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1 Diagnostic Radiology, Yale University School of Medicine, Tompkins East-2, New Haven, Connecticut 06520.
Received November 7, 2004;
accepted after revision November 9, 2004.
Address correspondence to J. A. Brink.
Abstract
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CONCLUSION. A variety of issues related to PET/CT were discussed at the 2004 ARRS annual meeting. Among the conclusions were that both PET and CT portions of a PET/CT scan need to be reviewed for adequate patient care, and that nuclear medicine should not be exempt from current self-referral legislation.
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The fusion of the established technologies of PET and CT into a single PET/CT system has prompted considerable discussion in the nuclear medicine and diagnostic radiology communities.
Both technologies have proven integral in diagnostic imaging, and combining the two methods into a single imaging device has shown superior results compared with producing and correlating separate PET and CT scans. However, with this tremendous advance in diagnostic imaging potential comes the inevitable questions of how best to use the technology to help patients and further research. The answers to these questions are particularly elusive as the two imaging methods are the domain of separate subspecialties. Questions surrounding the use of PET/CT include who should interpret the PET/CT scans; how much training is needed for the physicians and other staff; how the appropriate quality of both the scanner and the scan can be determined; and, what the safest and most effective protocols are for producing the scans. There are also important medico-legal and reimbursement issues that must be addressed to make the best possible use of PET/CT.
Because PET/CT is already in use in medical institutions worldwide and its use is expected to grow, there is an imperative to explore and resolve the issues connected to the merging of PET and CT. A focus group was convened in May 2004 at the ARRS annual meeting in Miami Beach, Florida to begin a dialogue on PET/CT. The focus group was sponsored by PETNET Pharmaceuticals and was composed of nearly 20 radiologists and nuclear medicine physicians from across the country who represented both academic and private sectors, and tertiary care and community-based practitioners. Each participant was invited for his or her experience and expertise in the realms of PET and/or CT. The purpose of the focus group was to delineate the various issues born from the merging of PET and CT and to identify future areas of discussion. The focus group participants were Todd Blodgett, University of Pittsburgh Medical Center, Pittsburgh, PA; Homer Macapinlac, MD Anderson Cancer Center, Houston, TX; Javier Villanueva-Meyer, River Oaks Imaging and Diagnostic, Houston, TX; Paul Shreve, Advanced Radiology Services, P.C., Grand Rapids, MI; Dave Townsend, University of Tennessee Medical Center, Knoxville, TN; Paul Shyn, Radiology Associates of Tarrant County, Fort Worth, TX; Harry Agress, Hackensack Radiology Group, River Edge, NJ; Farrokh Dehdashti, Mallinckrodt Institute of Radiology, St. Louis, MO; Hao Vuong, Baptist Hospital, Miami, FL; Richard Baron, The University of Chicago, Chicago, IL; James Brink, Yale University School of Medicine, New Haven, CT; Joseph K.T. Lee, University of North Carolina at Chapel Hill, Chapel Hill, NC; Reginald Munden, MD Anderson Cancer Center, Houston, TX; Erik Paulson, Duke University Medical Center, Durham, NC; Robert Stanley, University of Alabama at Birmingham, Birmingham, AL; John Madewell, MD Anderson Cancer Center, Houston, TX; Steven Teplick, University of South Alabama Medical Center, Mobile, AL; James Thrall, Massachusetts General Hospital, Boston, MA; and James Provenzale, Duke University Medical Center, Durham, NC.
After a brief introduction and statement of goals for the proceedings, the participants were divided into smaller discussion groups. The participants for each group were specifically chosen in advance to ensure that the particular types of physicians were evenly represented. The issues contemplated by the focus group fell into four basic categories: imaging protocol, training matters, reporting and billing issues, and legal concerns.
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The focus group also outlined some areas in which specifications for PET/CT should be defined. Group participants recommended that, at a minimum, 4-MDCT units should be used, and the radiation exposure of dedicated PET/CT personnel should be addressed. The group also commented that appropriate waiting areas are essential for patients following injection with the radiopharmaceutical, and they suggested that suitable body positions for various PET/CT applications should be defined. For example, whereas the "arms down" position is best for head and neck applications, the "arms up" position is most appropriate for body applications. For whole-body imaging, one may wish to perform two separate scans with the arms down for the head and neck and then with the arms up for the remainder of the body.
