Cardiac CT Angiography - Coming to a You Via Modern Medicine

Contrast-enhanced cardiac computed tomographic angiography, and often shortened to
several names including CCTA, CTA, and CCT. And also loosely referenced by the terms calcium scoring, or spiral, helical, electron beam, or Ultrafast CT.

These are tests done by cool new CAT scan-like machines, an example from GE Healthcare is here: http://www.gehealthcare.com/usen/xr/int/products/vascular.html
They can x-ray fast enough to eliminate the blur that would otherwise be caused by the movement of a beating heart. Inject into the blood some radio-opaque isotope with an affinity for calcium, and the disease state of coronary arteries can be visualized.

Think of the possible applications in health care! For example, diagnose chest pain in the emergency room, eliminate risky and expensive cardiac catheter angiography, no more worry and wait for those with CAD risk factors or vague symptoms.

However, there are questions about how precise results really are, when this testing should be done, and how meaningful testing becomes in influencing the treatment / prevention / outcomes of disease.

When we allow science to answer these questions through randomized clinical trials, it's called EBM.

Despite the apparent lack of substantial published credibility, some hospitals have been doing variations of CTA for years. They used established standards for billing Medicare and insurance. On claims, they used existing AMA CPT coding that describe CT imaging of the vessels in the chest cavity.

With newer, better ($1.7 mil) machines, and an associated greater technical expertise to "score" the smaller coronary vessels, hospitals and doctors began to demand more reimbursement than they could expect for the commonplace CT scan. The AMA considered creating new procedure codes in Summer 2005, and ended up assigning temporary codes to the cardiac CT scan procedures. By assigning the temporary codes to CTA beginning in 2006, the AMA considers the scans an "emerging technology."

So far, notice that the new machines and the new CT exams just kind-of evolved from standard scanning for specific (almost rare) indications, into highly technical radio-isotope scans with broad applications.

It's fun to speculate which laws of economics are applying here. The machine manufacturers might have known the Medicare-based payment for a CT scan wasn't likely to go up much, so a few new broad indications or ways to use CT scans becomes the key to raise sales. The doctor and radiologist need special training to "score" or interpret the new tests and to operate the new scanning equipment. Since it's more complicated, it's fair that they get comparatively more payment than they did for the old standard CT scans.

The trouble that happened is, the new AMA CPT temporary codes used for CTA aren't assigned a payment by Medicare. And, per CPT and Medicare rules, the new codes must be used on claims nevertheless. Suddenly in 2006, insurance companies started to get claims with these codes, and many didn't have a process to pay on them. Which, of course, led to them to ask, should they pay on them?

Hospitals and doctors began demanding a specific payment for the higher-tech CT scans from local Medicare Intermediaries. Six professional physician organizations including the American College of Radiology (ACR) and the American College of Cardiology (ACC) jointly published a draft coverage policy that Medicare Intermediaries, and private payors could adopt and endorse.
http://www.scai.org/pdf/FINAL%20Model%20LCD%20for%20CCT%20and%20CTCA.pdf#search=%22ccta%20acc%22
Some Medicare Part B payers adopted this model local coverage decision (LCD) and continue to pay for CTA.

Private insurance carriers have set their own path related to coverage of the new codes / new CT scan. Aetna, Cigna, and Humana are among bigger players who
all have published non -coverage policies for CTA. (Aetna example -
http://www.aetna.com/cpb/data/CPBA0228.html)

This month (August 2006) the BCBSA TEC reevaluated and reaffirmed that CTA had not met their scientific evidence-based technology evaluation criteria, and the technology remains experimental / investigational. http://www.bcbs.com/tec/tecinpress/8206.html
BCBSA TEC main results:
"Seven studies compared CTA to angiography for diagnosis of coronary artery stenosis, ranging in size from 30 to 84 patients. These studies enrolled essentially convenience samples of consecutive patients scheduled to undergo angiography, and thus may be subject to spectrum bias. No study specifically studied a lower-risk subset of those patients referred for angiography, which is the target population for this procedure."

Almost as if in response, the six fore-mentioned professional organizations will release a formal statement of science-based endorsement for CT angiography in the October 2006 issue of The American Journal of Radiology. The new policy outlines 8
specific indications where CT angiography will be indicated.

So there we have it. On one side, hospitals and doctors see the test as great way to understand cardiac health in any or all of their patients. Insurance companies see a test that everyone, to some extent, might benefit from, but the value of testing
has not been established.

Is CTA going to impact mortality or morbidity of CAD? Or will it become just another in the long stream of "risk stratification" tests, the results from which are nice to know, but they don't substantially impact real health outcomes in the huge majority of those who have it done?

