Virtual colonoscopy approved by US preventive task force!!

[Taurus]

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This is huge for radiology! Congrats to everyone who made this possible. Many kids of radiologists will be put through college because of this. First, CT lung screening and now this.

http://www.auntminnie.com/index.aspx?sec=sup&sub=cto&pag=dis&itemid=114461

June 15, 2016 -- In a decision long-awaited by CT colonography (CTC) advocates, the U.S. Preventive Services Task Force (USPSTF) has finally deemed the modality to be an acceptable option for colorectal cancer screening. The determination paves the way for Medicare reimbursement and broader coverage by private payors.

 

[DrBowtie]

This is huge for radiology! Congrats to everyone who made this possible. Many kids of radiologists will be put through college because of this. First, CT lung screening and now this.

http://www.auntminnie.com/index.aspx?sec=sup&sub=cto&pag=dis&itemid=114461

June 15, 2016 -- In a decision long-awaited by CT colonography (CTC) advocates, the U.S. Preventive Services Task Force (USPSTF) has finally deemed the modality to be an acceptable option for colorectal cancer screening. The determination paves the way for Medicare reimbursement and broader coverage by private payors.

My email has been blowing up from various radiology organizations touting this. I bet the ACR boot camp is going to be packed for the near future.

 

[FranzLO]

So can I actually apply to the specialty I have always preferred now or do I have to fear robots and 80 year olds who refuse to retire. I can't remember what my generation, with less job opportunities with much higher debt is supposed to hate more. I could use a reminder.

 

[vm26]

This is huge for radiology! Congrats to everyone who made this possible. Many kids of radiologists will be put through college because of this. First, CT lung screening and now this.

http://www.auntminnie.com/index.aspx?sec=sup&sub=cto&pag=dis&itemid=114461

June 15, 2016 -- In a decision long-awaited by CT colonography (CTC) advocates, the U.S. Preventive Services Task Force (USPSTF) has finally deemed the modality to be an acceptable option for colorectal cancer screening. The determination paves the way for Medicare reimbursement and broader coverage by private payors.

Apparently the time it takes a radiologist to get through a CTC (2ish RVUs), one can get through 3 brain MRIs w/con (>5-6 ish RVUs), so not quite sure how this will work outside of academics

 

[Taurus]

This a long term play. If you look at the history of other screening efforts such as mammo, it took some time before it became firmly established and part of most radiology practices. Radiologists at first hated mammo because the technology was still in its infancy and they were not well trained in it. Mammo practices closed down because they didn't know how to run it profitably. Eventually, the technology matured, residents were better trained, and practices learned to make a tidy profit. At my practice, mammo is the most profitable and highest margin area of our business.

I think it will take approximately 5-10 years before you see VC being offered broadly. When you look at the costs, stool studies and VC are much less costly and they make more sense as being the screening test of choice for most people. I think insurance companies will see that too and create a strong incentive for you to get either one before traditional colonoscopy.

I've been saying for years that VC and CT lung screening were coming. There were naysayers who ridiculed me and said never. First, CT lung screening passed. Now VC. By coming up with new technologies, that's how radiology stays relevant and enviable . We have to create new opportunities for ourselves and can't rely solely on outdated ones, ones that have had their reimbursements cut to oblivion, or areas where non-radiologists are trying to steal from us. I think that in the future you will see CT lung screening and VC contributing more and more to the group's revenue. They are perfect technologies for radiologists because there is no real danger of some other specialty usurping them from us because of the extrapulmonary or extracolonic findings. If anything, we will be taking away from GI's colonoscopy volume. Furthermore, as a screening tool, anybody can order these tests, from the PCP, midlevel, to the specialsts. We are not beholden to a subspecialtist to order them. That is why cardiac nucs was stolen by cards and why cardiac CTA and MRI are shamefully underutilized because typically cards would order them.

 

[WilliamofOckham]

...

I've been saying for years that VC and CT lung screening were coming...

