A New Jersey hospital was able to slash by more than half the number of inpatient pulmonary PET/CT scans being performed by having its nuclear medicine department act as a gatekeeper for exam orders, according to a study presented at the recent American Roentgen Ray Society (ARRS) annual meeting.
By requiring approval from the nuclear medicine department before imaging for chest indications, the group from Rutgers University's Robert Wood Johnson Medical School reduced inpatient PET/CT use for this indication by 60%, either shifting scans to an outpatient basis or eliminating them altogether.
Dr. Justin Alpert from Robert Wood Johnson Medical School.The study, led by senior radiology resident Dr. Justin Alpert, who presented the results at ARRS 2015, also found that the number of inpatient PET/CT scans for pulmonary nodules 1 cm or smaller decreased significantly.
"We created this memorandum that says you will need nuclear medicine approval in order to have an inpatient PET/CT," Alpert told AuntMinnie.com. "While we are happy to do these inpatient PET/CT scans, we found that many times [pulmonary indications] do not require inpatient management."
Quality improvement
Alpert and colleagues began the research as part of a quality improvement project for the hospital's radiology department. One of the assignments was to evaluate the use of PET/CT on an inpatient basis.
"The PET scans themselves were indicated, but what was called into question was whether they were indicated as inpatient," Alpert said. "Depending on the PET results, many times patients could be treated on an outpatient basis."
So Alpert and colleagues decided to conduct a retrospective review of inpatients who underwent PET/CT for pulmonary indications between May 2011 and July 2011, before the policy went into effect.
The data included patients' clinical histories, indications for PET and PET/CT examinations, and related imaging results to determine if inpatient PET/CT prompted any changes in subsequent management during hospitalization.
The tertiary care teaching hospital instituted its new policy in early 2013, requiring nuclear medicine physicians to review and approve all hospital inpatient PET scans. The researchers retrospectively looked at similar patient data for inpatient PET/CT scans performed between March 2013 and May 2013.
Decrease in requests
In three-month study period in 2011, 76 inpatient oncology PET/CT scans were requested. Of the 76 exams, 25 (33%) were performed for chest indications, including 17 (68%) for known or suspected lung cancer and eight (32%) to evaluate pulmonary nodules approximately 1 cm in size.
During the 2013 study period, there were 51 requests for inpatient oncology PET/CT studies. Of those, 39 PET/CT scans (76%) were approved and performed, while 12 (24%) were canceled, changed to a different examination, or scheduled as outpatient procedures.
Sixteen (31%) of the 51 imaging requests were for known or suspected lung cancer: 10 were performed as inpatient procedures, but six were canceled, changed to a different examination, or scheduled as an outpatient PET procedure. No inpatient studies were performed for 1-cm pulmonary nodules during the 2013 study period.
Alpert said the key comparison is the decrease in the number of inpatient PET/CT scans performed for chest indications, falling from 25 in the 2011 study period to 10 in the 2013 study period, representing a 60% reduction.
In addition, once the new prescan screening policy went into effect, the total number of requested inpatient PET/CT scans decreased by 33%, from 76 requests in 2011 to 51 requests in 2013, he noted.
"We really have cut down on the requests with the clinician and the ordering doctor saying, 'Well, the patient is already here, let's just get on the PET/CT scanner and we will go from there,' " Alpert said. "That is OK, but many times it should be done on an outpatient basis."
He added that when a physician calls and insists on an inpatient PET/CT scan, "we are not going to say no. We are doctors, too, and we all want the best thing for the patient."
The researchers are already expanding the study to determine how the prescan review may have affected patients with other conditions.
"We are going to break it down, not just to lung cancer but to lymphoma and other forms of cancers that are commonly done by PET/CT scans," Alpert said.
The study did not explore the financial effects of the new screening process. Alpert said that as the study progresses, they plan to look into the financial implications of the policy.
