Dr. Rumberger is Director of Cardiac Imaging at The
Princeton Longevity Center and educator at Cardiac CT Training
Associates, Princeton, NJ. He also is Clinical Professor of Medicine at
Ohio State Uiversity and a former Professor of Medicine at the Mayo
Over the years we have seen several imaging
technologies migrate from radiology to other specialties and
subspecialties. Echocardiography, nuclear medicine and even MRI have
found their way into cardiology practices. Ultrasound is now used in a
wide range of areas—cardiology, OB/GYN, surgery, vascular and even
emergency departments. As other groups gain education and demonstrate
growing competency, these procedures are gaining wider acceptance
outside of radiology, and these new players are showing a willingness to
take the necessary training steps to prove their competency.
next big area poised to see increased subspecialization outside of
radiology is cardiac/coronary CT angiography (CCTA). This cardiovascular
diagnostic test is, for certain inpatient and outpatient clinical
circumstances, supplanting other more conventional approaches such as
direct angiography, stress echocardiography, nuclear cardiac imaging and
magnetic resonance angiography. For example, CCTA has already been
shown to be accurate for triage and cost effectiveness when applied to
intermediate risk “chest pain” patients in the emergency department.
procedures currently appear evenly split between radiology and
cardiology. An enormous opportunity could be on the horizon for either
group, but is modulated by increased pressure regarding inappropriate
imaging in general. One ‘solution’ to this problem has come in the form
of a mandate that imaging centers be accredited (including proving
clinical competency of their physicians) to perform these procedures.
January 2012, the Centers for Medicare & Medicaid Services (CMS)
will require freestanding imaging centers to demonstrate CCTA competency
to receive procedure reimbursement from Medicare. It goes without
saying that other third party payers will follow suit. Once this
regulatory door is opened, it would be a safe bet that this new
requirement will be extended to all imaging facilities in the relatively
With tightening capital equipment budgets,
cardiology departments are challenged to find money to buy new CT
scanners, or much else for that matter. This leaves radiology in a
potentially enviable position. Either money is already allotted for new
CT scanner purchases or the department already has one. Availability of
the technology is thus not the problem, but validating clinical
competency and the quickly approaching CMS deadline, just about a year
from now, remain major obstacles.
Besides the business benefits,
obtaining/validating competency is simply the right thing to do from a
clinician’s standpoint, and this will ensure higher quality patient
So, what will satisfy the CCTA competency requirements? The imaging
center can get certification either through the American College of
Radiology (ACR) or through the Intersocietal Commission for
Accreditation of Computed Tomography Laboratories (ICACTL). But the
staff physicians need also to demonstrate clinical competency, meaning
they must document the reading of the required minimum number of cases.
This also entails picking a recognized mentor who will review the
results and validate CCTA interpretation skills through testing.
addition, mentored lectures are required on a variety of subjects, such
as physics, radiation safety and pathophysiology. The mentor also
supplies the recognition of completion and eligibility for the national
certifying examinations (CBCCT or CCT CoAP exams). Demonstrating
competency does not end with passing the exam. The physician must
maintain competency annually by reviewing and analyzing 50 or more CCTA
cases per year.
The increased pressure
for establishing clinical competency in CCTA is currently mitigated by
economic issues making it difficult to justify training fees and travel
expenses. In addition, simply taking the time from an active practice to
complete training is extremely difficult.
The availability of
case studies with variable pathology and dedicated or ondemand
workstations for study/case review and analysis are challenges as well.
Finding a competent mentor or program can be an issue too.
from demonstrating competency, there is the sticky subject of case
appropriateness. How do you provide the expertise to determine what is
or is not an appropriate test for the patient, yet make it work for the
referring physician? As we know, there can be significant numbers of
inappropriate referrals, but we need to balance what is best for the
patient with the need to keep the “customer” happy.
visualization workstation manufacturers all claim the capability to
perform CCTA with just a ‘point-and-click.’ That process can be
performed by the technologist and the CPR image sent to the PACS for
physician review and reporting. However, in reality these are 3D and 4D
images and most of the time it is not that simple. Physicians reading
CCTA must know more about problem solving in such complex images. They
must understand all of the nuances of obtaining appropriate tests and
how to manipulate the clinical data, which will lead to a more confident
diagnosis and active involvement with the referring physician in the
creation of a fine-tuned treatment plan. The laboratory accreditation
mandated for 2012 presents a challenge, but also will serve up a golden
opportunity for those diligent enough to get the required training and
documentation of clinical competency in CCTA.