The deck is stacked against coronary CTA; why it matters

November 3, 2010

In the middle part of the last decade, dozens of courses cropped up to train radiologists how to read coronary CT angiography, a first-line strategy for low- and intermediate-risk patients with what could be heart-related chest pain.

In the middle part of the last decade, dozens of courses cropped up to train radiologists how to read coronary CT angiography, a first-line strategy for low- and intermediate-risk patients with what could be heart-related chest pain. Thousands of radiologists took those courses. Today they are probably feeling their skills are a bit underutilized.

Why that is so is the subject of a commentary this month from Dr. David Dowe, medical director of the coronary CTA program at Atlantic Medical Imaging and one of those best qualified to address this subject. (“Coronary CTA really works, but why isn't its use soaring?” page 35.) Dowe, an early coronary CTA adopter, takes a look at the clinical, technological, political, and economic factors surrounding adoption of the new technology and the reasons it has yet to earn a respected place in our medical system.

Dowe's basic conclusion is that it is not clinical efficacy that's the problem, but rather a host of outside factors that have kept coronary CTA sidelined, and the result has been less effective care.

Even if you're no great fan of coronary CTA or not one of those who trained to read the scans, the article is worth reading, both for what it says about coronary CTA and also for what it says about some of the flaws in our medical system.

One problem is inadequate information. Coronary CTA was swept up in the dose concerns that have hit CT in general. Refinements of the procedure have brought dose levels way down, and puts them well below those from the still commonly performed SPECT stress scan, but the concerns still linger. The question for the medical community is, why hasn't coronary CTA been compared with nuclear stress scans for dose (and for efficacy), and are other CT strategies similarly being held back in favor of less efficacious approaches?

Two other problems are entrenched interests and slow bureaucracies. One answer to the question above is that many cardiologists have an interest in nuclear stress scans and catheter angiography and will stick with those even when coronary CTA offers a better first-line solution. We tend to count on the system, particularly insurance and radiology business management companies, to recognize clinical value and promote more efficient care, but that doesn't always happen. Progress in bringing them around on this issue has been painfully slow.

There's more in Dowe's article: self-referral, inertia, conflicts within cardiology, even a teleradiology model that has left radiologists unwilling to take up the coronary CT baton. The point is that our medical system doesn't always support and recognize value. The healthcare system is large, unwieldy, full of self-interest, and not always geared to bringing forward the best it has to offer.

Unfortunately, this is not unique to coronary CTA-think of CT colonography-and not likely to fix itself on its own. It's going to take a series of discrete steps to address the problems highlighted in Dowe's article. A big step will be the recognition of self-interest by the players, medical specialists among them, and enactment of reforms such as limits on self-referral. It will also require more long-term thinking that lets new technologies that show promise develop and prove themselves.

These principles, and what happened with coronary CTA, need to be kept in mind as we move forward with a series of reforms that will dramatically reshape the way healthcare is provided in the U.S.