Advanced Imaging`s Impact On The Cardiac Catheterization Lab Will Depend Upon Philosophy

Development of new and effective technological innovations creates demand by the consumer and the physician. Until recently, the option to have a dynamic view of the coronary and vascular systems by a noninvasive technique seemed unrealistic. Advanced imaging (AI) of computed tomography (CT), magnetic resonance (MR), and positron emission tomography (PET) gives us a glimpse into the future relative to truly addressing the number-one killer of both men and women cardiovascular disease. The current limitations for the widespread use of AI are the availability of technology and trained physicians and technicians, and the continuing rapid evolution of technology paired with the lack of reimbursement and acceptance as the standard of care. The impact of these noninvasive modalities cannot be underestimated, as demonstrated by the impact that these modalities have had on the diagnosis of cancer and the increasing use of MR for the diagnosis of vascular disease rather than angiograms. When used effectively, the cardiac catheterization lab becomes an even more crucial and vital access point to treat cardiovascular disease early in the disease process, and thereby reduce the length of stay and patient acuity. The efficient utilization of the catheterization lab is especially critical as we begin to look at the aging of the population, cost of health care, lab capacity when vascular disease is considered, and the shortage of physicians, especially cardiologists. Before looking at a hypothetical case study, several key questions will need to be answered. Will these new modalities completely replace the catheterization lab? No. Advanced imaging is not seen as replacing the catheterization lab in the next 10 to 15 years. The focus of the catheterization lab, however, will shift to longer interventional procedures-angioplasty and stents, along with new technology that will evolve. Eventually, AI will reduce catheterization lab diagnostics. It is in those labs where cardiologists view AI as a replacement for diagnostic catheterizations as well as in those programs with a high rate of normal catheterizations or repeat patients that volumes can have the most severe consequences. Can advanced imaging increase access and interventions? Most likely. Advanced imaging has the potential to increase volumes if it is truly embraced as a screening tool, similar to mammography, with follow-up every couple of years based on the person's history and risk factors. The limiting factor will be the cost of equipment, availability and access to equipment, along with the willingness of the payers to support AI utilization in order to reduce the long-term cost for treatment of cardiovascular disease, and the public's embrace of and demand for the technology. Are there opportunities to minimize the impact on the catheterization lab? Definitely. Many labs already have a wait-list for procedures. The new technology will eliminate the backlog for diagnostics. The capacity created will be filled by interventions. Programs have already begun to focus on vascular procedures and have begun to expand electrophysiology capabilities. In order to be successful and to be prepared for changes, particularly with respect to the treatment of vascular disease with technology such as stent grafts, new catheterization suites that are developed should have an endovascular focus with capabilities for cardiac and vascular procedures. Hypothetical Case Study. Now that an overview has been provided, the following case study illustrates the potential impact to a full-service program. Current program. Hospital ABC is a full-service program with two dedicated cardiac catheterization labs. The service area population is 200,000. The utilization of the catheterization lab mirrors the national average, with a cardiac catheterization rate of 11 diagnostic caths per 1,000 population (50% inpatient and 50% outpatient), and an intervention rate of 32% of cardiac catheterizations. Heart surgery is 13% of catheterizations. The current volumes are shown in Figure 1. Philosophy of advanced imaging as substitute for coronary diagnostics. Hospital ABC installed a dedicated AI modality. The physicians and payers embrace it as a viable alternative to catheterization. The utilization remains the same with the exception that 75% of outpatient caths will be performed with the use of AI. The volume change is shown in Figure 2. Philosophy of advanced imaging as a screening tool to annually reach a conservative 5% of the population with cardiac disease. Hospital ABC installed a dedicated AI modality and the physicians and payers embrace it as an adjunct to cardiac catheterization and a true screening tool. The catheterization volume decreases 20% to account for postprocedure follow-ups and normals. The overall volume is offset by the increase in interventions and heart surgery. The potential volume change is shown in Figure 3. The opportunity: Development of the true endovascular suite. Realizing the potential impact on the lab as shown in Figure 3, Hospital ABC focused on cardiac and vascular disease within the program and has installed a suite that is capable of cardiac and vascular procedures. The volume potential impact is seen in Figure 4. Conclusion: AI will impact the cardiac catheterization lab in the future. However, programs do have some control over the level of impact and will need to work with the physicians in order to meet the needs of the community. Factors such as the aging of the population, cost and payers, physician use, physician availability, and integration of vascular therapies and AI availability will ultimately influence the effect on the catheterization lab. While the overall impact of AI on the catheterization lab is one of wait and see over the next two to five years, hospitals and catheterization labs must embrace new technology and be leaders in the field in order to effectively treat heart and vascular disease. Email: CWeaver@jga-net.com

1. American College Of Cardiology/ American Heart Association Expert Consensus Document, American College of Cardiology Expert Consensus Document On Electron-Beam Computed Tomography For The Diagnostics And Prognosis Of Coronary Artery Disease, June 2000.

2. American Heart Association, Heart Disease And Stroke Statistics - 2005 Update, Dallas, Texas: American Heart Association; 2005.

3. Bronson, JG. Cardiac CT: Faster Scanners Deliver New Capabilities. April 14, 2005, http://www.imagingeconomics.com.

4. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention/National Center for Health Statistics, 2005, Hyattsville, Maryland.

5. Haugh, R. The Rise And Uncertain Future Of Cath Labs. April 14, 2005, http://www.hhnmag.com.

6. Jersild, S. CT Angiographers Predict Widespread Reimbursement. April 14, 2005, http://www.diagnosticimaging. com.

7. John Goodman and Associates, Inc. Proprietary Data, 2005.

8. Knapkik, ML. Positioning Your Catheterization Laboratory to Survive the Push for Noninvasive Diagnostics. J Cardiovasc Mgmt March/April 2005; 16(2):12-14.

9. Morgan, E. Cardiac Imaging: We Got The Beat. April 14, 2005, http://www.medicalimagingmag.com.

10. Society for Cardiovascular Angiography and Interventions, Cardiac CT and CT Angiography: Focused Training for Cardiologists. April 14, 2005, http://www.scai.org.

11. White, RD. New Innovations, Cardiac Imaging: Integrated, Applications-Driven Use of MRI and CT. April 14, 2005, http://www.clevelandclinic.org.

12. U.S. Census Bureau, 2004. Interim Projections by Age, Sex, and Hispanic Origin. April 15, 2005, http://www.census.gov.