Truly the "Paul Revere of Medicine." 😉

 

[PL198]

This a long term play. If you look at the history of other screening efforts such as mammo, it took some time before it became firmly established and part of most radiology practices. Radiologists at first hated mammo because the technology was still in its infancy and they were not well trained in it. Mammo practices closed down because they didn't know how to run it profitably. Eventually, the technology matured, residents were better trained, and practices learned to make a tidy profit. At my practice, mammo is the most profitable and highest margin area of our business.

I think it will take approximately 5-10 years before you see VC being offered broadly. When you look at the costs, stool studies and VC are much less costly and they make more sense as being the screening test of choice for most people. I think insurance companies will see that too and create a strong incentive for you to get either one before traditional colonoscopy.

I've been saying for years that VC and CT lung screening were coming. There were naysayers who ridiculed me and said never. First, CT lung screening passed. Now VC. By coming up with new technologies, that's how radiology stays relevant and enviable . We have to create new opportunities for ourselves and can't rely solely on outdated ones, ones that have had their reimbursements cut to oblivion, or areas where non-radiologists are trying to steal from us. I think that in the future you will see CT lung screening and VC contributing more and more to the group's revenue. They are perfect technologies for radiologists because there is no real danger of some other specialty usurping them from us because of the extrapulmonary or extracolonic findings. If anything, we will be taking away from GI's colonoscopy volume. Furthermore, as a screening tool, anybody can order these tests, from the PCP, midlevel, to the specialsts. We are not beholden to a subspecialtist to order them. That is why cardiac nucs was stolen by cards and why cardiac CTA and MRI are shamefully underutilized because typically cards would order them.

if you had to guess, what is next rads screening thing on horizon

 

[Taurus]

Radiology is very dynamic. Unlike other staid fields like pathology and radonc who rely 100 year technology or basically one technology, radiology has its hands in so many areas. Their job markets are not good either but they have no levers to pull except cutting resident positions. They don't have many exciting new technologies in the pipeline to drive up demand.

In addition to CT lung screening and VC, another huge win for radiology this year has been ultrasound contrast. Other countries have had access to it for many years but the FDA dragged its feet here. In the future, you will be able to evaluate liver, renal, and breast lesions more quickly and easily and in patients with iodine or gadolinium contrast allergies or renal insufficiency. As many specialties use bedside ultrasound without radiology involvement, I think ultrasound contrast will make more people realize that ultrasound requires more than a weekend course and that radiology involvement is important. The FDA also recently approved a new PET agent for prostate cancer. Bottom line, there is always new stuff coming out.

It will take time to digest all of these new wins. Medicine does not move as fast as the Silicon Valley tech companies. Depending on your group, it will take time before the small community practices offer some or all of these offerings. Groups have to consider the costs, return on investment, politics, expertise, etc. You can bet that GI will resist VC as much as possible but they are on the losing end because we won't depend on their referrals. Right now, barium enema or VC is typically ordered by GI because of a failed traditional colonoscopy. That referral pattern will change as PCP, midlevels, and specialsts will all order VC. I think it will probably take 5-10 years before CT lung screening and VC are widely offered.

 

[Taurus]

Once VC becomes commonplace, I predict that some visionary radiology practices will begin to do the colonoscopy themselves and biopsy the polyp. And why not? You have already done the hard job of finding the abnormality on the VC. The VC gives you a roadmap of the colon for you to follow. The patient came to our imaging center for the VC. Why should we refer the patient out? This assumes that reimbursements are still good at that point to do a colonoscopy with biopsy and that the radiologists are adequately trained. If the reimbursement sucks, then refer out the biopsy. Heck, if NPs, family doctors, and surgeons are doing sigmoidoscopies and colonoscopies, why can't radiologists? We already do most image guided procedures currently. This is probably 10-20 years in the future. First, VC has to be widely adopted.

 

[scootad.]

Does anyone forsee GI practices purchasing CT machines and doing VC themselves? I realize that CT machines aren't cheap, but if they can funnel all/most of their patients to them, the cost may pay for itself especially if they get older/leased machines.

 

[Taurus]

GI practices can certainly buy CT machines and do VC. However, they would need to hire radiologists to read the VC studies because there are so many extracolonic areas to review. We overread for a cardiology practice in town. The owner of the machine collects the technical fee while the radiologists collect the professional fee. This is nothing new.

