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For other articles and previous issues click here. February 27, 2006
Radiology Today Interview: David A. Dowe, MD —
Putting Cardiac CT Angiography Into Practice David A. Dowe, MD, is an attending radiologist at AtlantiCare Regional Medical Center, with campuses in Atlantic City and Galloway, N.J. He is also the medical director and chief operating officer of Atlantic Medical Imaging’s Galloway office, a freestanding imaging center. He has been involved with cardiac CT angiography (CTA) for more than four years. Radiology Today: What prompted you and your colleagues to jump in and offer coronary CTA? David A. Dowe, MD: It happened in the fourth quarter of 2001. When the eight-slice scanner came out, we knew it would have some capability of scanning the coronary arteries. We bought the eight-slice scanner and, lo and behold, it did CT angiography, but with great difficulty. We knew this was going to be an earth-shattering replacement technology because no one had ever noninvasively looked at the wall of the coronary artery, which is where the disease forms. Stress tests essentially look at the lumen and myocardial perfusion. Catheterization only looks at the lumen. Coronary calcium scoring just detects calcified plaque. There was no other noninvasive study that could do this. The market and people had been waiting for this for a long time. Way back then we knew how clinically important this was going to be some day. We knew that if we were in early and were able to perfect it, then it would be good for our practice. We knew reimbursement wasn’t going to happen for a long, long time—and it still hasn’t happened to a large degree—but we were right on about the clinical utility of coronary CTA. It is just changing the shape of cardiac care. RT: So back then your group made the decision that even if the technology wasn’t ready quite yet, you were going to be first in line? Dowe: Absolutely. RT: When you started to introduce coronary CTA, how did you present it in your community? Dowe: The first thing we did was present some of our images to the local cardiologists. We brought them into our office and showed them the images. They were quite skeptical for what I think were both academic and financial reasons. So, we ended up doing the same things with primary care doctors. They would come to the office and I would show them the images. Sometimes I would go to their offices at noon, bring some lunch, and make an academic presentation of both the images and the literature available at that point. The way we built the practice was very much hands-on. We’d hold public forums for patients. We’d have CME lectures for primary care docs. To be honest, I never went back to the cardiologists. If you’re doing coronary CTA in your community, the cardiologists are going to know. Some use it, some don’t. My largest referrer is a Cleveland Clinic-trained cardiologist, and she is excellent. She believes in it. Many other cardiologists won’t even look at the images. I’ve sent patients to cardiac catheterization—with disease subsequently demonstrated by the cath—where the cardiologist doing the catheterization refused to look at the images given to them by the patient. If someone had academic skepticism, they would look at those images. Clearly, it’s something some [cardiologists] are looking at and saying ‘if we validate it, it validates this radiology group doing it.’ So, I never went back to the cardiologists. Some refer; most don’t. In the fourth quarter of 2005, 91% of my referrals came from primary care docs, internists, surgeons seeking pre-op clearance, anesthesiologists seeking pre-op clearance, nurse practitioners, and physician assistants. Nine percent come from the cardiology community at large. When I first started out, I sent images with all my studies. I would send either CDs or a sheet of film with the relevant images with all my reports. Now the referring docs have asked me to stop sending images. They believe my report like it’s a two-view chest and say ‘please stop sending me images. I have no place to store them.’ RT: As times change, are you starting to see more interest from cardiologists in your area wanting to work with you or acquire this technology on their own? Dowe: Some are willing to work with us; some will send a patient now and then. With the exception of one or two cardiologists, there is no steady stream of patients. No cardiologist in our area has bought a 64-slice CT yet. I think one of them has it in the plans—and quite frankly, I welcome it. The only thing that has held back coronary CTA has been the somewhat negative opinion and backbiting by the cardiology community. Once one of them puts it in, it will pretty much render those arguments worthless. I’m not worried about cardiologists. Cardiologists will do what they have to do. My market is clearly the noncardiologists who have embraced this exam—they absolutely love it. RT: I understand that primary care doctors are very comfortable with the exam because they are not losing patients to you. Dowe: They love it for that reason—kind of a control reason. But, primary care doctors love that the exam tells them exactly where the patient stands with coronary artery disease. There are four triage categories: normal, mild, moderate, and severe. It renders coronary artery disease something that is safely handled in their hands. Most primary care doctors treat some cardiac patients with the basic prescription of statins and aspirin, and some they send on to a cardiologist for consultation. But the bottom line is that coronary CTA allows them to get a rapid, reliable answer to why their patient has chest pain. In the United States, 91% of cardiac catheterizations are