Launching a PET/CT program can put a practice on the cutting edge of diagnostic medicine and bolster its capture of other imaging services. However, implementing PET/CT is not a trivial undertaking; there are substantial up-front costs in acquiring the technology and considerable ongoing costs to staff, run, and promote the modality.
A practice will need to consider the volume indicators for PET/CT utilization, estimate its projected volume of those indicators, select a scanner and placement for the unit, and examine the operational issues for the service, according to Tim Ludwig, who presented his experiences with implementing PET/CT at the American Healthcare Radiology Administrators (AHRA) annual meeting earlier this month in Las Vegas.
Ludwig, director of imaging services for Craven Regional Medical Center, a community hospital in New Bern, NC, implemented PET/CT at his facility two years ago. The first steps he undertook in the implementation process were to define his primary and secondary service areas, then obtain cancer statistics from the North Carolina State Center for Health Statistics.
Ludwig noted that the agency provided projections for specific cancer sites, such as breast, lung, and skin for North Carolina as a whole. The historical cancer data are broken out by county, race, and sex, which allowed him to assess the cancer types and demographics, as well as a year-over-year growth rate of incidences, within his primary and secondary service areas.
He then determined the number of cases that would be appropriate for PET on the basis of cancer type for both its primary and secondary service areas.
In addition to calculating the current indications that Medicare reimburses for PET utilization, Ludwig suggested that practices considering PET/CT investigate the potential of the National Oncologic PET Registry (NOPR), which permits participating Medicare beneficiaries to receive PET coverage for many types of cancers not currently covered for reimbursement, including brain, cervical, small-cell lung, pancreatic, testicular, and ovarian.
"CMS (the Centers for Medicare and Medicaid Services) has committed to this for two years," Ludwig said. "I would be very surprised if, at the end of two years, that after all of those patients had been scanned and paid for by CMS that it suddenly pulled back and did not reimburse for those indications."
On the basis of the historical data he collected, Ludwig was able to determine an annual growth rate of the total number of cancer cases within his catchment areas, break out those that had potential for PET/CT reimbursement, and develop projections for the first three years of the project. He then assumed that the PET/CT program would pick up a percentage of market shares for these indications based on the current market share that the facility had earned for its other diagnostic imaging services. Next, he applied a reasonable market share to the caseload of projected incidences to determine a benchmark of cases that his institution would serve over the next three years.
"All of our numbers projected only one scan per patient," Ludwig noted. "Some oncologists will do only one scan per patient during the course of their treatment, while others will do two scans per patient, one at the beginning of their treatment and the other at the end."
"You'll have to look at the practices of your referring physicians," he said. "If they're ordering multiple CTs and multiple MRs on their patients now, it stands to reason that if you get PET/CT in there, they're going to follow the same ordering pattern."
When considering what configuration of CT to purchase (a four-, eight-, 16-, or 64-slice) in the PET/CT system, Ludwig suggested forecasting utilization of the higher-slice options. That is, determining if the modality will also be used as a standalone CT system and how it will be utilized. His facility had the option to purchase a 16-slice system but opted for a four-slice model as the hospital only uses the CT portion of the modality for attenuation correction and anatomic localization on the PET scans.
No matter what configuration is ultimately deemed best for the practice, Ludwig emphasized that the amount and availability of service that can be delivered by the vendor should strongly be considered when selecting a manufacturer.
When it comes to siting the technology, the process involves a mix of the political and practical, at least in a hospital setting. The radiology, oncology, and nuclear medicine departments all have a claim on the modality, and cardiology may weigh in with its stake on the service as well. Regardless of the location for the PET/CT, whether it is to be an in-patient or out-patient service, Ludwig advised bringing a physicist into the process as early as possible.
Shielding issues also need to be considered, as well as the number of dosing rooms to be created based on projected volume, hot labs for radiochemistry and hot toilets for patients after radiotracer application, and entrances and exits that may need modification.
Operational matters that need review include staffing, supplies, the location and pricing of FDG from suppliers as well as a backup source for the radiotracer, and marketing development for the program. In addition, there are nuclear medicine licensing considerations for PET/CT, training for clinical and clerical staff, radiation safety concerns, and billing and coding issues that will need to be addressed.
One of the pleasant elements of offering a PET/CT program in the facility has been the spill-over effect of the modality on other imaging services, Ludwig said.
"After we put in PET/CT, the number of CT-guided biopsies doubled overnight," he said.
Finally, a practice weighing the advantages and disadvantages of a PET/CT implementation should consider the business effect of not offering the service.
"If you have the opportunity to put PET/CT into your department and you don't, you'll lose those patients to a competitor," Ludwig said. "Are they also going to take your MRIs, your CTs, and your nuclear medicine cases? If you lose those patients, you don't get them back most of the time."
By Jonathan S. Batchelor
AuntMinnie.com staff writer
August 9, 2006
Related Reading
3D PET/CT demonstrates virtual vigor, July 27, 2006
PACS showing improvement for PET/CT SUVs, June 13, 2006
PET market continues double-digit growth, June 9, 2006
PET/CT has varied applications for oncologic imaging, June 4, 2006
Navigating PET/CT's logistical and legal issues, April 24, 2006
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