Cardiovascular Imaging - Reflecting on 2006 Predictions and New Predictions for 2016

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Cardiovascular imaging has advanced at breakneck speed over the past five years. With the steadily improving capability to image the cardiovascular system has come the appreciation that imaging is not an end in itself, but must lead to more effective and appropriate therapy in order to be clinically justified. Current economic challenges are particularly relevant to healthcare and will have major influence on further technical development and clinical application of advanced cardiovascular imaging modalities.

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In 2006, we predicted that clinical use of cardiac imaging would continue to expand and evolve, but at a slower pace than in previous decades, primarily because of economic challenges but also related to a healthy emphasis on developing a more robust and discriminating evidence base for appropriate usage of multiple, high-technology imaging modalities that provide overlapping, sometimes redundant diagnostic and prognostic data. This prediction was accurate in 2006 and is likely to remain true for the next five years.

Although there is no doubt that cardiac imaging has been one of the most useful developments in medicine over the past 50 years, it is also true that enthusiasm for this remarkable technology has led to sometimes uncritical, widespread adoption and too-frequent instances of over usage. We, physicians, our institutions and even our patients, have embraced new and rapidly advancing, highly sophisticated technology without enough critical assessment of its incremental impact on eventual patient outcome—does the patient actually feel better or live longer? This ultimate goal can be clouded by an understandable desire to make a complete and accurate diagnosis, avoid claims of malpractice and deliver the most ‘modern’ care, in competition with other institutions and physicians in the community. These influences are compounded by our medical payment system, which is largely run on a fee-for-services basis. This system provides incentives to hospitals, clinics, and physicians to perform more and more services, with insufficient emphasis on the true value these services impart to the patients for whom they are rendered. This is by no means an exclusive problem related to imaging, or to physician-owned imaging services, but these are easy targets.

As we noted five years ago, this ‘perfect storm’ of increasing usage of sophisticated and expensive medical services has resulted in extreme economic pressure being placed on the entire healthcare system and imaging in particular. Insurance companies continue to tighten payment policies by requiring pre-authorization for many procedures, including echocardiography, as well as more expensive magnetic resonance imaging (MRI), computed tomography (CT), and nuclear imaging procedures. Payments for imaging procedures have been reduced, particularly for independent imaging facilities and physician in-office services. This pressure will continue. Fairly or unfairly, the Medicare Payment Advisory Commission (MedPAC) and Centers for Medicare and Medicaid Services (CMS) are targeting physician in-office imaging services for reduced reimbursement if not outright banning. Reimbursement and profit margins for imaging services will continue to contract, with cuts extending next to hospitals, which currently receive favorable payments for outpatient imaging, compared with independently provided services.

The structure of private practice cardiology has changed dramatically over the past five years. An estimated 60 % of cardiologists have now left independent private practices and are now employed by hospitals. A related shift of imaging services to the institutional setting is underway. More successful healthcare organizations will preserve the outpatient-friendly service and high quality found in the best private practices, but also promote efficient use of expensive equipment and personnel, fund costly electronic, integrated medical records, electronic reporting, telemedicine, and picture archiving and communication systems (PACS), and institute sophisticated quality assessment and continuous quality improvement programs that can be difficult to implement in small, independent laboratories and physician offices. The danger is that management systems in many hospitals are not geared to delivering convenient, high quality, efficient outpatient care and imaging services. Patient satisfaction and personal service are likely to suffer as budget cuts force ever more drastic consolidation and efficiency measures. These pressures will only increase over the next five years. Regardless of the outcome of the current political battle over healthcare reform, imaging will be a focus for reducing costs.

Although we hold that none of our predictions of five years ago were entirely wrong, several of our predictions will require some modification as we look toward the next five years. Cardiac MR remains a promising modality, with many exciting applications in the cardiomyopathies and complex congenital heart disease. However, its complexity and expense are likely to continue to restrict its use to large referral centers, and its penetration to community-based healthcare will be limited. Similarly, we predict that advanced positron emission tomography (PET), PET-CT and molecular imaging will continue to develop, but with modest penetration at the community hospital level.