I think the Hospitals and Doctors will trump the analytical EBM scientific reviews of the insurance companies. If so, will the application of CTA be too broad, will we do too many? What's the risk that they will be one more straw on the back of the runaway cost of medicine in our society? (All told, they are about $1,700 apiece.) Does the potential for good outweigh the risks, or offset the costs?

Since there is not the science or data for predictions, we'll just have to wait and see.

Nawledge

Viruses Make Me Who I Am

>>>>"I'm currently reading a book called The Dancing Matrix: Voyages Along the Viral
Frontier by Robin Marantz Henig. There's a discussion in chapter 5, about whether or not viruses cause chronic disease. I thought one part was particularly relevant to certain discussions we have here.
>
> "It would be a strange irony indeed if some of the attributes we most value, the
qualities that make us believe we are most human and most individual, are traceable to the subtle workings of a virus..."

>>>snip<<<
---------------------------

Cc, the first popularized cloned cat had distinctly different fur markings than Rainbow, her genetically identical mother. This was not caused by a virus, but I think the example creates enough of an analogy to lend some plausibility to the I-am-the-result-of-my-viral-past postulation. And what a timely story for those of us who just heard the CNN "stupid pill" discovery report.

Nothing changes the fact that we have individual attributes that make us who we are. Maybe it's a theological conviction, but I believe we will always maintain a degree of personal free agency, unless of course, our decisions lead to relinquishing it. I hope this doesn't become one more argument to avert accountability for our actions and claim that "it's not my fault."

Nawledge

NEJM Reports What happens When Too Few Get Vaccinated

Interesting article in the current issue of The New England Journal of Medicine, full text available online:

http://content.nejm.org/cgi/content/full/355/5/447?query=TOC

This article about a case series investigation makes some very succinct points and clearly demonstrates the reality of illness that directly results from not being vaccinated.

I found myself hoping this review would also clearly show the risks of how much more likely you are to get measles when you are not immunized/vaccinated.

The opening statement suggests that 50 out of 500 people at a church function were not vaccinated, but both of these numbers were derived based on interviews with church clergy. The authors go on to say, "The church estimated that 35 of its members declined vaccination... Of these, 31 (89 percent) became infected." It seems that any conclusions about rates of infection among vaccinated versus unvaccinated
parishioners is mostly speculative at best, because the vaccination rates and number of exposed individuals are based merely on clergy estimations.

The "89 percent" infection rate above doesn't jive with the more real "57 percent" listed later in the article:

"Of 69 persons in the 11 affected households, 56 (81 percent) lacked evidence of immunity according to the ACIP standards. Of these, 32 (57 percent) acquired measles"

But, I worry about this number, too. Immunization proved per ACIP standard doesn't mean you have, or have not been effectively immunized in every case.

The article might show a case in point about the problems with having a documented immunization record.

"The other patient with vaccine failure was a 34-year-old hospital phlebotomist who was hospitalized for severe measles.... She had received one dose of measles vaccine at 12 months of age but did not have documentation of a second dose and had not been tested for serologic evidence of immunity on employment. The ACIP recommends either proof of measles vaccination with two doses or evidence of immunity for health care
workers."

Anyone have any idea how easy it might be to forge a an employer required vaccination record?

Suffice to say that because I am vaccinated, I could have attended the church function without fear, because 16 out of the 18 people who got measles there were not vaccinated. And, a good number of (all) ACIP-proved vaccinated persons in affected homes did not get sick. But, there was also a good number of
un-vaccinated people who did not get sick. Thus, "natural immunity remedies really work."

It would be nice to know how many people interacted with "Measles Mary," and whether they were actually vaccinated, immune, or not vaccinated, so we could have a rate-of-infection argument. Maybe, given all the variables, even if I had these numbers they could not be definitive. But, they would be better than basing them on guesses by clergy.

Nawledge

When is medical treatment fraud?

For those who have nothing nice to say about Chiropractors:

By way of real-life anecdotes in my 8 years experience with a commercial payor, I've had more experience with mainstream health care professionals in places like hospital-based rehab clinics and orthopedic surgery-based PT clinics using VAX-D, and the myriad of unproved electronic diagnostic and therapy gizmos than you might expect in a market full of chiropractors. I have had physical therapists passionately swear by such interventions and argue that their personal experience with them is all the proof they need that they work. I've had facility administrators and physician medical directors argue for coverage for services using the latest device that is clearly on the outer fringes of science and/or efficacy.

Let's face it: Mainstream medicine is not always evidence-based medicine, and quackery is not always complimentary medicine. And, I'd say that all mainstream medicine does not have to be evidence-based, and thus, all complimentary medicine does not have to be quackery.

The distinction I hope we're trying to make here is premise. I believe it is the premise that can clearly define whether something is health fraud. If the reason for advocating a particular health intervention has to do primarily with a monetary return on investment, vitalistic belief or philosophy, or self gratification, well, chances are...