, but utilization rates increased only modestly. Our results suggest that, within the VA, growth in the use of echocardiography resulted from an increase in the number of patients receiving care from the VA on regular basis rather than the performance of a greater number of echocardiograms on a fixed patient population.

Trends in the utilization of medical procedures that use ionizing radiation

Medical procedures that use ionizing radiation have grown rapidly in volume over the last two decades and constitute a substantial portion of the collective radiation doses to the U.S. population. The purpose of this study is to describe the components of this growth. Summarized claims data from Medicare are used to describe trends for the period 1986-2005; supplemental data from other payers and surveys are used for verification and to describe age distributions of those who have these procedures. A notable trend is the rapid growth of CT and nuclear medicine, with CT volume per fee-for-service Medicare enrollee growing, on average, at 8% per y and nuclear medicine at 7% per y during the period 1986-2005. Cardiac procedures-nuclear medicine and interventional radiology-grew at over 15% per y per fee-for-service enrollee during the same period. The share of nuclear medicine procedures performed in physician offices increased from 10% in 1986 to 55% in 2005; the share of CT in the emergency room increased from 3% in 1992 to 17% in 2005. With this expansion in imaging volumes across practice settings, there is an increased need for radiation safety education of ordering physicians, imaging physicians, and patients, so that adequate consideration is given to radiation risk when determining the appropriateness of a prescribed procedure.

Residency training as technology matures a survey of radiology residents' training experiences

RATIONALE AND OBJECTIVES

The aim of the study is to assess radiology resident training experience in cardiac magnetic resonance imaging (MRI), positron emission tomography (PET), obstetrical (OB) ultrasound (US), carotid US, and barium esophagram.

MATERIALS AND METHODS

One hundred eighteen radiology residents completed surveys. Surveys assessed resident year of residency training, hospital size, program affiliation with an academic institution, state, performance of the examinations listed, number of examinations performed per week, and number of weeks spent on rotations for each modality. The study was approved by the institutional review board and was Health Insurance Portability and Accountability Act (HIPAA) compliant. t-Test and chi-square test were performed, and results were analyzed for statistical significance.

RESULTS

Most (94 respondents; 80%) respondents were third-year residents, 101 residents (86%) stated their program was affiliated with an academic institution, 92 residents (78%) performed cardiac MRI, 104 (88%) performed PET, 84 (71%) performed OB US, 71 (60%) performed carotid US (one did not respond), and all performed esophagrams (although one did not respond). Only performance of cardiac MRI and PET correlated positively with a larger average hospital size (P < .01). Residents at an academically affiliated program were significantly more likely to perform cardiac MRI (P < .05). Geographic region significantly affected likelihood of performance of cardiac MRI only.

CONCLUSION

Such factors as hospital size, academic institution affiliation, and geography affect radiology resident training, particularly for such maturing applications as cardiac MRI and PET. This information may be useful in attempts to standardize radiology residency training.

Turf Wars in Radiology: Should It Be Radiologists or Cardiologists Who Do Cardiac Imaging?

In recent years, the cardiac capabilities of computed tomography, magnetic resonance imaging, and to a lesser extent positron emission tomography have rapidly advanced. This has led to contention between radiologists and cardiologists over who should perform and interpret these studies. The authors present the arguments favoring both sides and discuss strategies radiologists should pursue. Although the arguments favoring radiologists are more compelling, this may be an instance in which both sides should work together.