Plan for growth when establishing a PET center

Getting a PET program up and running is only the beginning, according to a veteran imager

By: Deborah R. Dakins

PET offers heady rewards for radiologists, creating a critical impact on patient management with every scan. More than most imaging services, PET offers the potential for radiologists to become full partners in patient care. But with those rewards come responsibilities. A successful PET center demands radiologists' involvement in every phase, from pre-start-up education to patient follow-up weeks after the scan.

Few know this better than Dr. Harry Agress Jr., director of nuclear medicine at Hackensack University Medical Center (HUMC) in Hackensack, NJ, and a clinical professor of radiology at Columbia University in New York City. Agress pioneered PET at HUMC, which has provided the service since May 1999. In that time, the center has performed more than 2800 PET studies.

HUMC used a coincidence scanner in its first 18 months of operation but installed a dedicated PET system in November 2000. Since January 2002, the center has seen a nearly twofold increase in scanning and scheduling volume for PET.

The key to HUMC's success in attracting PET referrals is a coordinated strategy of communication, education, and clinical follow-up that goes beyond what most radiologists are accustomed to.

"PET is an opportunity to have a major impact on patient care," Agress said. "It is a significant leap. Ultimately, it is this impact on patient management that makes PET so satisfying."

In presentations given at meetings of the Society of Nuclear Medicine, the Academy of Molecular Imaging, and the RSNA, Agress has described a systematic plan to ensure the success of a PET center.

The first essential element is a physician champion who is willing to assume responsibility for learning about PET applications and who can teach colleagues about it. This includes taking advantage of educational training programs such as those offered at PET training centers and at the SNM PET Learning Center, as well as reviewing journal articles on PET advances and applications.

Tracking PET scan results and their correlates with CT is an excellent way to learn about the modality's capabilities. Early on, Agress created both electronic and paper-based systems for following patients. Unusual and interesting cases are tracked electronically with digital PowerPoint patient files that include the CT and PET scans and related clinical and referring physician information. The paper file includes patient name, referring physician information, patient diagnosis, and follow-up results acquired by contacting the primary physician.

"This has proved critical in terms of developing my own confidence about PET's clinical abilities and my credibility with referring physicians," he said. "This is especially true when the PET finding is something that was not obvious on the CT."

Because Agress started this patient management system at the same time he began reading PET studies, adding new information is relatively easy. In addition to increasing his own learning, the electronic file Agress created with PET and CT correlates is also useful for educational presentations to colleagues and referring physicians. The file now includes hundreds of cases that compare CT and PET findings in a wide range of disease states.

CRITICAL COMMUNICATIONS

Educating local physicians about PET capabilities and limitations is critical to developing a referral base, Agress said. He began by sharing his file of comparative cases with other specialists and collecting articles on PET applications in different specialties.

"If an oncologist, pulmonologist, or other cancer specialist came by, I had a case that was appropriate for them," Agress said. "I'd explain that this new modality could be very helpful and show them the case. This helped to at least put PET on their radar."

Distributing packets with two or three key articles about PET in each subspecialty creates an educational context for the encounter. Giving talks at grand rounds and tumor boards is another way to showcase PET's impact on patient management.

"An additional source of good referrals may be your fellow radiologists," Agress said. "We show our good PET cases to the entire radiology group, which has become very PET-savvy. My partners therefore frequently recommend PET when reading CT scans that pose diagnostic problems."

But expect some resistance, at least initially.

"It can be slow to start. This is a real paradigm shift in which you are changing the way physicians are managing cancer patients," he said. "Referring doctors, for good reason, are set on ways that are proven to them, such as CT and clinical evaluation. There can be a lot of initial skepticism."

Introducing PET services to the community is a two-pronged effort. Send a letter announcing the center to the entire medical staff, especially those in the oncologic (including medical, surgical, and radiation therapy), pulmonary, cardiac, and neurologic specialties.

Next, work with the hospital's public relations department to get the word out through local media that a new modality is coming to the area. That includes alerting local newspapers, radio, and television stations. Schedule tours of the facility for reporters and prepare a presentation suitable for a lay audience about the new center and what it has to offer patients. If you are fortunate enough to be the first in your area to offer PET, the event could prove quite newsworthy. HUMC's PET center, for instance, was featured on a segment of the "Today Show."

But be sure the letter notifying local physicians and hospital medical staff about the center is sent prior to commencing a public campaign.

"It's a bad thing if patients start calling doctors about a new service being offered at the local hospital, and the physicians don't know anything about it," Agress said.

INFORMATION GATHERING

Once the service does catch on, be prepared for the challenges of higher volume. Have the right staffing and organization in place to manage the incoming referrals.

"The single biggest mistake we made was not being prepared for how complex the process was," Agress said. "We figured it was just one more scan. But that is not the case."

Expensive downtime can result if patients aren't prescreened for potential complications or inappropriate indications. Patients who are potentially claustrophobic should visit the center in advance of the test to see if they can tolerate lying inside the scanner. Special considerations also have to be made for diabetic patients.

Agress and his team of technologists and receptionists developed an information sheet for prospective PET patients, which is faxed to the referring physician's office at the time of scheduling. In addition to routine patient data, it includes information about both the referring physician and the patient's primary-care physician (for follow-up purposes), brief history and diagnosis, any past therapy (radiation and/or chemotherapy), and the main reason for the PET scan.

Most of the PET requests fall into two categories, Agress said. The first involves the requests to determine whether a finding on a CT exam is malignant. The second involves patients with a cancer diagnosis who require staging, restaging, or monitoring response to therapy. In either case, a copy of any prior CT report is requested.

