JOURNAL OF NUCLEAR CARDIOLOGY NEWS UPDATE FACING THE CURRENT CHALLENGES IN NUCLEAR CARDIOLOGY
.
President E. Gordon DePuey, MD, FASNC It is the best of times. It is the worst of times. There are opportunities. There are challenges. We must recognize and embrace both. As the incoming President of ASNC, I sincerely believe that we are presented with an evolving payment and practice environment that brings new challenges to how we practice medicine; we can and must adopt a proactive, creative approach in order to ensure that our practice evolves in a meaningful way. There are new and exciting innovations in the field; new SPECT and PET instrumentation and software have been developed to improve image quality and allow for lower patient radiation dose. There are new radiopharmaceuticals on the horizon with higher myocardial extraction than those currently available, holding promise in further improving the diagnostic accuracy of myocardial perfusion imaging in the detection and characterization of coronary artery disease. Concurrently we face the challenges of healthcare reform, which could decrease reimbursement and put these important advancements beyond the reach of the majority of us in nuclear cardiology. However, I believe we can comply with the
J Nucl Cardiol 2014;21:222–4. 1071-3581/$34.00 Copyright Ó 2014 American Society of Nuclear Cardiology. doi:10.1007/s12350-013-9831-y 222
requirements of healthcare reform and enhance the quality of our practices at the same time. For example, CMS strongly encourages subscription to the Physician Quality Reporting System (PQRS), whereby quality metrics from individual laboratories are reported to CMS. The program is designed to promote laboratory quality and efficiency. It includes appropriateness of imaging studies and other parameters to be determined by expert panels from various national medical societies such as ASNC. Although compliance with the PQRS program may seem burdensome, laboratories in full compliance may realize a bonus in total Medicare Part B payments, whereas those who fail to comply may see a reduction in payment. Conceptually, this program encourages and rewards quality and efficiency. The resulting financial gains could be applied to technical advancements, provide practices a competitive advantage, and increased referrals and profit. In contrast, those laboratories not in compliance would face decreasing reimbursement, likely resulting in a downward spiral of poorer quality and service and fewer referrals. ASNC is now developing the ImageGuide Registry, focused on assuring appropriateness of patient referrals, quality of imaging and reporting, and containment of downstream costs. Participation in the ASNC Registry should allow laboratories to comply with PQRS requirements, demonstrate quality of care to patients and third-party payers, and potentially increase reimbursement, allowing for investment in more advanced technology. With regards to technical advancements, PET holds immense promise. It has demonstrated higher diagnostic specificity and sensitivity than conventional SPECT primarily due to higher photon energy and inherent attenuation correction. More recently PET’s ability to quantify coronary fractional flow reserve has facilitated the diagnosis of ‘‘balanced ischemia’’, and multivessel disease and ischemia in remote vascular territories in patients with prior myocardial infarction. The majority of advancements in molecular imaging utilize novel PET radiopharmaceuticals. Challenges exist with the current PET landscape related to supply issues. However, the clinical utilization of PET is flourishing in nuclear medicine for oncologic and neurologic imaging. Whereas nearly twenty years ago nuclear cardiology pursued a productive and fulfilling path forward
Journal of Nuclear CardiologyÒ Volume 21, Number 1;222–4
independent of nuclear medicine, it is now time to consider re-establishing and strengthening ties in order to provide nuclear cardiologists greater access to PET and to allow nuclear medicine physicians, technologists, and basic scientists to once again become partners in the advancement of nuclear cardiology. The existing barriers that prevent advancement in both nuclear cardiology and nuclear medicine perhaps can be bridged by a closer collaboration between ASNC and the Society of Nuclear Medicine and Molecular Imaging (SNMMI). As a nuclear medicine physician myself, I am committed to working towards closer collaboration between these two organizations and engagement of nuclear medicine technologists and basic scientists in ASNC’s educational and research framework. Likewise, there should be a more integrated approach to the diagnosis and management of patients with suspected or known cardiac disease. Nuclear cardiology cannot exist in a vacuum. Instead we must reach out to collaborate with other organizations such as the American College of Cardiology, American Society of Echocardiography, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance to optimize an integrated approach to care. For a variety of reasons, including pre-certification requirements, consolidation of nuclear cardiology practices into hospitals, competition from other cardiac imaging modalities, and perhaps even better medical control of coronary artery disease risk factors, the number of nuclear cardiac imaging procedures performed in the United States has progressively declined of the past several years. However, there is the potential for incredible growth of Nuclear Cardiology in the developing world. Presently coronary artery disease and fatal myocardial infarctions are far more common in low- and middle-income countries than in high-income countries, most likely due to poorer control of risk factors. However, the number of nuclear cardiology studies now performed in the developing world is only a small fraction of those performed in the United States and the most developed European nations. Therefore, there is an enormous need for better diagnosis, management, and prevention of coronary artery disease in developing countries. Although other imaging modalities may, in many instances, be logistically preferable to nuclear imaging in fulfilling these needs, there is unquestionably enormous potential for growth of nuclear cardiology in the developing world. It is beyond the scope of ASNC alone to reach out to nuclear cardiology practitioners in the developing world to provide education, technical support, and the means to engage referring physicians. However, other organizations, particularly the International Atomic Energy Agency and the World Federation of Nuclear Medicine and Biology already have well