I would argue that it's more possible for radiologists to learn how to do colonoscopies themselves than GI docs to fully read a VC study without radiology overread. If you think about it, it makes a lot of sense for radiologist to do the colonoscopy. The patient would have the same prep for either procedure. So if the patient has already been prepped, then it's easy to do the colonoscopy same day as the VC.

Once I have a patient in my imaging center, that is my patient until I refer them out. That is radiology's version of "owning" the patient. You have to take advantage of that opportunity and maximize it. To use an analogy, that is why mammo is such a powerful area in radiology. The radiologist screens and sees the abnormality. They decide to do the biopsy. They only involve the surgeon, oncologist, and radonc much later in the process after most of the diagnostic workup is done.

 

[meister]

I like the aggression but who on earth will train the X-ray doc to do a colonoscopy? It's not like you have an online nursing degree.

 

[Taurus]

Who trained the cards to read cardiac nucs? Who trained the vascular surgeons and neurosurgeons to do endovascular work? Who trained the nephrologists to do fistula work? It has to start somewhere. It's not insurmountable.

 

[PL198]

GI practices can certainly buy CT machines and do VC. However, they would need to hire radiologists to read the VC studies because there are so many extracolonic areas to review. We overread for a cardiology practice in town. The owner of the machine collects the technical fee while the radiologists collect the professional fee. This is nothing new.

I would argue that it's more possible for radiologists to learn how to do colonoscopies themselves than GI docs to fully read a VC study without radiology overread. If you think about it, it makes a lot of sense for radiologist to do the colonoscopy. The patient would have the same prep for either procedure. So if the patient has already been prepped, then it's easy to do the colonoscopy same day as the VC.

Once I have a patient in my imaging center, that is my patient until I refer them out. That is radiology's version of "owning" the patient. You have to take advantage of that opportunity and maximize it. To use an analogy, that is why mammo is such a powerful area in radiology. The radiologist screens and sees the abnormality. They decide to do the biopsy. They only involve the surgeon, oncologist, and radonc much later in the process after most of the diagnostic workup is done.

who says they have to look at extracolonic findings while doing VC? like is that a requirement? I look at that as icing on the cake but I could see them making argument if the whole point is for colon cancer then they don't need to be able to look extracolonic

 

[DrBowtie]

who says they have to look at extracolonic findings while doing VC? like is that a requirement? I look at that as icing on the cake but I could see them making argument if the whole point is for colon cancer then they don't need to be able to look extracolonic

If it's visible, you're liable.

 

[PL198]

Didn't know that but I guess that's good for rads

 

[shark2000]

who says they have to look at extracolonic findings while doing VC? like is that a requirement? I look at that as icing on the cake but I could see them making argument if the whole point is for colon cancer then they don't need to be able to look extracolonic

It is not ethical to irradiate the whole abdomen and then ignore many parts. It is like saying that you order a CBC to look only at WBC count. So if the Hb is low, you should ignore it or you should not take any action because the whole point is to look at WBC.

 

[cowme]

Apparently the time it takes a radiologist to get through a CTC (2ish RVUs), one can get through 3 brain MRIs w/con (>5-6 ish RVUs), so not quite sure how this will work outside of academics

Think your numbers are flipped. CTC is about 6-7 RVUS while brain and spine are 2ish. But neuro is a notoriously RVU heavy field, so you can't really look at it like that. CTC pays about 5X that of a barium enema, which is far more of a resources and time sink. Anything that can help barium enemas meet their long overdue and inevitable death is a huge step for physician and patient sanity.

 

[meister]

I have personally seen cardiologists completely ignore extra-cardiac findings in cardiac CT/MR. And this is just the stuff that's processed/displayed. Some places the techs won't even send over all the imaging data.

I have never heard of a missed finding triggering a lawsuit in such a case though.

 

[scootad.]

That's interesting that you mention the scenario where cardiologists ask the CT tech only to send the reconstructed images of the organ of interest (in this case the heart), and all the rest of the raw data including the other organs gets deleted. I'll take your word for it, because we don't do cardiac where I work.

