Understanding Your Nuclear Medicine Stress TestPosted on: 06.21.18
Myocardial Perfusion Imaging, also called a Nuclear Stress Test, is used to assess coronary artery disease, or CAD. CAD is the narrowing of arteries to the heart by the build up of fatty materials.
CAD may prevent the heart muscle from receiving adequate blood supply during stress or periods of exercise. This frequently results in chest pain, which is called angina pectoris. Perfusion imaging usually consists of stress and rest tests.
Images are taken of your heart while at rest and after exercising or under stress. The comparison allows your physician to evaluate blood flow under different levels of exertion. After the images are reviewed, they’ll meet with you to discuss the results.
Normal or abnormal, what does it mean?
A normal test result indicates there is sufficient and unrestricted blood flow to your heart, both during periods of rest and exercise. Generally, there’s little concern for coronary artery disease and, in most cases, you won’t require any further testing.
An abnormal result, which means your heart’s blood flow is insufficient, may occur only during the exercise phase of your stress test. During rest, your blood flow may be normal, but during strenuous activity, when your heart is working harder, it may not be getting the blood supply it needs. It’s likely that there is some level of coronary artery disease or blockage.
An abnormal result in both phases of your stress test is an indication that your heart’s blood flow is poor, regardless of your exertion level. The restricted blood flow suggests significant coronary artery disease. If your stress test images show areas of the heart that are not highlighted with the radioactive isotope, it may also be an indication of scar or damaged tissue caused by a previous heart attack.
Regardless of the results, your doctor will explain the findings and address your concerns. If necessary, they’ll recommend a treatment plan that can potentially improve or better manage your heart’s function.
Seven mistakes to avoid when choosing between a new and refurbished nuclear cameraPosted on: 04.26.18
With the continual advancements in healthcare technology and service, investing in your cardiac practice, upgrading equipment, and improving efficiency is an ongoing process. One of the most significant considerations is not only when to replace a camera, but also if refurbished, or new equipment might be a better decision.
It’s important to take the time to look beyond your immediate imaging needs and consider the long-term goals of your practice. Both refurbished and new camera systems come with advantages, but be sure to consider these factors before signing on the dotted line:
1. Focusing only on purchase price vs. the long-term cost of ownership
A nuclear gamma camera is a significant investment for any practice, so it’s natural to focus on the cost. There are times when prioritizing price is a smart idea, but only when the product still retains an acceptable level of value. There are many refurbished cameras that have a considerable amount of life left and could be a wise investment.
When you evaluate new versus used equipment, consider how much image quality has improved in recent years, the availability of new software programs, and the viability of the camera’s current operating system. When the camera is in need of repair, will parts be readily available and will the manufacturer agree to service it? Some manufacturers include a firm end-of-service date on their equipment, which leaves you at the mercy of third-party service providers and replacement parts. Some service companies may even decline service because of age, limited part availability, and the associated risk.
2. Overlooking the ability to maintain image quality
Older, refurbished cameras may undoubtedly be in working order, but their boards and analog methodologies could be less effective. With age, the camera’s light pipe, which includes crystals that eventually yellow and crack, will no longer respond, sometimes without warning. Replacement crystals for older cameras may not be available. Even with newer refurbished cameras, the crystals have already aged, may be hydrated, and are potentially unfixable. Be sure to inquire about and examine the crystals if you’ve considering a refurbished camera.
3. Putting your HIPAA compliance at risk
Another important factor to consider is HIPAA compliance. Many refurbished cameras cannot be upgraded to current software versions, and, because they’re no longer supported by the manufacturer, they can’t they be patched securely. Consequently, the camera cannot be connected to a network because internet access imposes new risks. You also may not be able to add additional processing programs and, in the end, may be forced to purchase an entirely new software package, which will be costly.
4. Not factoring in the credit rating of the practice
While many physicians may have excellent credit, they may not be willing to put their personal credit history on the line when purchasing capital equipment such as a nuclear gamma camera. Instead, they opt to leverage the business credit, and this can have a direct impact on the approval process and interest rate.
If the practice does not have an extensive credit history, it’s more challenging to secure a loan, and interest rates are likely higher on pre-owned equipment. Additionally, if a financial institution feels that you may have issues with part availability on refurbished systems, they may be hesitant to approve a loan for older medical equipment. Be sure to discuss the details and get loan pre-approval before the sales process begins.
5. Failing to consider the true patient volume
Volume is another important factor to evaluate when deciding between used or new equipment-or even whether to outsource your imaging services completely. Not all cardiac practices need a camera on site five days a week. If you’re imaging one, two, or even three days a week, you might consider partnering with a mobile imaging company.
Your volume should factor into your financial investment. Without it, the lack of revenue wouldn’t warrant spending dollars on maintenance costs and might eventually lead to a decline in the integrity of the equipment.
6. Purchasing camera that offers limited use
Any new or used camera that you plan to purchase should be able to expand and grow with your practice. A camera should be able to fill your current imaging needs, but also serve your practice in other ways. Would it lend itself to increased productivity, improved efficiency, and greater patient satisfaction? Sometimes it may be worth the extra investment if it allows you to move forward on another strategy that has the potential to increase revenue or to reach other goals.