News update
223
developed liaisons and educational programs, primarily in nuclear medicine, in place in many developing nations. Through our International Advisory Panel, ASNC intends to strengthen ties with these organizations, offer substantially discounted memberships to individuals from the developing world, and expand our educational offerings with particular emphasis on basic knowledge and techniques. With new developments in nuclear cardiology, the emergence of molecular imaging, and advancements in both the medical and interventional management of patients with coronary artery disease, the necessary knowledge base to intelligently and effectively practice nuclear cardiology seems to be increasing exponentially. In parallel, Continuing Medical Education (CME), Maintenance of Certification (MOC), and Maintenance of Licensure (MOL) requirements are also increasing. As practicing physicians we are required to obtain and maintain these necessary certifications despite increasing clinical demands and decreasing funds and time to attend educational venues. In the coming year the ASNC Education Committee intends to expand our educational programs, offering more web-based educational activities, more CME, and provide activities that fulfill MOC and MOL requirements. In particular, we plan to make the annual meeting a venue where physicians can satisfy the majority of their educational and certification requirements. Not only are we as nuclear cardiology professionals focused on quality, but also, as stated above, in a ‘‘value-based performance’’ environment reimbursement is increasingly dependent upon the quality of our work. For many years, one of the most important roles of ASNC has been to establish guidelines for the use of nuclear cardiology procedures. These guidelines have been embraced by the entire Cardiology community and set a standard for our industry. With advancements in technology, the introduction of new radiopharmaceuticals, an emphasis on Patient-Centered Imaging and reduced patient radiation exposure, the Quality Assurance Committee is now hard at work updating the ASNC Guidelines. The revised guidelines will include easily accessible links to references in the literature and relevant clinical case examples and illustrations. These updated guidelines will further attest to ASNC’s role as a beacon to excellence in non-invasive cardiac imaging. As the incoming ASNC President I am, of course, enthusiastic about the potential for technical advancements and new clinical applications of nuclear cardiology. I am even more stimulated and energized by the challenges that lie before us in stabilizing payment reform, meeting regulatory requirements, and expanding the capabilities of Nuclear Cardiology to benefit the patient population we serve. These challenges and
224
News update
opportunities apply to the most sophisticated academic centers, stand-alone nuclear cardiology laboratories, and facilities just beginning to provide care in developing
Journal of Nuclear CardiologyÒ January/February 2014
countries. Please join with me in embracing these potentials and challenges and supporting ASNC in helping to fulfill your professional goals and aspirations.
.
President E. Gordon DePuey, MD, FASNC It is the best of times. It is the worst of times. There are opportunities. There are challenges. We must recognize and embrace both. As the incoming President of ASNC, I sincerely believe that we are presented with an evolving payment and practice environment that brings new challenges to how we practice medicine; we can and must adopt a proactive, creative approach in order to ensure that our practice evolves in a meaningful way. There are new and exciting innovations in the field; new SPECT and PET instrumentation and software have been developed to improve image quality and allow for lower patient radiation dose. There are new radiopharmaceuticals on the horizon with higher myocardial extraction than those currently available, holding promise in further improving the diagnostic accuracy of myocardial perfusion imaging in the detection and characterization of coronary artery disease. Concurrently we face the challenges of healthcare reform, which could decrease reimbursement and put these important advancements beyond the reach of the majority of us in nuclear cardiology. However, I believe we can comply with the
J Nucl Cardiol 2014;21:222–4. 1071-3581/$34.00 Copyright Ó 2014 American Society of Nuclear Cardiology. doi:10.1007/s12350-013-9831-y 222
requirements of healthcare reform and enhance the quality of our practices at the same time. For example, CMS strongly encourages subscription to the Physician Quality Reporting System (PQRS), whereby quality metrics from individual laboratories are reported to CMS. The program is designed to promote laboratory quality and efficiency. It includes appropriateness of imaging studies and other parameters to be determined by expert panels from various national medical societies such as ASNC. Although compliance with the PQRS program may seem burdensome, laboratories in full compliance may realize a bonus in total Medicare Part B payments, whereas those who fail to comply may see a reduction in payment. Conceptually, this program encourages and rewards quality and efficiency. The resulting financial gains could be applied to technical advancements, provide practices a competitive advantage, and increased referrals and profit. In contrast, those laboratories not in compliance would face decreasing reimbursement, likely resulting in a downward spiral of poorer quality and service and fewer referrals. ASNC is now developing the ImageGuide Registry, focused on assuring appropriateness of patient referrals, quality of imaging and reporting, and containment of downstream costs. Participation in the ASNC Registry should allow laboratories to comply with PQRS requirements, demonstrate quality of care to patients and third-party payers, and potentially increase reimbursement, allowing for investment in more advanced technology. With regards to technical advancements, PET holds immense promise. It has demonstrated higher diagnostic specificity and sensitivity than conventional SPECT primarily due to higher photon energy and inherent attenuation correction. More recently PET’s ability to quantify coronary fractional flow reserve has facilitated the diagnosis of ‘‘balanced ischemia’’, and multivessel disease and ischemia in remote vascular territories in patients with prior myocardial infarction. The majority of advancements in molecular imaging utilize novel PET radiopharmaceuticals. Challenges exist with the current PET landscape related to supply issues. However, the clinical utilization of PET is flourishing in nuclear medicine for oncologic and neurologic imaging. Whereas nearly twenty years ago nuclear cardiology pursued a productive and fulfilling path forward