Echocardiography (echo) remains at the ‘heart’ of cardiology. Accreditation of laboratories and credentialing of physicians and technologists has perhaps its greatest impact here because variability in image quality can be high for this nearly ubiquitous procedure. Use of ultrasound contrast improves image quality, particularly with stress echo, and we predict that its use will continue to grow. Amazingly inexpensive and technically sophisticated handheld devices are now available that can easily be used at the bedside in a manner similar to the stethoscope. We predict that some hardy cardiologists will continue to venture out of their digital lairs to lay hands on their patients over the next five years.

These bedside ‘personal’ echo machines may get greater use if we move away from a fee-for-service model to more bundled care model, in which there will be less concern for documenting each individual component of service to bill and receive additional payment. How bundled payment will affect new and developing echo technologies such as speckle tracking and 3D echo is difficult to predict, but it is safe to say that evidence of efficacy and proof of impact on outcomes will be emphasized for these as for all imaging procedures.

Our predictions of five years ago were perhaps least accurate regarding coronary CT angiography (CTA). Nuclear and echo stress testing still dominate the evaluation of patients with chest pain of uncertain but potentially cardiac etiology. This may change with the publication of additional trials showing that CTA is more rapid, less expensive, and more definitive than stress nuclear or stress echo in identifying patients with normal coronary arteries. We predict that coronary CTA use in the emergency setting will increase over the next five years, particularly as the newer technology allows a lower radiation dose to be used, even when image acquisition protocols are used to simultaneously detect not only coronary disease but also to diagnose aortic dissection and pulmonary embolism. Further development of low radiation CT methods for assessment of myocardial perfusion, atherosclerotic plaque characteristics, and cardiac gross anatomy, as well as coronary angiography, may threaten both cardiac MRI and diagnostic catheter angiography.

Single-photon emission computed tomography (SPECT) stress testing has proved remarkably resilient, in part because it has enjoyed a good track record over many years. The Clinical outcomes utilizing revascularization and aggressive drug evaluation (COURAGE) trial in particular showed that an overemphasis on coronary anatomy is less useful than an approach that couples coronary anatomy with function, assessing the degree of ischemic burden using nuclear stress testing or other techniques. It is now common to measure fractional flow reserve in the catheterization laboratory in conjunction with coronary angiography when the degree of functional stenosis is uncertain. Functional assessment of ischemia can be obtained using other imaging modalities, including stress echo, stress MRI, PET, and even CTA, but SPECT is robust and has proven effective, and there are a lot of SPECT cameras in use, and not so many stress MR and PET facilities.

In the coming years, greater emphasis will be placed on methods that efficiently and accurately demonstrate ischemic burden and its response to treatment, be it surgical, interventional, or pharmacologic. We may see similar imaging advancements in assessing the morphology and functional state of atherosclerotic plaque and its response to therapy, using a variety of unique technologies.

As we pointed out in 2006, the ‘target’ for cardiac imaging continues to move. As preventive measures are successful in reducing rates of smoking, and more effective treatment is used to combat hyperlipidemia and hypertension, the rates of acute myocardial infarction continue to decline in the US. These demographics may be countered by the aging of our population. As baby boom doctors retire, and they and their baby boom patients enter their 70s and 80s, we can expect rates of cardiovascular disease to increase and, with it, the demand for services, including imaging. These needs will be met by a work force that expects regular hours rather than by the independent, entrepreneurial private practitioners of the past. Physicians working fewer hours will strive to increase their efficiency and productivity using technology such as telemedicine, integrated health records with digital images and computer-assisted interpretation and reporting, and by embracing physician extenders.

Physician and institutional accountability will be addressed through regulation, certification, accreditation, and mandatory contribution to public databases that will be used to measure cost, quality, and value. Without doubt, physician autonomy will continue to be challenged and the exercise of individual professional judgment closely scrutinized. Stay tuned. The future of cardiac imaging for the next five years is not for sissies.