7. Not performing your own due diligence
Lastly, knowing from whom you’re purchasing your equipment is of critical importance. An investment of this size should only be made through a reputable company with a proven track record, especially if it’s a refurbished camera. Prepare a due diligence checklist and take the time to get better acquainted with the camera, just as you would with a home, used car, or any other purchase in the second-hand market. Ask to see it, or have it inspected by an independent service company, and ask for the repair and maintenance records.
It’s well within your rights to investigate the camera’s history, current value, and the likelihood of any future issues before making a final commitment. If you don’t, you’re exponentially increasing your chance of winding up with a lemon and having no recourse.
Cost shouldn’t be the only consideration when buying a camera. It may be high on your list, but the value it brings to your practice should be well worth the money you spend.
PET/CT Imaging New Tracer GuidePosted on: 03.30.18
The landscape of PET/CT imaging is rapidly changing. Traditionally, physicians have used a sugar based radiopharmaceutical, 18Fluorodeoxyglucose or 18FDG, to perform the majority of PET/CT imaging. Over the past 20 years, this imaging agent was the only option available to many facilities across the United States.
Recent breakthroughs in research, reimbursement, and radiopharmaceutical manufacturing have made it so that physicians and patients will begin to have access to medicine that is designed for their unique situations.
RECENTLY APPROVED TRACERS
Axumin (18F-Fluciclovine) is indicated for PET imaging in men with suspected prostate cancer recurrence based on elevated blood prostate specific antigen (PSA) levels following prior treatment.
Mechanism of localization
It has been found that there is an over expression of amino acid transporters in certain cancer cells. This overabundance of amino acid transporters is typically easier to identify among normal, healthy tissue than traditional imaging methods. The body recognizes this drug as an amino acid and actively transports it to potential areas of concern.
Why look into this radiopharmaceutical?
- Axumin allows healthcare providers to pinpoint the overexpression of amino acids associated with prostate cancer.
- Increased visualization of the prostate bed— no bladder interference during imaging, as with traditional 18FDG.
- PET imaging with Axumin can lead to quicker detectionof tumors. Other imaging methods rely on physical (structural) changes in the body for tumor detection, whereas Axumin detects changes on the physiological (cellular) level, which can occur weeks, even months quicker than physical changes.
Prescribing information and use
- A standard 10 mCi dose of 18F-Fluciclovine is provided
- Patient is injected and imaged immediately
- Exam takes less than 30 minutes from start to finish
Axumin is a great tool for visualizing the prostate bed which can be challenging using traditional methods.
NETSPOT (68Ga-Dotatate) is indicated for use withPET for localization of somatostatin neureceptor positive neuroendocrine tumors (NETs) in adult and pediatric patients.
Mechanism of localization
68Ga-Dotatate binds to somatostatin receptors, with highest affinity for subtype 2 receptors (sstr2). It binds to cells that express somatostatin receptors including malignant cells, which overexpress sstr2 receptors.
Why look into this radiopharmaceutical?
Improved image quality over the traditional Gold Standard
The Gold Standard method of imaging NETs has traditionally been an Octreotide scan
- Often times leaves physicians without answers
- Takes up to a week to acquire the entire exam
- Results are only qualitative
- Results are conclusive
- Improved patient satisfaction: no bowel prep needed or dietary restrictions, 3 hours to complete examination
- Results are quantitative and qualitative
The FDA has recently approved a therapy for NETs that uses the same Dotatate as the PET imaging agent and replaces the 68Ga with 177Lu. The theranostic (see it, treat it) approach to treatment has finally become a reality!
Prescribing information and use
- A patient specific, weight based dose of 68Ga- Dotatate is provided
- Patient is injected and imaged at 40-90 minutes post administration
- Must be off somatostatin receptor blocking agents
Same Patient— Different Outcome
A) Standard imaging using Octreotide
B) Improved tumor visualization and treatment planning using 68Ga-Dotatate
- Adults with cognitive impairment who are being evaluated for Alzheimer’s disease and other possible causes of cognitive decline
- Currently 3 approved PET/CT imaging agents areavailable: Neuraceq (18F-Florbetaben), Amyvid (18F-Florbetapir), Vizamyl (18F-Flutemetamol)
Mechanism of localization
- There are many studies that demonstrate a relationship between increased β-amyloid plaque and Alzheimer’s disease.
- The radiopharmaceuticals bind to this β-amyloid plaque.
Why look into this radiopharmaceutical?
- Until recently, there was no way to image the presence of the physiological changes associated with Alzheimer’s disease:
- A positive scan indicates an increase β-amyloid plaque which is consistent with AD and other cognitive disorders: To be used in conjunction with other neurological testing to establish a diagnosis
- A negative scan indicates that there is a low amountof β- amyloid plaque which is inconsistent with a neuropathological diagnosis of AD
- Helps to rule out the possibility of AD
Prescribing information and use
- Each radiopharmaceutical has its own prescribing and dosing information
- Patient is injected and imaged
- Entire exam takes less than 90 minutes from start to finish
- Cancer—most common
- Infection & inflammation
- Viable myocardium (cardiac)
- Brain – seizure, epilepsy, Alzheimer’s disease, dementia, tumors
Mechanism of localization
18Fluorodeoxyglucose (18FDG) is a sugar molecule that concentrates in areas of high glucose metabolism. Healthcare providers are seeking to determine whether there is an abnormal amount of uptake of this tracer in a particular area of the body which may be indicative of a particular health concern.