Journal of Nuclear CardiologyÒ Volume 21, Number 1;222–4
independent of nuclear medicine, it is now time to consider re-establishing and strengthening ties in order to provide nuclear cardiologists greater access to PET and to allow nuclear medicine physicians, technologists, and basic scientists to once again become partners in the advancement of nuclear cardiology. The existing barriers that prevent advancement in both nuclear cardiology and nuclear medicine perhaps can be bridged by a closer collaboration between ASNC and the Society of Nuclear Medicine and Molecular Imaging (SNMMI). As a nuclear medicine physician myself, I am committed to working towards closer collaboration between these two organizations and engagement of nuclear medicine technologists and basic scientists in ASNC’s educational and research framework. Likewise, there should be a more integrated approach to the diagnosis and management of patients with suspected or known cardiac disease. Nuclear cardiology cannot exist in a vacuum. Instead we must reach out to collaborate with other organizations such as the American College of Cardiology, American Society of Echocardiography, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance to optimize an integrated approach to care. For a variety of reasons, including pre-certification requirements, consolidation of nuclear cardiology practices into hospitals, competition from other cardiac imaging modalities, and perhaps even better medical control of coronary artery disease risk factors, the number of nuclear cardiac imaging procedures performed in the United States has progressively declined of the past several years. However, there is the potential for incredible growth of Nuclear Cardiology in the developing world. Presently coronary artery disease and fatal myocardial infarctions are far more common in low- and middle-income countries than in high-income countries, most likely due to poorer control of risk factors. However, the number of nuclear cardiology studies now performed in the developing world is only a small fraction of those performed in the United States and the most developed European nations. Therefore, there is an enormous need for better diagnosis, management, and prevention of coronary artery disease in developing countries. Although other imaging modalities may, in many instances, be logistically preferable to nuclear imaging in fulfilling these needs, there is unquestionably enormous potential for growth of nuclear cardiology in the developing world. It is beyond the scope of ASNC alone to reach out to nuclear cardiology practitioners in the developing world to provide education, technical support, and the means to engage referring physicians. However, other organizations, particularly the International Atomic Energy Agency and the World Federation of Nuclear Medicine and Biology already have well
News update
223
developed liaisons and educational programs, primarily in nuclear medicine, in place in many developing nations. Through our International Advisory Panel, ASNC intends to strengthen ties with these organizations, offer substantially discounted memberships to individuals from the developing world, and expand our educational offerings with particular emphasis on basic knowledge and techniques. With new developments in nuclear cardiology, the emergence of molecular imaging, and advancements in both the medical and interventional management of patients with coronary artery disease, the necessary knowledge base to intelligently and effectively practice nuclear cardiology seems to be increasing exponentially. In parallel, Continuing Medical Education (CME), Maintenance of Certification (MOC), and Maintenance of Licensure (MOL) requirements are also increasing. As practicing physicians we are required to obtain and maintain these necessary certifications despite increasing clinical demands and decreasing funds and time to attend educational venues. In the coming year the ASNC Education Committee intends to expand our educational programs, offering more web-based educational activities, more CME, and provide activities that fulfill MOC and MOL requirements. In particular, we plan to make the annual meeting a venue where physicians can satisfy the majority of their educational and certification requirements. Not only are we as nuclear cardiology professionals focused on quality, but also, as stated above, in a ‘‘value-based performance’’ environment reimbursement is increasingly dependent upon the quality of our work. For many years, one of the most important roles of ASNC has been to establish guidelines for the use of nuclear cardiology procedures. These guidelines have been embraced by the entire Cardiology community and set a standard for our industry. With advancements in technology, the introduction of new radiopharmaceuticals, an emphasis on Patient-Centered Imaging and reduced patient radiation exposure, the Quality Assurance Committee is now hard at work updating the ASNC Guidelines. The revised guidelines will include easily accessible links to references in the literature and relevant clinical case examples and illustrations. These updated guidelines will further attest to ASNC’s role as a beacon to excellence in non-invasive cardiac imaging. As the incoming ASNC President I am, of course, enthusiastic about the potential for technical advancements and new clinical applications of nuclear cardiology. I am even more stimulated and energized by the challenges that lie before us in stabilizing payment reform, meeting regulatory requirements, and expanding the capabilities of Nuclear Cardiology to benefit the patient population we serve. These challenges and
224
News update
opportunities apply to the most sophisticated academic centers, stand-alone nuclear cardiology laboratories, and facilities just beginning to provide care in developing
Journal of Nuclear CardiologyÒ January/February 2014
countries. Please join with me in embracing these potentials and challenges and supporting ASNC in helping to fulfill your professional goals and aspirations.