The focus group emphasized the importance of communication between the physicians interpreting the scans and the physicians requesting them. Referring physicians should be provided with guidelines that outline when a CT should be ordered by itself, when a PET scan should be ordered by itself, and when a PET/CT is appropriate. When a PET/CT scan is contemplated, guidelines should be developed that specify when a low-dose CT scan is used only for attenuation correction and anatomic correlation, and when a diagnostic CT technique is used, possibly including the use of IV contrast material. The group suggested the need for further research to determine the appropriateness of these imaging options.
Some focus group members added that the term "PET/CT" seems to imply that the CT portion will be diagnostic, and thus performed with IV contrast material. If this is not the case, the referring physician needs to be informed. The group also emphasized that the CT portion of the scan must be labeled specifically as either diagnostic or nondiagnostic. Otherwise, the referring physician might think that ordering a PET/CT scan will ensure that the patient has received a full CT work-up and thus he or she may fail to order a necessary follow-up CT scan.
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Focus group participants suggested that if a physician were not already trained in CT, 1 year of additional training would be an acceptable minimum for him or her to become knowledgeable about oncologic applications of PET/CT. On the other hand, they believed that additional training requirements might be necessary for nuclear medicine physicians interpreting PET/CT for neurologic applications. The group recognized that many nuclear medicine physicians would not be able to devote a full year to PET/CT training. These physicians potentially could incorporate PET/CT into their practices through a combination of continuing medical education, overreading by experienced practitioners, and visiting fellowships, similar to what has been done by many physicians when new MRI and CT applications have been introduced.
For radiologists, most felt that the idea of a PET/CT subspecialty was inappropriate. In the private sector, the radiologist who performs nuclear medicine would be most likely to embrace PET/CT, and, radiologists with experience in CT should be trained to interpret PET images. As such, recommendations need to be made to the relevant radiology organizations for training regulations and procedures. Many felt that, at the very least, criteria are needed for radiologists taking postgraduate courses and then viewing a specific number of cases that have been interpreted by someone with the requisite knowledge base. The group concluded that the ideal way to arrange training, if the resources were available, would be to have an in-house authority well trained and knowledgeable in PET/CT who would then be responsible for training other staff members.
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However, many believed that dual reporting is unrealistic, with the caveat that despite its impracticability in private practice, interpreting physicians should not be exempted from seeking consultation for cases with which they are not comfortable or for which they are not adequately trained. In addition, separate PET and CT reports might suggest possibly contradictory findings or conclusions. The consensus was that there should be a single report, with the acknowledgment that the report might be broken down into separate PET and CT components.
The focus group addressed two issues related to billing: the potential for reduced reimbursement when multiple body parts are scanned in the same patient encounter, and the relative discrepancy between the professional and technical components of the bill.
Some argued that just as much effort, if not more, is expended to interpret a head, chest, abdomen, and pelvis scan on one patient as compared with interpreting four individual scans from four different patients. Thus, the concept that payment for the professional component for reading the second, third, or fourth scans should be reduced, as is the case in some surgical applications, should be resisted. However, on the technical side, it was noted that an economy of scale may exist in conducting four scans of one patient, and as a result, an argument could be made for reduced technical reimbursement.
For most radiology procedures, the professional component is 15-20% of the total bill, but for PET, the professional component is only between 3-6% of the total. The group identified this as a major problem for physicians with PET scanners that are connected to hospitals. Whereas physicians may receive only $90 for interpreting a given examination, the hospital may receive approximately $1,700 for performing the same study. As a result of this limited reimbursement, many radiologists are hesitant to read PET/CT examinations, particularly given the added liability and lengthy interpretation time.
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A major point in the legal discussion was the implication of the self-referral prohibition statute, the Stark law. Whereas PET and nuclear medicine are exempt from the Stark law, CT is not. As a result, peculiar potential situations may arise in which a physician group that owns a PET/CT scanner can bill for PET, even though they would be prohibited from billing for CT. The group emphasized that PET/CT needs to be covered under the Stark law, and that nuclear medicine should not be exempt from self-referral legislation.
In conclusion, although PET/CT is a wonderful advancement for patient care, bridging two imaging techniques that have been under the purview of separate imaging specialties poses significant challenges for seamless integration in clinical practice. Focus groups such as this where nuclear medicine physicians and radiologists can exchange ideas on how best to implement this new technology are critical for smooth implementation and long-term success.
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