Why look into this radiopharmaceutical?
This is the most widely used imaging agent in the world of oncology. Many referring physicians are familiar with this drug and its applications for oncologic purposes. It is generally accepted as the drug to use for most cancers.
Many physicians and facilities are not familiar with the other indications and usages of this imaging agent. Examples include: Viable myocardium—this drug can be used to determine what sections of the heart are still viable and have living, functioning cells.
Brain – Many times, 18FDG can add valuable information that a neurosurgeon needs prior to surgery. Functional changes occur much earlier than physical changes—PET/CT images often compliment CT or MRI images.
This radiopharmaceutical is most commonly used to identify cancers of the bone or cancers that have metastasized (spread) into the bone. The Sodium 18Fluoride (NaF18) ions are deposited directly into the bone matrix and bone surface. Common sites are newly mineralized bone, such as during growth, infection, malignancy (primary or secondary), after trauma, or during inflammation.
Why look into this radiopharmaceutical?
This drug is much better at targeting skeletal activity than FDG and provides a much clearer image than traditional nuclear medicine bone scans. These 3D images are also quantitative which allows physicians to precisely measure the activity within a lesion – allows for a more accurate interpretation of the response to treatment.
Prescribing information and use
- The imaging agent is ordered and delivered for each specific patient
- There is no patient prep
- Patient is injected and imaged
- Entire exam takes roughly 90-120 minutes
Intraoperative benefits of Ergo touted in the Journal of Pediatric SurgeryPosted on: 03.15.18
The portability of the Digirad Ergo Imaging System is making a significant impact in the pediatric oncology world. The Journal of Pediatric Surgery recently published an article on its intraoperative use. Most notably, it reported on how nuclear imaging with the Ergo effectively reduces the time under anesthesia and offers real-time confirmation of lesion removal. Digirad recently spoke with Dr. Marcus M. Malek of Children’s Hospital of Pittsburgh of UPMC, to further elaborate on the study.
Single environment reduces time under anesthesia
In order to guide lymph node biopsy, pre-surgery lymphatic mapping is done via lymphoscintigraphy. Adults and teens are generally able to tolerate the procedure while awake. It does, however, involve an injection and the need to remain still, which can often be difficult for a child. For that reason, young pediatric patients, and some adults for that matter, are sedated and mapped in the nuclear medicine suite and then transported to the operating room. The additional step takes a considerable amount of time and coordination, which leads to downtime in the OR.
The portability of the Digirad Ergo allows the patient to be anesthetized while they’re in the operating room. Prior to the start of the surgery, the nuclear medicine technologist or physician injects the radiotracer in standard fashion. After the tracer has moved to the area of interest, the Ergo acquires the images needed for the lymphoscintgraphy. Once the sentinel nodes are marked and the area is prepped, the surgery can begin without delay. When the procedure and the surgery are done in one environment, it’s safer for the patient, spares them additional time under anesthesia, and alleviates the need for transport.
Visual confirmation in real-time
Beyond reduced anesthesia time, a camera in the operating room allows the surgeon to confirm the lesion of interest has been removed in real time. Certainly, a preoperative lymphoscintigraphy can help with mapping, but it cannot visually confirm the lesion’s removal. The Ergo allows confirmation of lesion removal or, in some cases, identification of lesions that were thought to be removed or hidden behind another. Visual representation is a fail-safe that ultimately improves surgical outcome.
In the past, some have equated portability with lower quality images, but the Digirad Ergo doesn’t trade one benefit for another. It delivers high-quality images that technologists say rival any static nuclear camera and its compact, portable design offers maximum clinical versatility.
Read the full article, Use of intraoperative nuclear imaging leads to decreased anesthesia time and real-time confirmation of lesion removal , at the Journal of Pediatric Surgery.
Move from HEU to LEU Nearing Completion in the United StatesPosted on: 03.08.18
Technetium (Tc-99m), the decay product of molybdenum-99 (Mo-99), is an essential component in cardiac nuclear imaging. In the past, the primary source for this radioisotope was highly enriched uranium (HEU), but market dynamics and legislative action have changed that. The last five years have seen a sustained move to low-enriched uranium (LEU), and the United States is expected to be fully transitioned to LEU by the end of 2018.
The Call for Change
The American Medical Isotope Protection Act of 2011 was enacted to not only promote the domestic production of molybdenum-99, but to replace the role of HEU in the production of medical radioactive isotopes.
Uranium is considered highly enriched when the concentration of the U-235 isotope exceeds 20%. If the proportion of U-235 is less than 20%, it’s categorized as low enriched uranium (LEU).
In an effort to reduce the amount and potential misuse of HEU, the Department of Energy promoted an initiative to reduce the dependence on HEU in the United States. Reactors around the world responded and have been moving toward the conversion from HEU to a process that uses LEU.
