Letters to the Editor

Re: The CARE Bill Dear Editor, In response to the letter to the editor sent by Messrs. Garay, Ishihara, Mashino and Takara (Cath Lab Digest January 2006, page 30) regarding the proposed CARE legislation, we would like to point out that: 1. The CARE bill will not affect Hawaii’s licensure law. The CARE bill requires that persons performing medical imaging and radiation therapy procedures meet federal education and credentialing standards as a condition in federal health programs such as Medicare and Medicaid. State licensure can be used to evidence to the Secretary of Health and Human Services that technologists in a particular jurisdiction meet the federal standard, but it is explicitly stated in S. 2322 (the RadCARE bill passed by the Senate in the 109th Congress) that Nothing in this section shall be construed to prohibit a State or other approved body from requiring compliance with a higher standard of education and training than that specified by this section. Notwithstanding any other provision of this section, individuals who provide medical imaging services relating to mammograms shall continue to meet the standards applicable under the Mammography Quality Standards Act of 1992. 2. PL 97-35, also known as the Consumer-Patient Radiation Health and Safety Act of 1981 (42 U.S.C. 10001-10008), does not set standards for any medical imaging or radiation therapy personnel. Section 10004 directs the Secretary of Health and Human Services to develop standards for the accreditation of educational programs and standards of certification, but does not specify a specific standard to be followed. The 1981 Act also mandates that Such standards shall include minimum certification criteria for individuals with regard to accredited education, practical experience, successful passage of required examinations, and such other criteria as the Secretary shall deem necessary for the adequate qualification of individuals to administer radiologic procedures. Such standards shall not apply to practitioners. The Alliance for Quality Medical Imaging and Radiation Therapy has been working on draft standards since 2000 that will be submitted to the Secretary of Health and Human Services once the CARE bill is enacted. A copy of the draft standards is available for public review at https://www.asrt.org/media/pdf/ DraftRegulations.pdf. 3. The CARE bill does not endorse limited licensure, but recognizes that limited x-ray machine operators are licensed in the majority of states and will set educational and competency assessment standards for such personnel. Currently states that license limited personnel have requirements as lax as watching a video tape on universal precautions and sending in a check. The CARE bill will set higher standards for limited x-ray machine operators. The recommended educational standards are equivalent to the ASRT limited x-ray machine operator educational curriculum and specify between 220 and 250 didactic hours along with 160 to 480 clinical hours of education (depending on anatomical area). The HSRT asserts in its letter that limited x-ray machine operators will get only 2 to 8 weeks of training; however, for a podiatric permit there is a total minimum educational requirement of 380 hours. 4. The American College of Radiology has participated in the development of the CARE bill and the Alliance for Quality Medical Imaging and Radiation Therapy since work began on this initiative in 1998 and continues to work in tandem with ASRT on issues dealing with the technical provision of medical imaging and radiation therapy. 5. The full quote in the November 2006 article in Cath Lab Digest made by Christine Lung states: Any time you are in the legislative process, your initiative or bill is always amendable until Congress passes it and the president signs it. It’s pretty much anyone’s game. However, one of the reasons our bill has been relatively protected and has not had any unfriendly or opposing amendments attached to it is the fact that just about every group that would want to bring an amendment to this bill is a member of the Alliance. The HSRT cannot argue the verity of this comment or its context. 6. S. 2322 (the CARE bill in the 109th Congress) permits the Secretary of Health and Human Services to develop alternate standards for rural areas or health professional shortage areas if he or she determines that alternative standards are appropriate to assure access to medical imaging and radiation therapy. The geographic area must be determined by the Medicare Geographic Classification Review Board to be a rural or health professional shortage area based upon the health care facility’s petition to the Board to classify them as such. According to the Medicare Geographic Classification Review Board’s 2006 determinations, all counties in Massachusetts, New Jersey and Rhode Island are classified as urban areas (https:// www.cms.hhs.gov/MGCRB/Downloads/Rural_Area_List.pdf. The ASRT Board of Directors has enacted sanctions against the Hawaii Society of Radiologic Technologists in response to the HSRT’s active opposition to the CARE bill. Sanctions were a last resort, implemented only after three years of unsuccessful negotiations during which the ASRT Board gave the HSRT many opportunities to adopt a neutral position on the CARE bill. The CARE bill is the ASRT’s principal legislative initiative. The CARE bill has the support of the ASRT House of Delegates, the ASRT’s legislative body. This issue has been discussed many times during the House of Delegates’ meetings and HSRT has always had the opportunity to voice their position on the CARE legislation. HSRT’s opposition to this governing body was one of the factors the Board took into account when it made the decision to move forward with the sanctions. The HSRT is correct in some of its assertions. Yes, there will always be challenges to state laws for medical imaging and radiation