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 Clinic.

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.

The 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.

CCTA 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.

In 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 near future.

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 care.

Demonstrating competency

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.

In 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.

Challenges

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.

Apart 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.

Conclusion

Advanced 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.