What the Move from HEU to LEU Means for Nuclear Imaging
The final product, Tc-99m, remains exactly the same regardless of the source material. There is no difference in the quality or effectiveness – only the raw material processed by the radiopharmacy. Both LEU and HEU approaches result in the same isotope with equivalent performance.
Even though there have been changes in the production process, nuclear medicine providers will not be affected by the shift. The availability of isotopes sourced from LEU generators is steadily increasing as the conversion continues throughout 2018.
U.S. manufacturers who produce Technetium-99 generators, and supply the radiopharmaceutical industry, are in full support of the conversion and are establishing a steady supply of radioisotopes derived from LEU sources. Although some feared that the shift would increase isotope prices, it appears that much of the conversion costs have already been factored in, and no dramatic increases are expected.
Ultimately the move from HEU to LEU will result in a more stable market and reliable supply of Tc-99 which is positive for the entire industry.
Diversified Molybdenum-99 Production Easing Supply ConcernsPosted on: 02.22.18
In recent years, there’s been a heightened focus on the supply of Molybdenum-99, the radioisotope used in nuclear diagnostic imaging. Previous regulatory and capacity issues have caused shipment delays, but today the outlook for molybdenum-99 supply has never been stronger.
Reactors step up production
One unlikely catalyst for the turnaround has been the closing of Canada’s National Research Universal (NRU) reactor in Chalk River, Ont., in 2016. At its closing, Chalk River produced nearly 30% of the world’s supply of molybdenum-99. The nuclear medicine community feared that the shortfall would jeopardize the supply.
Not only did the remaining world reactors in Europe, South Africa, and Australia more than fill the deficit left behind by the closing of Chalk River, an additional three reactors have come online, which has further strengthened the radioactive isotope’s supply.
The more stable supply can also be attributed to diversification. With almost one-third of the world’s supply produced by Chalk River and another significant portion from the High Flux Reactor in the Netherlands, any prolonged breakdown of the remaining worldwide reactors would cause disruption on the supply chain. Now, with the supply diversified across many more reactors, one reactor’s supply issue is less likely to cause a global impact.
Radiopharmacies and diversification
Radiopharmacies are also working smarter and using diversification to their advantage. Maintaining multiple relationships among suppliers allows them to minimize any potential service disruptions. If one reactor source suffers an extended setback, a well-positioned radiopharmacy can leverage the diversity they’ve created in their supply chain to continue providing reliable service and delivery.
In order to hedge against the impact of one reactor’s shortage, it’s critical for nuclear medicine departments, cardiology practices, and other consumers of radiopharmaceuticals to make sure their radiopharmacy partner has a diversified supply chain.
Exclusivity with one supplier may offer the most advantageous pricing. However, diversification opens additional doors and allows you to sidestep a shortage without interruption. In the molybdenum-99 supply chain, each cog in the wheel must run smoothly. When one breaks, those providers who have diversified their sources will be able to adjust while others who have exclusive contracts may not.
If you’re negotiating a radiopharmacy contract, it’s also prudent to protect yourself with a serviceability guarantee. This performance clause will allow you to exit the contract if your supply needs cannot be filled due to lack of diversification.
The future of isotope production
Diversification has proven to help successfully and effectively manage the delicate supply and demand of molybdenum-99. But, as we move forward, the industry is also looking at domestic sources of production that would not only increase availability in the United States, but also alleviate the time and travel challenges that come with crossing international boundaries.
While the supply chain is strong and the industry is continually working to mitigate any potential supply challenges to customers and the marketplace as a whole, there’s always room for improvement. Pursuing domestic production, new methods and improved technologies are sure to positively impact the future of isotope production.
ASNC 2017 Year in Review by Raymond RussellPosted on: 02.01.18
In 2018 ASNC will be celebrating their 25th anniversary. As the year began, ASNC’s 2017 President, Raymond Russell, wrote an excellent post to Members looking back at the achievements of 2017. Digirad values the role ASNC plays in Nuclear Cardiology, and we look forward to collaborating with ASNC in the new year. Here’s Dr. Russell’s post:
It is hard to believe that the year is over-it has gone by in a blink of the eye. However, during that eye blink, the members and staff of ASNC have done an incredible amount of work to support the appropriate use of nuclear cardiology that helps improve the care of our patients. I am proud to have been given the honor to represent ASNC as president and work alongside the talented and hard-working individuals that make up ASNC. I would like to share with you the many accomplishments we have achieved in 2017 and my hopes for a healthy, prosperous, and peaceful 2018 for all.
17: Sharing Knowledge with Referring Health Professionals
ASNC continues to be welcomed at forums across the United States where attendees are seeking knowledge and insight to optimize appropriate referrals for cardiovascular imaging to ensure that patients are neither over- or undertreated. At the 50th anniversary conference of the American Academy of Physician Assistants, ACP.17, ASNC launched the Refer Wisely program, hosted an event that drew more than 280 attendees and positioned its booth as a hub for discussion about primary care professionals’ understanding of relevant appropriate use criteria.
