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Group Sets Action Plan to Improve Quality in Cardiovascular Imaging

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Duke Health News 919-660-1306

DURHAM, N.C. -- A panel of national experts has developed a
plan for improving the use of imaging technologies in patients
with cardiovascular disease.

It is hoped that implementing the plan would not only
improve patient health outcomes but also improve patients'
quality of life, reduce the expenses they incur and increase
their overall satisfaction with their treatment, the panel
said.

The panel, which was composed of officials from professional
societies of imaging specialists, companies that develop
imaging technology, government regulatory agencies and
insurance companies, published its recommendations in the Nov.
14, 2006, issue of the Journal of the American College of
Cardiology.

Officially called the American College of Cardiology-Duke
University Medical Center Think Tank on Quality in
Cardiovascular Imaging, the panel met in Washington DC in
January 2006. The meeting was supported by unrestricted grants
from a number of health-care and medical-imaging companies [see
list below].

In diagnosing heart disease, physicians often rely on one or
more imaging technologies to provide pictures of the heart and
the arteries that supply it. Among the technologies are
"noninvasive" tests such as ultrasound, CT scans and magnetic
resonance imaging, as well as more invasive tests such as
angiography, where a dye is injected into the bloodstream and
x-rays are used to illuminate areas where blood vessels may be
blocked.

"Imaging has transformed our ability to prevent, diagnose
and manage cardiovascular disease," said Pamela Douglas, M.D.,
chief of cardiovascular medicine at Duke, past president of the
American College of Cardiology and first author of the journal
report. "Cardiovascular imaging has enjoyed both rapid
technological advances and sustained growth, yet less attention
has been focused on quality than in other areas of
cardiovascular medicine.

"We are in the midst of a national debate on the rising use
and costs of these technologies," Douglas continued. "We
believe there is good reason to change the debate from how to
cut costs to how to provide the best value to patients. So we
assembled a group of experts who have a stake in the
appropriate use of imaging technologies to come up with
consensus definitions of quality and then develop strategies to
measure and achieve these goals."

The group's proposed action plan represents a first step,
Douglas said. Working in conjunction with the American College
of Cardiology and the professional societies representing the
different imaging specialties, the group plans to develop and
disseminate more detailed quality guidelines within the next 18
months, she added.

Douglas said that while drugs or medical devices must be
rigorously tested for safety and effectiveness in clinical
trials before receiving government approval for use, imaging
technologies tend not to be as rigorously studied, since most
tests pose few immediate risks to patients.

"Imaging technologies, since they are diagnostic, are rarely
associated with specific patient outcomes, yet the results of
imaging studies form the basis of more than 80 percent of the
treatment decisions made by physicians," she said. "While
imaging can provide abundant information for a diagnosis, few
randomized clinical trials have examined imaging's effect on
clinical decision-making or patient outcomes."

In their analysis, the experts looked at four broad aspects
of how imaging technologies are used in evaluating heart
patients: matching patients with the best imaging technique,
acquiring the best images, correctly interpreting the images
and communicating the results of the tests to the patients'
physicians.

Using the most appropriate technique for each individual's
circumstance is essential, Douglas said.

"To put it simply, quality in patient selection entails
referring the right patient for the right test at the right
time," she said. "Our goal is to identify which patients would
benefit the most from each technique while minimizing
inappropriate testing."

Panel members agreed that more studies are needed to collect
data on which techniques are used for specific medical
circumstances and then to correlate that information with
patient outcomes, Douglas said. As a first step, the panel
recommended that the American College of Cardiology work with
professional imaging societies to develop standardized methods
for collecting and analyzing data and for communicating the
findings back to referring physicians.

The panel also agreed that standard protocols and procedures
need to be developed and followed to ensure that whenever a
patient has a test performed, there is high confidence that the
resulting images will be of high quality. Also, the experts
said that whenever possible, the technicians who perform the
tests should receive advanced training or certification in
their areas.

Once an image has been generated, correct interpretation is
essential to a proper diagnosis, the panel said. At a minimum,
physicians who read and interpret the images must be certified
by their respective credentialing societies. But the panel
concluded that certification alone is not enough: independent
groups should be established to conduct regular reviews of
physicians' interpretations to determine if the correct
interpretation was made. Comparative studies using databases of
standardized images also could help ensure that the correct
interpretation was made.

"Regardless of the approach taken, it is critical that some
form of ongoing measurement of accuracy and reproducibility be
performed routinely and that reasonable standards for both
should be established," Douglas said.

Once an accurate image has been made and appropriately
interpreted, the findings must be communicated effectively to
the referring physician in a timely fashion, the panel said.
The experts called for development of standardized language and
forms so that referring physicians can easily and quickly
understand the results of the test and act on them.

The group's activities were supported by unrestricted grants
from Aetna Inc., Anthem, Astellas Pharma U.S. Inc., AstraZeneca
Pharmaceuticals, Blue Cross Blue Shield, Bristol-Myers Squibb
Medical Imaging, General Electric Health Care, Pfizer Inc.,
Point Biomedical Corp., Siemens Medical Solutions Inc., Toshiba
America Medical Systems, United Healthcare Services and
Wellpoint Inc.

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