The direct costs of coronary CT angiography relative to contrast-enhanced thoracic CT: Time-driven activity-based costing

Access to CCTA at safety-net hospitals across the United States

BACKGROUND

Coronary CT angiography (CCTA) has received a class 1A indication for the evaluation of patients with acute and stable chest pain after studies revealed the use of CCTA reduces mortality, rates of MI, unnecessary invasive procedures, and healthcare expenditure compared to traditional stress testing. Despite this recommendation, hospitals across the U.S. have not adopted CCTA at levels expected for standard of care. We sought to evaluate the availability of CCTA at U.S. safety-net hospitals.

METHODS

U.S. safety-net hospitals were identified using the Lown Institute definition. The ability to perform CCTA at each of these hospitals was assessed. Data was stratified based on rural vs. urban geography, bed size, state, and academic status. Critical access hospitals, specialty hospitals, and those without emergency services were excluded. Variations in CCTA availability were compared with Chi-square tests.

RESULTS

391 safety-net hospitals in the U.S. were identified according to the criteria, of which 179 (45.8 ​%) offer CCTA. Availability of CCTA varied significantly depending on the size of the facility (0-49 beds: 7.7 ​%, 50-99 beds: 43.8 ​%, 100-199 beds: 45.6 ​%, 200-399 beds: 71 ​%, and ≥400 beds: 88.9 ​%, p ​< ​0.001), rural vs. urban setting, (22 ​% vs. 57 ​%, p ​< ​0.001), and academic vs. non-academic settings (97 ​% vs. 41 ​%, p ​< ​0.001).

CONCLUSIONS

Fewer than half of identified U.S. safety-net hospitals were found to provide CCTA for the evaluation of cardiac patients despite its 1A recommendation. This research highlights alarming trends in cardiovascular health care disparities and serves as a call to action to combat inequity through the expansion of CCTA availability.

Evaluation of reporting in time-driven activity-based costing studies on cardiovascular diseases: a scoping review

Aim: This scoping review evaluates the application of the time-driven activity-based costing (TDABC) methodology in cardiovascular disease (CVD) studies. Materials & methods: The evaluation was conducted using the 32-item TDABC Healthcare Consortium Consensus Statement Checklist. A systematic search was performed in Medline, Embase and Scopus in September 2023, including only full-text, peer-reviewed studies reporting the application of TDABC in CVD research. Results: Twenty studies were included in the review. The positive response rate for individual studies ranged from 31 to 81%. The most frequently addressed checklist item was the clear definition of study objectives, while presenting costs per patient included in the analysis was the least reported item. Although 70% of the studies achieved a positive response rate above 50%, adherence to the TDABC checklist remains inconsistent. Conclusion: There is significant room for improvement in the reporting of TDABC methodology in CVD studies. Providing a more comprehensive and standardized description of the methodology would enhance the utility, reproducibility and accuracy of the information generated, supporting the development of evidence-based health policies and improving accountability in healthcare cost assessments.

Impact of an institutional process change adopting end-systolic coronary CTA acquisition and automated dose selection on patient throughput and image quality

INTRODUCTION

Guidelines recommend prospective ECG-triggered mid-diastolic coronary computed tomographic angiography (CCTA) acquisition after achieving optimal heart rate (HR) control in order to optimize scan image quality. With dual-source CCTA, prospective end-systolic acquisition has been shown to be less prone to motion artifacts at higher heart rates and may improve scan and CT laboratory efficiency by allowing CCTA without routine pre-scan beta-blocker (BB) administration.

METHODS

We implemented an institutional process change in CCTA performance effective January 2023, comprising a transition from prospective ECG-triggered mid-diastolic acquisitions individually supervised by a physician at the scanner to an algorithmic approach predominately utilizing prospective end-systolic acquisition (200-400 ​ms after R peak), employing an automated dose selection algorithm, without BB administration. All scans were performed on a third-generation 192-slice dual-source scanner. We reviewed 300 consecutive CCTAs done pre- and post-process change in Jan 2022 (phase 0), Jan 2023 (phase 1), and in May 2023 (phase 2) after implementation of a process improvement involving more selective utilization of automated tube potential/current algorithms (CARE kV) to optimize image quality. Coronary segmental image quality was assessed by two experienced CCTA readers by consensus using an 18-segment SCCT model on a 5-point Likert scale (1 ​= ​non-interpretable; 2 ​= ​poor; 3 ​= ​acceptable; 4 ​= ​good; 5 ​= ​excellent). Measures of radiation dose, medication administration, and time required for patient scanning were compared. Logistic regression was used to determine factors associated with patient-level reduction in image quality (IQ) and with repeat scans.