16: Making MIPS Manageable
ASNC continues addressing MACRA and the move toward value-based healthcare on multiple fronts. Society volunteers and staff are in constant communication with government officials, advocating for simple, streamlined policies that will actually serve to improve patient care and outcomes. ASNC is developing a suite of tools to ease the challenges imaging professionals will face as new policies are enacted. The ImageGuide Registry has emerged as an unbeatable tool for meeting MACRA’s Merit-based Incentive Payment System (MIPS) requirements and avoiding reimbursement penalties. Enrollment in ImageGuide – now designated by CMS as a Qualified Clinical Data Registry for the fourth consecutive year – gives facilities access to benchmark data that are invaluable for improving the program quality while fulfilling MIPS reporting obligations. ASNC members are invited to enroll their facilities in ImageGuide Registry at no cost. The complimentary webinar, “Fulfill MIPS Requirements with ImageGuide Registry” explains how it works.
15: ASNC Across the Globe
In 2017, ASNC continued to grow its international presence as ASNC co-sponsored educational programs at meetings in Canada, Japan, Mexico, Portugal, Saudi Arabia, and Spain. ASNC members were invited to present at meetings in Argentina, Austria, Brazil, Chile, China, Cuba, Mexico, and Spain. Almost 10% of the ASNC membership’s practice in 64 countries. ASNC and IAEA hosted its first webinar delivered entirely in Spanish “Elaboración de un informe de cardiología nuclear con SPECT o PET,” it featured Erick Alexanderson, MD, and Fernando Mut, MD. 125 physicians and scientists attended the session. ASNC-IAEA also held its first Arabic/English Webinar entitled “Nuclear Cardiology in the Arab World: Challenges and Opportunities”
14: ASNC Secures AUC Program Delay until 2020
ASNC led an advocacy effort composed of multiple physician stakeholder groups calling for indefinite delay of the AUC Program while its value and necessity were evaluated in the context of the Quality Payment Program (QPP). By delaying the program in the Final Rule, CMS is acknowledging that it agrees with commenters that the goals of the QPP are consistent with those of the AUC program. CMS has delayed the effective date of the Appropriate Use Criteria (AUC) Program to Jan. 1, 2020.
13: Achieving New Heights with ASNC Education
ASNC has received the highest level of recognition, Accreditation with Commendation, from the Accreditation Council for Continuing Medical Education (ACCME). Accreditation with Commendation is awarded to CME providers that demonstrate compliance in all aspects of accreditation requirements and for demonstrating exemplary engagement with the environment in support of physician learning and quality improvement. ASNC demonstrated compliance with all 22 of ACCME’s accreditation criteria through a system of reporting for each and all of its 35 to 45 CME activities hosted each year, including live programs, enduring materials, journal CME, manuscript CME review and online learning reaching an average of more than 6,000 physicians annually. ASNC thanks its leaders, Education Committee members and Chair Donna Polk, MD, MPH, FASNC, program directors, Journal of Nuclear Cardiology CME editor and editor in chief, and staff for ensuring excellence in the Society’s educational initiatives.
12: Boosting JNC’s Impact Factor
The impact factor for ASNC’s esteemed Journal of Nuclear Cardiology climbed to its highest point since it was founded 24 years ago, a full point above its 2015 score. JNC now ranks 17th out of 126 current journals, up from the 27th position, in the Radiology, Nuclear Medicine and Medical Imaging category. JNC also jumped several positions in the Cardiac & Cardiovascular Systems category, from 49th to 38th.
11: ASNC in the Heart of America
There were a number of firsts at ASNC2017. ASNC’s annual meeting was held in Kansas City, Mo. for the first time. Physicians from 58 developing countries were able to access select ASNC2017 sessions as part of a livestreaming initiative supported by the International Atomic Energy Agency (IAEA) and ASNC2017 welcomed several new speakers and the Mayor of Kansas City. MOC points were offered for the attending the live annual meeting and the live Board Prep Course for the first time. Focus for last year’s meeting was disease-based sessions and peer networking. Check out ASNC2017 photos. Save the Date for ASNC2018 in San Francisco, Sept. 6-9!
10: Announcing Category III Code for Myocardial Blood Flow
As 2017 drew to a close, ASNC was pleased to announce that a new category III CPT code for Absolute Quantitation of Myocardial Blood Flow in PET would go into effect on Jan. 1, 2018. The new code is 0482T – Absolute quantitation of myocardial blood flow, positron emission tomography, rest and stress. Category III codes are important tools that help to substantiate utilization and clinical efficacy.
9: Improving Imaging in Women
ASNC advanced its mission of optimizing cardiovascular outcomes with two new resources focused on female patients. The latest ASNC consensus statement, “Myocardial Perfusion Imaging in Women for the Evaluation of Stable Ischemic Heart Disease: State-of-the-Evidence and Clinical Recommendations,” outlines themes that support effective imaging in women and has been heralded as an important step toward precision medicine. ASNC also teamed up with MedPage Today to produce “Women with Suspected Ischemic Heart Disease: What Is the Best Diagnostic Approach?”