Agress reviews the CT report prior to approving the request to schedule a PET scan. He can then ensure that the indication is appropriate and that the abnormality viewed on CT is within the scope of PET, (i.e., that a solitary pulmonary nodule is greater than 7 mm). If the CT was not acquired at HUMC and is not on the hospital PACS, patients are asked to bring a copy of their scan when they arrive for the PET study.

Last but not least, patients must be precertified by their insurer prior to PET scanning. This avoids the problem of performing scans that are not reimbursable.

"We review every request," he said. "Doing so helps educate referring physicians about what is clinically approved and what isn't. The Centers for Medicare and Medicaid Services-approved indications for PET at this point are very specific. They are expanding, but you have to be aware of exactly what these indications are. Some private insurers allow additional applications of PET, and this is quite variable."

In addition to the patient information sheet, the technologist performing the scan also completes a form on each patient, answering key questions such as injection site, glucose level, patient weight, and any problems encountered during the scan. This information

is included in the patient packet forwarded to Agress with the scan for interpretation.

"It took a while to develop this whole system, but it has been worth it," he said. "When I read the scan, I have all the information I need on two pieces of paper, in addition to the patient's CT. Every case we've read, with the exception of a few follow-up cases, has been interpreted in the context of the patient's clinical setting and CT findings. This provides the referring physician with a more thorough view of the patient's overall condition."

TRACKING VOLUME

Part of the organizational effort includes tracking scans and referrals. Michael Petrenko, HUMC's chief nuclear medicine technologist, monitors weekly how many scans have been performed, how many are scheduled, and how many are awaiting insurance approval.

During the first week of January, for example, HUMC scanned 25 patients and had 25 patients scheduled or waiting. By July that number had risen to 39 patients scanned per week, with 63 waiting.

"The sum of those two numbers tells you not only how busy you were in a given week, but how busy you will be," Agress said. "In January, our combined number was 50. By July, it topped 100. This is why you have to be very organized and prepared. When PET catches on, it really catches on. We have responded by increasing our daily scanning schedule and adding Saturday slots for patient convenience."

Successful PET center operations also require appropriate staffing. Even though the PET center at HUMC is in a separate building from the hospital's nuclear medicine department, the two initially shared one phone line and one secretary.

"You really need to set up PET as a separate entity, at least mentally," Agress said. "We hired another receptionist, and ultimately added a third, and those three rotate between routine nuclear medicine and PET scheduling. We created a separate phone number for the PET center. You also need a dedicated technologist who can ultimately train others to do the scans."

Key to averting difficulties are top-level administrators who support the service. That support is invaluable in a number of ways, from designing the center to hiring additional staff. Agress credits HUMC's president and CEO, John P. Ferguson, executive vice president and COO Robert C. Garrett, and vice president of operations Barbara Hopkins for their foresight in establishing the PET center with high-end equipment and a patient-friendly environment. The management team also responded rapidly to problems that arose in getting the center off the ground, according to Agress.

"Without the right amount of staff, you begin to overwhelm your receptionists and technologists," he said. "The large number of phone calls from physicians with clinical and certification questions, as well as from patients, initially threw us for a loop. The administration was quick to give us the FTEs we needed to get the job done."

Once a patient has a PET scan that determines his or her management, it is likely that future treatment for that patient will also require PET scans, Agress said. As a result, volume can increase rapidly.

CONSULTATIVE ROLE

Once all the organizational aspects are squared away, the key to PET center success is ongoing relationships with referring physicians. That requires radiologists and nuclear medicine physicians to adopt a more consultative role than in other modalities, Agress said. Attention to details and time spent following up cases have proved vital to building strong relationships with referring physicians at HUMC.

From prescreening cases through dictating the report, the differences are clear, he said. Unlike a routine nuclear medicine dictation, for example, it may be helpful if the PET report resembles a consultation.

Agress typically discusses the patient's history and CT scan, and then reviews the PET findings and how they correlate with the CT. Finally, he includes his impression of whether the patient has new or residual cancer and recommends the next steps to take.

"It boils down to communication," he said. "Because it is such an important test, PET requires a lot of one-on-one with referring doctors. Major patient management decisions are made based on PET scans. That gives us an opportunity to become much more involved in patient care."

EXPECT THE UNEXPECTED

The intense follow-up and patient tracking system Agress has devised has yielded some surprising clinical findings in the past three years. Expecting the unexpected is an important part of being a good PET physician, he said.

In reviewing the first 1500 dedicated PET cases performed at HUMC, Agress tracked 33 abnormal findings that did not fit the patients' suspected cancers. Based on tissue confirmation follow-up, 25 of these abnormalities proved to be malignant or premalignant cancers different from the type that originally prompted the PET scan, he said.

"We picked up a new, clinically unsuspected cancer or precancerous lesions in 25 of 33 unexpected abnormalities," he said. "In one case, we scanned a female patient who had a nodule in the lung. The lung nodule was positive but was one of the few unusual benign lesions that can give a positive PET. But, coincidentally, we also found a small focus in her left breast. At biopsy, it turned out to be a very early cancer. There are numerous cases that are just as dramatic as this case."

This kind of patient follow-up-usually done a month or more after the PET scan is over and filed-can be time-consuming, Agress said, but it is worth doing.

"You can have a very interesting conversation with the referrers about these cases, and it shows you are truly interested," he said.

He describes this as a way for radiologists to establish themselves as someone who not only knows PET but also cares about patients.

"Even if you do it only for your own education, it creates more confidence and credibility for yourself and your referring physicians," Agress said.

"This is just one more example of the way PET allows you to become more involved with patient care and management."

Ms. Dakins is a freelance writer in Ben Lomond, CA.