RESULTS

Post-process change, there was a significant reduction in the median overall patient appointment [phase 0: 95 (75-125) min vs. phase 1: 68 (52-88) min and phase 2: 72 (59-90) min; P ​< ​0.001] and scan times [phase 0: 13 (10-16) min vs. phase 1: 8 (6-13) min and phase 2: 9 (7-13) min; P ​< ​0.001]. Median IQ score in both post-process change phases was 4 (4-5) compared to a median score of 5 (4-5) pre-process change (P for comparison <0.001). The majority of segments post-process change had "good" IQ (Phase 1 segmental IQ scores: 5 ​= ​36.7 ​%, 4 ​= ​46.8 ​%, 3 ​= ​13 ​%, 2 ​= ​2.6 ​%, 1 ​= ​0.9 ​%; Phase 2 segmental IQ scores: 5 ​= ​26 ​%, 4 ​= ​49.7 ​%, 3 ​= ​16.3 ​%, 2 ​= ​6.1 ​%, 1 ​= ​1.9 ​%), whereas pre-process change, the majority of segments had "excellent" IQ (Phase 0 segmental IQ scores: 5 ​= ​56 ​%, 4 ​= ​34.3 ​%, 3 ​= ​7.5 ​%, 2 ​= ​1.8 ​%, 1 ​= ​0.4 ​%) There was no significant increase in non-interpretable scans at the patient level. The 22 ​% re-scan rate in phase 1 (vs. 6 ​% in phase 0, P ​= ​.002) improved to 15 ​% in phase 2. While patient related factors of body mass index [adjusted OR obese 2.64, 95 ​% CI 1.12-6.51, P ​= ​0.03; aOR morbidly obese 6.94, 95 ​% CI 2.21-23.52, P ​= ​0.001] and average HR [aOR (per 10 bpm increase) 1.51, 95 ​% CI 1.21-1.9, P ​< ​0.001] were associated with the scoring of any segment as ​≤ ​3 ​at the patient level in a fully adjusted model, the improved phase 2 of the process change was not [aOR 1.61, 95 ​% CI 0.78-3.32].

CONCLUSION

Implementation of an institutional process change utilizing prospective ECG-triggered dual-source end-systolic acquisition avoided the use of beta-blockers, significantly reduced patient appointment and scan times with acceptable diagnostic performance.

Cardiac CT angiography: Financial implications of different practice types

Cardiac computed tomography (CT) is an important diagnostic tool in the management of cardiovascular disease. Various factors influence the overall financial viability of a cardiac CT program, including hardware, software, personnel, billing, and practice type. This review offers a comprehensive analysis of these different cardiac CT costs, and how programs across various practice types manage them.

SCCT Health Policy and Advocacy Efforts

Cardiac computed tomography has a growing presence in multiple guidelines supported by a growing evidence base as to its accuracy and impact on clinical outcomes. Despite this, dissemination into widespread routine clinical practice has been slow, largely restricted to large academic centers and urban settings. The reasons of this are multifactorial, but one of the most impactful of these reasons is undeniably reimbursement. Currently, there is marked discrepancy between the costs of performing cardiac CT and the renumeration provided for this. Until this is addressed, cardiac CT will not reach its potential for the benefit of patients. It is for this reason that the SCCT continues to dedicate significant efforts to represent the need of the cardiology and radiology communities in bringing about changes in policy and billing. Significant momentum has been gained in recent years with the engagement of both congress and Medicare in moving towards a system of payment that recognizes the time and expertise required to acquire high quality cardiac CT. In this article we cover these recent efforts, and the next steps in this continued effort over the coming years.

Highlights of the 16th annual scientific meeting of the society of cardiovascular computed tomography

The 16th Society of Cardiovascular Computed Tomography (SCCT) annual scientific meeting welcomed 781 digital attendees from 55 countries. The program included 27 sessions across three simultaneously streaming channels, 11 exhibitors, 153 poster presentations, and 32 ​hours of on demand videos. The main themes of the meeting included coronary artery disease, valvular heart disease, structural heart disease, and advanced analytics including machine learning. This article summaries the main themes of the meeting and some of the key presentations, which will shape the future of cardiovascular computed tomography in clinical practice.