8: Achieving a Better National Coverage Decision for Cardiac PET
ASNC led a multi-society advocacy effort to remove prerequisite language for cardiac PET coverage in a local coverage policy. ASNC successfully advocated that the local policy should be aligned with the less onerous national coverage policy.
7: Expanding Your Imaging Toolbox with ASNC Practice Points
ASNC members have access to a growing database of Practice Points and other resources designed to help medical professionals select the best tests for each patient. 2017 saw the addition of a new downloadable Practice Point that distills key take-aways from ASNC’s 2016 Stress Protocols and Tracers Guideline. The Practice Point offers a clear, concise outline of indications, action mechanisms, procedural guidance, contraindications and test limitations for exercise stress testing as well as pharmacologic stress testing with adenosine, dipyridamole, dobutamine and regadenoson.
6: Expanding the ImageGuide Registry to Include Echo
ASNC and the American Society of Echocardiography (ASE) announced at ASNC2017, a partnership to develop an ASE Echocardiography Module, ImageGuideEcho™. This new module will allow the registry to support both nuclear cardiology and echocardiography laboratories as well interpreting physicians, technologists and sonographers from both fields. ImageGuide’s Qualified Clinical Data Registry (QCDR) designation from the Centers for Medicare and Medicaid Services combined with these new echocardiography performance measures will increase the registry’s value as a tool for meeting Merit-based Incentive Payment System (MIPS) requirements.
5: Announcing $50K in Research Fellowship Funding
ASNC and the Institute for the Advancement of Nuclear Cardiology (IANC) are inviting early-career nuclear cardiology investigators to apply for $50,000 in research project funding. The IANC Research Fellowship Award was established in 2017 to encourage and support careers in nuclear cardiology research while growing the science of cardiac imaging and advancing the specialty. The competition is open to most trainees, including post-doctoral fellows and junior faculty who intend to pursue academic careers in nuclear cardiology research. Submit your application for a chance to win funding to support your research, or share this opportunity with your colleagues. Please note: All applications must be received at ASNC headquarters by Jan. 31, 2018.
4: Just Starting Out
CareerStarter, a quarterly publication provides helpful tips to physicians starting their careers from those of us who have weathered those early steps. The CareerStarter newsletter has several focus areas: “JumpStart”–articles on key career hurdles, including employment negotiations and contracts. “Tips for FITs” (advice from mid-career ASNC members to help those at earlier phases of their career), “Freebies & Deep Discounts” (current best deals for education, networking and career advancement in nuclear cardiology)
3: Seek and You Shall Find
Continuing to be a resource for young professionals in the field, the nuclear cardiology community now has a new career-advancement tool! The ASNC Career Center, launched this past Fall and is a comprehensive resource for job-seekers and employers. Users will find job postings and will be able to add their own resumes, making it easy for employers and nuclear cardiology professionals to forge connections. Organizations seeking quality candidates are invited to post positions-at the ASNC member discounted rate!
2: 4,300 and Counting
ASNC continued its upward trend of new and returning memberships, achieving its strategic goals and ensuring that cardiovascular patients receive optimal imaging care this year, especially with our early-career/Fellow-In-Training members. There were more than 650 new members who joined ASNC in 2017, making this year’s total number of memberships the highest it’s been in the last 5 years! Thanks to ASNC’s Membership Committee chaired by Randy Thompson, MD, FASNC, and to every one of ASNC’s 4,300+ members for joining in our effort to lead the field and support education, advocacy, quality and professional development. Become an ASNC member
1: ASNC turns 25!
With the arrival of 2018, ASNC marks 25 years of supporting the nuclear cardiology community – its patients, professionals, partners and friends. We’ve launched a year-long celebration of our silver anniversary, so stay tuned for special communications that will highlight past accomplishments, provide access to special resources and opportunities and test your ASNC knowledge!
Raymond Russell, MD, PhD, MASNC
2017 President, ASNC
Is a single-head camera acceptable in today’s market?Posted on: 01.25.18
As nuclear cardiac imaging technology has evolved, gamma cameras have graduated from single-head to multiple-head detector technology. Although single-head SPECT cameras are not necessarily obsolete, there are an increasing number of drawbacks if you choose to continue using it to diagnose cardiac patients.
Dual-head cameras reduce scan time by half, simply because there are two heads. Each rotation is only 90 degrees compared to a single-head that is responsible for the full 180 degrees. A triple-head camera can complete a scan in about one-third of the time of a single-head camera.
The popularity of Gated SPECT
In years past, higher vs. lower volume dictated the need for a single or dual-head camera. But, as technology evolved, gated SPECT (GSPECT) became state-of-the-art and grew into one of the most frequently performed procedures in nuclear cardiology. The additional combined minutes of scan time needed to gain enough count density was significantly improved with a multi-head camera.
Nuclear medicine is, by all counts, a low statistic science. Anything done to lower the statistic results in an inferior image, and consequently, anything done to increase the statistic improves the image. The goal is to use as little dosing or time as possible to reach the medical diagnosis. By using a multi-head camera, you may increase the total counts per stop, thereby improving the counting statistics with a significantly shorter total scan time and/or lower dose, resulting in a better image.