elective. Only 9% are done as an emergency out of the emergency room or doctor’s office. Of the catheterizations that are done for diagnosis—which is something like 1.6 million of them—40% to 50% are normal. The selection criteria by which someone gets a cardiac catheterization is obviously very flawed when you end up with 40% to 50% normal diagnostic studies. The internists and primary care doctors have known that for a long time, as have the cardiologists. Lo and behold, 64-slice CTA comes along—actually, we started at eight slices, then went to 16 and 64, but it has always had a negative predictive value of 97% or greater. What I like to say—and I believe this with all my heart—is that every elective cardiac catheterization should be preceded with a 64-slice coronary CTA because the 40% to 50% of diagnostic catheterizations that will prove normal will never happen, which will save billions of dollars to the healthcare system, not to mention the 1% mortality from cardiac catheterization. That should happen right now. That should happen with 16-slice technology, which has a 97% to 99% negative predictive value. RT: So this exam draws a pretty clear line about when a primary care physician should hand off a patient to the cardiologist? Dowe: It basically answers the question, Does this patient have coronary heart disease or not? Many times patients have been cycled through cardiology when in fact they should have gone right to a gastroenterologist because their chest pain is esophageal in origin. Coronary CTA helps the primary care doctor not only keep more patients, but more accurately place others into the proper specialist’s hands without the patient having to see a cardiologist, pulmonologist, and gastroenterologist. RT: It would seem that once your primary care doctors see this and grow comfortable with it, that it’s a no-brainer to them. At that point, presuming you provide a quality service properly, does the rest take care of itself? Dowe: Absolutely. RT: Does this have any effect on your relationship with hospitals? Dowe: We read for two separate competing hospital systems. One has put in a 64-slice scanner and is preparing to offer coronary CTA, but not on an emergency basis because the work that would come out of an emergency [department] would be overwhelming. Patients admitted for chest pain don’t get a SPECT stress scan in the middle of the night. They get it in the next day or two. The hospital wants to use coronary CTA on a 16-hour-per-day basis to decrease the length of stay for the chest pain diagnosis. Our hospitals will typically get reimbursed somewhere around $5,000 for the chest pain DRG [diagnosis-related group] and it is a huge money-loser for the hospital. The work-up typically lasts two or three days. The patient is typically admitted and sees the cardiologist the next day, gets a stress test the following day, and then gets discharged. The hospital system that we read for wants us to do coronary CTA 16 hours a day—anyone who comes in from midnight to 8 am we can catch up to in the morning. Doing that will drastically decrease the length of stay for patients with suspected coronary artery disease. It’s a huge money saver to the hospital, so we are working with an administration to come up with a plan to implement that. RT: So you’ll read the tests done on the hospital’s scanner for those patients who come to the emergency department with chest pain and are admitted with chest pain? Dowe: Yes. Usually, chest pain patients bounce off the ER back to their primary care doctor in the community and are referred for coronary CTA on an elective basis. Those patients who are admitted with chest pain but don’t have coronary artery disease soak up a lot of hospital dollars for a workup that ends up being noncardiac. RT: Is this going to grow to the point where you are competing with cardiologists on this front? Dowe: Unequivocally, yes. Cardiologists, I think, for many years have enjoyed a monopoly on workup of coronary artery disease. If you need a stress test or cardiac catheterization anywhere in the United States, you need a cardiologist. Now you have CT technology, which radiologists have been trained on and are very familiar with using everywhere else in the body—that can now do the heart. And radiologists naturally feel that they’re the experts in the technology and looking at the atherosclerosis of vessels, and cardiologists feel that they are the natural experts to deal with the patient with coronary artery disease. Both parties have something real to offer; that’s where the rub is. Cardiologists feel that they own the patient. In reality, they own yesterday’s patient. Tomorrow’s patients—the ones who walk into our imaging center today from primary care docs—want to have the best exam done by the best doctor and they don’t care who it is. When I speak to cardiologists, the No. 1 emotion I hear in their voices is not anger—it’s fear. This world was their monopoly and we are reshaping their entire environment. Some cardiologists are very eager and willing to dig in and learn the technology, but most are ending up in partnerships with hospitals and radiologists. When it’s all said and done, I think coronary CTA will be done 70% in joint ventures with radiologists and cardiologists working together, 25% or greater by radiologists working alone, and a very small fraction by cardiologists working alone, because 35% of cases have some ancillary findings. No cardiologist, despite what they think, is going to learn CT from a weekend course. It takes years to become good at CT. You’ll see a lot of joint ventures early on. RT: I’ve heard that once this all shakes out, there is just going to be so much demand that it will keep everybody busy. Dowe: That is