Is this possible regarding the colon? If yes, are there laws/regulations that prevent this from happening? I'm genuinely interested, because once you take out the extra-colonic issue, I see little reason why GI would give this turf up.

 

[DrBowtie]

I have personally seen cardiologists completely ignore extra-cardiac findings in cardiac CT/MR. And this is just the stuff that's processed/displayed. Some places the techs won't even send over all the imaging data.

I have never heard of a missed finding triggering a lawsuit in such a case though.

That's interesting that you mention the scenario where cardiologists ask the CT tech only to send the reconstructed images of the organ of interest (in this case the heart), and all the rest of the raw data including the other organs gets deleted. I'll take your word for it, because we don't do cardiac where I work.

Is this possible regarding the colon? If yes, are there laws/regulations that prevent this from happening? I'm genuinely interested, because once you take out the extra-colonic issue, I see little reason why GI would give this turf up.

I believe Leonard Berlin wrote an article about this topic within the past two years in AJR. I don't recall all the details but suggested that you're responsible for the raw data too. The potential saving grace comes with its deletion from the scanner rather than archival to PACS.

I'll try to track it down. Edit: Found it, see below.

 

[PL198]

I believe Leonard Berlin wrote an article about this topic within the past two years in JACR. I don't recall all the details but suggested that you're responsible for the raw data too. The potential saving grace comes with its deletion from the scanner rather than archival to PACS.

I'll try to track it down.

that seems like such a weak argument if you're recalling correctly. would be a stupid precedent, magically delete all documents and you aren't liable anymore? doesn't seem logical

 

[DrBowtie]

that seems like such a weak argument if you're recalling correctly. would be a stupid precedent, magically delete all documents and you aren't liable anymore? doesn't seem logical

Found the article:
AJR August 2016 Ahead of Print Online Only.
Leonard Berlins Medicolegal Series "Interpreting Large FOV versus Limited FOV"

 

[scootad.]

My understanding is most (all?) CT scanners only save images for a limited amount of time, like 2-4 weeks. So if the selected series images were never sent to PACS by the CT tech, they get automatically deleted from the machine.

So this makes sense. Thanks for the article Dr. Bowtie. I haven't had a chance to read it yet, but how timely (Ahead of print Aug 2016).

 

[DrBowtie]

My understanding is most (all?) CT scanners only save images for a limited amount of time, like 2-4 weeks. So if the selected series images were never sent to PACS by the CT tech, they get automatically deleted from the machine.

So this makes sense. Thanks for the article Dr. Bowtie. I haven't had a chance to read it yet, but how timely (Ahead of print Aug 2016).

Additionally, he has written articles about standard of care for non radiologist interpreting imaging and discussed pulmonary findings on cardiac CTs read by cardiologists (most analogous to the current discussion probably). Pretty much his whole article series is worth a read.

 

[meister]

The reason GI would have issues getting in on this is that they are busy already and don't own scanners. Plus they're not imaging specialists already.

Say what you want but cardiologists get training on imaging so it's not too much of a stretch for them.

 

[scootad.]

But if insurance companies steer a large % of GI's patients away from optical colonoscopy toward VC, I have a hard time believing GI would just sit around and take it. Why wouldn't they pool together and buy a CT scanner and start scanning VCs?

 

[vm26]

Think your numbers are flipped. CTC is about 6-7 RVUS while brain and spine are 2ish. But neuro is a notoriously RVU heavy field, so you can't really look at it like that. CTC pays about 5X that of a barium enema, which is far more of a resources and time sink. Anything that can help barium enemas meet their long overdue and inevitable death is a huge step for physician and patient sanity.

My data was from AM. Someone stated that CTC has a relatively low work RVU (2.28) compared to CT A/P (1.8). They also stated that one could read about 4 CT a/p in the time that it takes to supervise/perform and interpret a CTC exam. They/I may be wrong

 

[shark2000]

My data was from AM. Someone stated that CTC has a relatively low work RVU (2.28) compared to CT A/P (1.8). They also stated that one could read about 4 CT a/p in the time that it takes to supervise/perform and interpret a CTC exam. They/I may be wrong

You may be right. But it is not a valid reason for not doing it. For example, CXR pays peanuts but we end up doing it. The days that I read Xray the whole day, the RVUs that I generates is nothing compared to the days that I read MRI the whole day.