From the patient’s perspective
Time is not only relative to the procedure and your overall volume, but it’s also important to patients. A higher quality outcome completed in less time leaves the patient with a better overall experience. It also allows them to be more compliant during the scan. A patient who can remain still results in a better image than one from a patient who moves, even if the image is motion corrected. In fact, the correction itself can create artifacts. Consider the practicality, too. When a patient is uncomfortable or in pain, a procedure that finished even five minutes sooner could make a world of difference.
Improving your single-head camera
Over the last decade, advanced reconstruction algorithms, like Digirad’s nSPEED™, have been developed to mathematically improve statistics. Today, if your single-head camera doesn’t include the algorithm, you can invest in a software package, which can increase the speed of the scan time without degrading the image.
While software upgrades can lead to improvements of a single-head camera, a multi-head camera is still faster, includes higher statistics, and results in a better image. You also won’t benefit from all the other advantages should you have chosen to replace your equipment. It simply might not be the best available use of your time, energy, or money.
Upgrading in today’s market
If you upgrade your equipment to a dual or triple-head camera, your advantages are significant.
Today, advanced reconstruction algorithms are standard features, so you’re choosing to improve the image quality in half the time, thereby increasing your lab’s overall efficiency. You’ll also have access to the latest versions of software.
A dual or triple head camera also gives the technologist the flexibility to deliver the very best image. A multi-head camera with an advanced reconstructive algorithm can offer improved image quality and lead to a more confident and accurate diagnosis. Additionally, with tools like Digirad’s TruACQ Count-based Imaging™, each scan is fully personalized to each patient by quickly reading the activity originating from the myocardium prior to the scan, and recommending the appropriate seconds per stop to meet ASNC count density guidelines. This individualized care doesn’t prolong the technologist’s workday because they have the tools to do the best job possible.
Upgrading is not just about how many detector heads your system has. It’s investing in a better and more sophisticated way to deliver nuclear cardiology.
Smart ways to take advantage of the ASNC ImageGuide RegistryPosted on: 01.18.18
Launched in 2015, the ASNC ImageGuide Registry is the first national registry developed to support non-invasive cardiac imaging and reduce the increasing regulatory reporting burden. It effectively promotes and ensures continuous quality improvement for referring physicians, technologists, and laboratories by improving efficiency, elevating the level of patient care, and reducing downstream costs. With equal weight, it was designed with the desire to build a database that spurs new research that will, in turn, grow and expand the nuclear cardiology field.
Why is it important to physicians?
Across the entire healthcare insurance industry, plan payers are continuously moving toward value-based purchasing where cost and quality are major factors that help determine reimbursement levels. Alternative payment models, bundled payments, and higher deductible plans in the commercial insurance market and Medicare’s new quality payment and the MACRA MIPS programs are clear indications of the shift in direction. All lend themselves to physicians practicing within the clinical practice guidelines. The ImageGuide Registry can promote and reinforce the highest quality delivery of care and improve outcomes at an appropriate cost point, which, in turn, can help increase reimbursements.
In addition, the measures, which were created by and for ASNC members, are more meaningful to the nuclear cardiology industry than what would be reported through traditional MIPS measures, another way ASNC has committed to helping physicians achieve appropriate reimbursements and promoting the highest level of excellence in diagnostic imaging.
What are the benefits?
The ImageGuide registry allows physicians to submit data and, based on ASNC reporting guidelines, determine their level of performance. Are they testing the proper patients with the appropriate indications and using the applicable protocols? Are they using dose optimization strategies and returning reports to referring physicians on a timely basis? Physicians, or the practice administrator, can review the data over a given time period and identify areas for improvement.
Given the change in healthcare reform and the increase in out of pocket costs, patients are becoming more savvy. As consumers, they want to make sure they choose a physician that delivers the highest quality service, orders only the appropriate tests, and helps them avoid multiple copayments for unnecessary visits. The registry offers concrete evidence that helps physicians demonstrate the value they provide to patients who are paying more than they have in years passed.
Physicians will be able to use the registry to compare their performance against the 15 different metrics it tracks. And, because CMS has recognized ASNC’s ImageGuide Registry as a Qualified Clinical Data Registry (QCDR), physicians who participate and submit data to the registry will also meet the Physician Quality Reporting System (PQRS) requirements each year.
How do physicians submit data?
Data can be quickly and easily submitted manually through the register’s portal, which takes a speedy 60-90 seconds. If offices are using reporting software, like Sytermed, Cedars-Sinai, or INVIA, they’ll be able to automatically submit their data and bypass the manual entry.
ASNC asks that physicians submit their tests on a regular basis, without any cherry picking of cases. The objective is to review all tests to identify opportunities for improvement. Physicians will be able to view their individual data, but the practice administrator will be able to look a comprehensive report of the entire lab’s performance. Even though it’s physicians who are being tracked, it’s also helpful for the technologists because the registry tracks overall quality. It takes a whole team to improve the quality of service and care, so the reporting applies to the entire lab.
Who should join the ASNC Registry?
