April Mann

Comparison of Electrocardiographic- Gated Technetium-99m Sestamibi Single-Photon Emission Computed Tomographic Imaging and Rest- Redistribution Thallium-201 in the Prediction of Myocardial Viability

Although the combined assessment of perfusion and function using rest electrocardiographic (ECG)-gated technetium-99m (Tc-99m) sestamibi single-photon emission computed tomographic (SPECT) imaging has been shown to improve sensitivity and accuracy over perfusion alone in the prediction of myocardial viability, no data are available comparing this technique with rest-redistribution thallium-201. Thirty patients with coronary artery disease and left ventricular dysfunction (ejection fraction < or = 40%) underwent rest-redistribution thallium-201 and rest ECG-gated Tc-99m sestamibi SPECT imaging before revascularization and rest ECG-gated Tc-99m sestamibi SPECT imaging at 1 or 6 weeks after revascularization. All thallium-201 and Tc-99m sestamibi images were interpreted by a consensus agreement of 3 experienced readers without knowledge of patient identity or time of imaging with Tc-99m sestamibi (before or after revascularization) using a 17-segment model. Concordance between techniques for the prediction of viability was 89% (kappa 0.556 +/- 0.109). With rest-redistribution thallium-201, sensitivity, specificity, positive predictive value, negative predictive value, and predictive accuracy were 95%, 59%, 88%, 78%, and 86%, respectively. With rest ECG-gated Tc-99m sestamibi SPECT imaging, sensitivity, specificity, positive predictive value, negative predictive value, and predictive accuracy were 96%, 55%, 87%, 80%, and 86%, respectively (p = NS vs rest-redistribution thallium-201). Although both techniques are comparable for detecting viable myocardium, rest ECG-gated Tc-99m sestamibi SPECT imaging allows direct assessment of both myocardial perfusion and ventricular function, which may be clinically useful in patients who require assessment of myocardial viability.

Nuclear Medicine Technologist's Perception and Current Assessment of Quality: A Society of Nuclear Medicine and Molecular Imaging - Technologist Section (SNMMI-TS) Survey

In 2015, the Society of Nuclear Medicine and Molecular Imaging Technologist Section (SNMMI-TS) launched a multiyear quality initiative to help prepare the technologist workforce for an evidence-based health-care delivery system that focuses on quality. To best implement the quality strategy, the SNMMI-TS first surveyed technologists to ascertain their perception of quality and current measurement of quality indicators. Methods: An internet survey was sent to 27,989 e-mail contacts. Questions related to demographic data, perceptions of quality, quality measurement, and opinions on the minimum level of education are discussed in this article. Results: A total of 4,007 (14.3%) responses were received. When asked to list 3 words or phrases that represent quality, there were a plethora of different responses. The top 3 responses were image quality, quality control, and technologist education or competency. Surveying patient satisfaction was the most common quality measure (80.9%), followed by evaluation of image quality (78.2%). Evaluation of image quality (90.3%) and equipment functionality (89.4%) were considered the most effective measures. Technologists’ differentiation between quality, quality improvement, quality control, quality assurance, and quality assessment seemed ambiguous. Respondents were confident in their ability to assess and improve quality at their workplace (91.9%) and agreed their colleagues were committed to delivering quality work. Of note, 70.7% of respondents believed that quality is directly related to the technologist’s level of education. Correspondingly, respondents felt there should be a minimum level of education (99.5%) and that certification or registry should be required (74.4%). Most respondents (59.6%) felt that a Bachelor’s degree should be the minimum level of education, followed by an Associate’s degree (40.4%). Conclusion: To best help nuclear medicine technologists provide quality care, the SNMMI-TS queried technologists to discern perceptions of quality in nuclear medicine. The results show that technologists believe image quality and quality control are the most important determinants. Most respondents felt that quality is directly related to the level of education of the technologist acquiring the scan. However, the responses obtained also demonstrated variation in perception of what represents quality. The SNMMI-TS can use the results of the study as a benchmark of current technologists’ knowledge and performance of quality measures and target educational programs to improve the quality of nuclear medicine and molecular imaging.