therapy personnel. These professions reside in a health care environment that is closely scrutinized and where every penny counts. There will always be challenges from groups that want income for providing services for which they may not be qualified, certified or educationally prepared. However, this type of situation most frequently takes place where no educational or credentialing standards exist to mandate what is required from those best equipped to provide imaging examinations and therapeutic radiation. And yes, there are quite a few organizations that could influence the passage of the CARE bill and/or the standards. That is why the Alliance for Quality Medical Imaging and Radiation Therapy exists; to provide a forum for these organizations to discuss, debate and reach consensus on which legislative approach and regulations best serve the ultimate consumer: the patient. It is unfortunate that the gentlemen representing the HSRT do not understand the intent behind the CARE bill, which is to set enforceable education and credentialing standards for all individuals who perform medical imaging and radiation therapy, not just radiologic technologists. Their continual reference to the 1981 Act evidences that this group does not understand that medical imaging is the new frontier of medicine and no longer the sole purview of radiology or radiologic technology. The reality of 2007 is that medical imaging is part of every medical specialty. The position taken by these individuals representing the HSRT is that the medical imaging organizations making up the Alliance for Quality Medical Imaging and Radiation Therapy are less than the other organizations that they believe will ultimately determine the fate of the CARE bill and ensuing regulations. ASRT does not believe this to be true. The HSRT representatives further assert that some Alliance participants (medical assistants, sonographers, the American College of Radiology and cardiovascular technologists) will oppose an initiative that the Alliance that they all participate in has adopted and endorsed. It’s unfortunate that the HSRT representatives have not made themselves aware of the organizations that have been consulted regarding the CARE legislation such as the AHA, AAPA and ACC. Finally, to answer the question, Will future patients receive the same care that we render to patients now? Our response is no, we truly hope not. The CARE bill will ensure that equitable standards are developed and enforced for not only radiographers or radiation therapists, but for every person who performs, plans and delivers medical imaging and radiation therapy. Ultimately the patients will receive better care than they receive today and will receive even better care as technology inevitably advances. Cindy M. Daniels, M.S., R.T.(R) ASRT President Christine J. Lung, CAE ASRT Director of Government Relations Re: Breath Holds The following letter to the editor from Jack P. Chen, MD, is reprinted from The Journal of Invasive Cardiology December 2006:18(12):642. Dr. Chen joined the Cath Lab Digest Editorial Board in January 2007. Dear Editor, Today’s vast armamentarium of percutaneous coronary interventional devices has both simplified and complicated the procedure. While user-friendly catheters, wires and stents have allowed the seasoned interventionalist to conquer increasingly difficult anatomies, the complexity of these cases has likewise grown. Sometimes, however, a basic maneuver such as breath-holding can be of great assistance. Deep inspiration causes caudal displacement of the diaphragm, resulting in increased distance between a stationary catheter in the aortic root and the heart. This technique is commonly used with clockwise catheter rotation to engage a superior right coronary ostium. Moreover, increased cardio-diaphragmatic separation also allows for a better-defined cardiac silhouette in left ventriculography. During transradial catheterization or intervention, access into the ascending aorta can be problematic in the presence of an acute aortic arch to subclavian artery angle. Through downward displacement of the heart and ascending aorta, a deep breath hold frequently will improve that angulation and allow smooth entry.¹ Relative negative intrathoracic pressure thus created may also aid in drawing the catheter centrally. At times, resistance is encountered during intracoronary device advancement due to inhospitable vessel anatomy, such as tortuosity or calcification, as well as hindrance from previously deployed stent struts. We have found deep inspiration to be quite useful in these situations as well, likely due to the same mechanisms outlined above. Moreover, the caudal cardiac displacement can straighten out vessel anatomy and provide more parallel alignment of the advancing device with the stent lumen to avoid strut entanglement. We have found this technique particularly helpful when difficulty is encountered during advancement of high-profile devices such as the FilterWire EX retrieval catheter, both straight and angled (Boston Scientific Corporation, Natick, Massachusetts); the Export thrombectomy catheter (Medtronic Corporation, Minneapolis, Minnesota); as well as a new stent through an existing stent. Thus this familiar, simple maneuver should not be forgotten as a useful addition to techniques and equipment such as the buddy wire and Wiggle Wire when obstacles are encountered. For this reason, we prefer to administer only light sedation during our cases. As an added benefit, we have found that patients frequently like the idea of active participation in their treatment. Jack P. Chen, MD Northside Cardiology, P.C. Atlanta, Georgia E-mail: chenjackapollo at yahoo.com The author discloses no conflict of interest regarding the content herein.

1. Babunashvili AM. Difficult access into ascending aorta in cases of tortuosity of brachiocephalic and subclavian arteries. Radialforce.org 2006.