In reality, if it becomes the standard of care two things will happen:
1- The fee for optical colonoscopy will go down because insurance will not pay for OC at higher price.
2- Radiologists will end up doing it even if they don't want to. Similar to mammo or CXR.

There may be a push from GI community to learn the technology. I don't say they won't. Many general surgeons are doing screening colonoscopies these days, mostly outside academic places. Family doctors also do sigmoidoscopy. So yes. GI doctors will learn it. But in a big picture, since it is a screening tool, radiology will dominate the field. There is not need for the patient to see a GI doctor. Similar to mammograms. People just come in for their screening mammograms and most of them are referred by family doctors. Even some insurances don't need referral from family doctors and the radiology can do it without an order. Similarly, CTC won't need referral from GI. It will be referred from family doctors or even without referral.

I personally don't know about any cardiology group that cuts extra-cardiac findings. Most cardiologists who read CTA coronaries have radiology overread extracardiac findings. It is not easy just to cut anything outside heart. Do they just draw a line at the level of pericardium? The best they can do is to decrease the FOV but still some parts of mediastinum and lungs and bones are visible.

Anyway cardiac CTA is different since most of it is referred from cardiology and some from CT surgery. It is not a true screening test and the results needs to be put in a clinical context. Somehow like cardiac SPECT. The patient usually has chest pain. You can not say it is normal and go home. On the other hand, for TRUE screening tests like mammo or colonoscopy, you can tell the patient to go home and come back in a year or 5 years. No need for GI or breast surgeon.

Having said that, I personally see the DNA test in stool a more "revolutionary" step. Sooner or later, it will replace OC or CTC. It is just a matter of time. I know many GI docs and many others will disagree with me but let's face the reality. The current practice of GI will change dramatically in the future when it comes to screening for colon cancer. It is very effective but at the same time very "aggressive" for just a screening test. Screening test does not need to be perfect and once the stool DNA reaches a certain level of sensitivity and specificity it will replace CTC or OC.

Which one is better? To have 60% of population screened by OC with 98% accuracy or 65% screened by CTC with 92% of accuracy or 90% screened by stool DNA with for example 85% accuracy. Be sure that the third option is the most viable option.

 

[cowme]

Not to mention, a highly complicated 90 year old ICU ct abdomen pelvis takes far longer than an 18 year old with appendicitis. Should we not read the 90 year old CTs because the RVU is the same?

Shark, If the stool test is only 85% accurate, that sounds like a lot of business to assess false positive tests. Since when did screening tests replace diagnostic ones?

 

[shark2000]

Not to mention, a highly complicated 90 year old ICU ct abdomen pelvis takes far longer than an 18 year old with appendicitis. Should we not read the 90 year old CTs because the RVU is the same?

Shark, If the stool test is only 85% accurate, that sounds like a lot of business to assess false positive tests. Since when did screening tests replace diagnostic ones?

Nope. Like mammography or CT chest screening, colonoscopy also has two aspects: screening and diagnostics.

70% of GI revenue comes from the screening part. It is fast, negative most of the time and the patient is stable/outpatient unlike an ICU patient with GI bleeding.

I didn't say stool test will replace colonoscopy, but there is a potential that it replaces screening colonoscopy. Screening test does not need to be 100% accurate. The best example is like mammo. I have not read any mammo in the last 4 years. But in screening mammo we used to give BIRADS zero to everything that was thought to be abnormal. Similarly, on a stool test you don't need to make a diagnosis. Just call it incomplete.

 

[vm26]

Not to mention, a highly complicated 90 year old ICU ct abdomen pelvis takes far longer than an 18 year old with appendicitis. Should we not read the 90 year old CTs because the RVU is the same?

Complicated 90 year old ICU exams usually take longer but trade off is that incidentalomas become relatively irrelevant, plus we have to read these in-pt studies...Many community practices do not offer somewhat bread and butter services such as MR guided breast biopsies, don't think they will offer elective out-pt CTC at this point given reimbursement.