what I believe. Within a year or so, the radiation dose from coronary CTA will drop by 50% to 75% because of different things we are working on with General Electric [Atlantic Medical Imaging is a GE Healthcare luminary site]. Once that happens, then you have a screening exam. Women get a mammogram because they have breasts. You get a colonoscopy at the age of 40 or 50 because you have a colon. Likewise, we will be getting coronary CTA of our hearts, based on our risk factors, on a screening basis. Obviously, reimbursement will be much less, but if you look at the prevalence of disease in society, coronary artery disease outweighs everything. I think this is going to be a screening test. I think this is going to be ubiquitous across the United States. It is an outstanding test and the winners and losers will sort out over the next few years. Some will be cardiologists and some will be radiologists, but at the end of the day, we’ll likely not refer to them as cardiologists or radiologists; they’ll be cardiac CTologists—and where they started, no one will really know or care. RT: So, if I am a radiologist in private practice, is this a hard thing to get into? Dowe: If you are an adequately trained radiologist and you’ve done a bunch of cases being proctored, I think it is easy to do. With a strong background in CT, it should take you around 50 cases or so to get a handle on this. I’ve trained hundreds of radiologists in three years and train 50 or 60 radiologists a month right now. It’s very graspable. It’s easier to teach this to radiologists than cardiologists, but it’s not impossible to learn as a cardiologist. I mentioned that cardiologists have their fears, but radiologists have their own brand of fear: Radiologists have had a monopoly on CT and now they have another aggressive subspecialty that thinks they can learn CT and do it just as well. RT: Is building a cardiac CTA practice significantly different than building any other aspect of their practice? Dowe: Yes, it is. But to be honest, the hard work is done. The public has embraced coronary CTA. From a patient acceptance standpoint, it’s over and done. RT: Yes, it has already been endorsed by Oprah. Dowe: And Matt Lauer, and Time magazine and Newsweek—all within a 60-day period. Have we ever had an exam that is so new, and largely unreimbursed across the United States, that is so popular? This exam is unreimbursed and I can’t train enough radiologists fast enough. I did a course in Orlando last weekend and sold it out and it has no money behind it. I think that speaks for the power of what it can do for people. RT: So patients are lining up to pay you to have this done? Dowe: Some insurances do pay. There’s a local Medicare policy in New Jersey that says we can bill this as a CTA chest; that is one alternative. No. 2 is cash, and the price is $1,200. But we also have option No. 3, which is a foundation that we set up because not every patient has $1,200. Coronary CTA is not just for rich people’s hearts. Our accountants developed a needs-based formula that helps patients get a coronary CTA either for free or at a reduced rate. Finally, because we were in this early on and have a technology agreement with GE Healthcare, we provide some free CTA exams on research grants. We have research programs with Yale University and Thomas Jefferson University. RT: Is the reimbursement issue still scaring away many radiologists at this point? Dowe: Yes, both radiologists and cardiologists. GE’s scanner lists for $1.7 million. You really don’t need a high-end, 64-slice scanner to do anything except the heart. There’s a huge price difference for equipment that’s not dedicated to anything that is currently reimbursed. Proceed into this area cautiously, or you’re going to find yourself getting burned. RT: When do you think the reimbursement situation will change? Dowe: I think we’re going to have reimbursement on January 1, 2007. Most likely, it will begin with category three, so-called “T” codes. People are using them and gathering utilization data. These T codes will eventually mutate into formal CPT codes. RT: You seem confident that reimbursement will start in 2007—that could change people’s thinking. If I’m considering adding this to my practice, I have this year to figure out the economics of it. You can plan for something when you are confident about the return. As that becomes clearer, it should push things forward. Dowe: Yes. Right now, you have some aggressive private practice radiology and cardiology groups with 64-slice technology that can handle the financial burden. Eventually, it will make sense for everybody to do it. When this exam becomes a screening exam, I don’t care if every cardiology practice in the United States has its own 64-slice scanner, they’ll never be able to do all of them. That’s what I tell radiologists. If you have
to do a joint venture with the cardiologists, do the joint venture.
But always preserve your right to do coronary CTA for primary care
doctors, internists, nurse practitioners, and others. Radiologists
are the natural experts in CT. The application of CTA technology
and CTA protocols to the heart is not a huge leap for a radiologist.
And regardless of what cardiologists think or how strong they are
in their community, the radiologist will win. They’re not
going to win 100% market share, but the first CTA patient is gravy
to them because they’re not seeing any of these patients now.
If you get 20% to 25% of the coronary CTAs in your market once the
test becomes a screening exam, that will be an enormous amount of
work. I encourage every radiologist to get trained and involved
because they will at least be a partial winner in coronary CTA.
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