The registry is available to any nuclear cardiology lab or physician. In fact, for cardiologists who perform nuclear cardiology, participation in MIPS through ImageGuide is the most cost-efficient and effective method of submitting data. Because the benefit from Medicare applies to total Medicare receivables, and ImageGuide is specific to nuclear cardiology, physicians are able to track their imaging, improve it, and reap the benefits without having to submit as much data. Other registries often require the submission of all patient management.
Practices can be set up in the registry as a cardiac imaging group, a smaller practice, or simply as physicians performing nuclear cardiology. If you’re an ASNC member, the registry is complimentary with your paid membership. If you’re not a current member, the cost is $750 per year, which is still a prudent investment given the potential reduction in Medicare reimbursements it could help avoid.
An easy transition
If you think that participation in the registry will require heavy lifting, it’s quite the opposite. ASNC has support that can help will registration and data submission, initially and ongoing, so it’s not as difficult as one would think. If you’d like to get started, simply visit the ImageGuide portal and begin the enrollment process. If you have questions or need assistance, contact an ASNC representative.
Where to get Nuclear Medicine CME credits in 2018Posted on: 12.21.17
One of the requirements for Intersocietal Accreditation Commission (IAC) or American College of Radiation (ACR) accreditation renewal is the successful completion of 15 continuing medical education (CME) credits per physician and the 15 continuing education units (CEU) per technologist.
It’s important to note that the credits must be specifically relevant to nuclear medicine. This critically important detail is often overlooked and can lead to a practice being cited for non-compliance.
In order to have enough time to complete the appropriate number of courses, it’s essential that physicians and technologists begin the continuing education process early. One CME/CEU is equal to 1 hour, so each staff member should expect to dedicate 15 hours per 3-year accreditation period toward earning these credits.
Some course choices are subject to a registration fee, and others are offered for FREE. Ultimately the courses you choose should be interesting and provide information that will further your education on the subject.
Below are four of our preferred classes for earning your Nuclear Cardiology CME credits.
This on-demand course is comprised of sessions and presentations from the Core Track of the live ASNC2017 22nd Annual Scientific Meeting. The focus is to showcase current best practices when performing nuclear cardiology imaging studies that include strategies for reducing radiation dose and applications of appropriate use criteria in the clinical practice. It offers 13 CME credits to physicians and it expires on October 26, 2018. Cost: Members $250, non-members $350
This on-demand activity is comprised of sessions and presentations from the Read With The Experts Track of the live ASNC2017 22nd Annual Scientific Meeting. The focus is to showcase current best practices and practical solutions to common nuclear cardiology dilemmas when dealing with patients with cardiovascular disease undergoing cardiac imaging studies. It offers 10 CME credits to physicians and it expires on October 26, 2018. Cost: Members $250, non-members $350
Recent Advances in Clinical Nuclear Cardiology and Cardiac CT: State of the Art Updates and 101 Evidence-Based Case Reviews
The objectives of this multimodality imaging course are designed to meet the needs of professionals who perform or request nuclear cardiology, cardiac CT or Cardiac MRI studies. The course emphasizes the use of these modalities across the spectrum of patients routinely seen by physicians for both the evaluation of individuals with suspected or known coronary disease as well as other non-coronary cardiac disease states. Join a faculty of expert cardiac imaging clinicians and scientists from across the country who will guide you through the latest advances in nuclear cardiology, cardiac CT and other imaging modalities. The ACCF designates this live activity for a maximum of 21.75 AMA PRA Category 1 Credits™. Cost: Member $550, non-member $750
This course is a comprehensive review of radiation physics, better images and interpretation, understanding safety, radiation biology, and tests, procedures, and protocols. It follows the CBNC exam content outline and includes an additional CBNC Board Review Course as an option at no additional charge. It offers 15 CME credits. Cost: $295
This on-demand activity is comprised of sessions and presentations from the live ASNC2017 22nd Annual Scientific Meeting. Cost: Members $599.00, non-members $799.00
This is an online video discussion focuses on choosing the appropriate diagnostic cardiac imaging test in women. Cost: FREE
This session of the live ASNC2017 22nd Annual Scientific Meeting focuses on nuclear cardiology studies for known or potential ischemic heart disease. Cost: Members $75, non-members $125
This on-demand board prep course delivers 19 hours of education from the live ASNC2017 22nd Annual Scientific Meeting. Cost: Members $1,299.00, non-member $1,399.00.
ASNC 2017: Boot Camp: A Comprehensive Boot Camp for Heart Service Line Administrators, Laboratory Managers, and Nuclear Cardiologists
These sessions focus on practice management topics such as staffing of a nuclear cardiology lab, staff training, economics of coding and billing, and optimal protocols. Cost: Members $75, non-members $125
This brief lesson will review some of the basics of nuclear physics. It will concentrate on those principles important in patients undergoing myocardial perfusion imaging. Cost: Free
This tutorial will review the methods for determining the characteristics of a diagnostic test, including sensitivity, specificity, positive predictive value, and negative predictive value. Cost: Free
Essential to the application of stress testing with nuclear imaging to a patient in your office is the clear understanding of Bayes’ Theorem. Cost: Free
Review the important literature which forms the basis by which we use nuclear perfusion imaging to diagnose CAD. Cost: Free