The Importance of Quality in Ventilation–Perfusion Imaging

As the health care environment continues to change and morph into a system focusing on increased quality and evidence-based outcomes, nuclear medicine technologists must be reminded that they play a critical role in achieving high-quality, interpretable images used to drive patient care, treatment, and best possible outcomes. A survey performed by the Quality Committee of the Society of Nuclear Medicine and Molecular Imaging Technologist Section demonstrated that a clear knowledge gap exists among technologists regarding their understanding of quality, how it is measured, and how it should be achieved by all practicing technologists regardless of role and education level. Understanding of these areas within health care, in conjunction with the growing emphasis on evidence-based outcomes, quality measures, and patient satisfaction, will ultimately elevate the role of nuclear medicine technologists today and into the future. The nuclear medicine role now requires technologists to demonstrate patient assessment skills, practice safety procedures with regard to staff and patients, provide patient education and instruction, and provide physicians with information to assist with the interpretation and outcome of the study. In addition, the technologist must be able to evaluate images by performing technical analysis, knowing the demonstrated anatomy and pathophysiology, and assessing overall quality. Technologists must also be able to triage and understand the disease processes being evaluated and how nuclear medicine diagnostic studies may drive care and treatment. Therefore, it is imperative that nuclear medicine technologists understand their role in the achievement of a high-quality, interpretable study by applying quality principles and understanding and using imaging techniques beyond just basic protocols for every type of disease or system being imaged. This article focuses on quality considerations related to ventilation–perfusion imaging. It provides insight on appropriate imaging techniques and protocols, true imaging variants and tracer distributions versus artifacts that may result in a lower-quality or misinterpreted study, and the use of SPECT and SPECT/CT as an alternative providing a high-quality, interpretable study with better diagnostic accuracy and fewer nondiagnostic procedures than historical planar imaging.

Goals of the SNMMI-TS Quality Committee

As the health-care environment continues to change into a quality-focused system centered on evidence-based outcomes, the nuclear medicine community continues to face external pressures, including scrutiny about patient radiation exposure, a continued perception of overuse of testing, a decrease in reimbursement, and a decrease in technologist jobs because of the nation’s economy. These changes in health care, coupled with additional external pressures, will play a significant role in molding the future of nuclear medicine. To remain successful in this ever-changing health-care environment, SNMMI-TS will need to focus on, first, raising awareness in the health-care community about the value of nuclear medicine procedures in patient care and treatment and, second, ensuring that technologists have the training, competence, and credentials to perform these procedures in the new hybrid multimodality environment. It is also imperative that SNMMI-TS collaborate and build relationships with all stakeholders within the community to ensure widespread acceptance and credibility. Quality systems that focus on evidence-based patient outcomes and satisfaction are being used by the Centers for Medicare and Medicaid Services for reimbursement and education—from competency to recertification. Additionally, several states have mandated reporting of specific measures, and private payers are using other, similar, quality initiatives as an efficient way to cut costs and drive down reimbursement. Although the strong emphasis on quality is relatively new to most health-care professionals, almost 12 y ago the Institute of Medicine published the 6 elements every healthcare system should encompass in order to achieve high-quality patient care (1): safety (avoiding injuries to patients from the care that is intended to help them), effectiveness (providing services based on scientific knowledge to all who can benefit, and refraining from providing services to those not likely to benefit), patient-centeredness (providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions), timeliness (reducing waits and sometimes-harmful delays both for those who receive care and for those who give care), efficiency (avoiding waste, including waste of equipment, supplies, ideas, or energy), and equitability (providing care that does not vary in quality because of personal characteristics such as sex, ethnicity, geographic location, and socioeconomic status). One of the most important areas within the health-care field is the understanding and implementation of the transition to evidence-based outcomes and quality measures to drive high-level performance. The technologist of today must be skilled in assessing patients, applying safety practices for staff and patients, and educating and instructing patients. In addition, the technologist must be able to evaluate images for technical issues, demonstration of anatomy, and overall quality. Technologists must also be able to triage and understand the disease processes being evaluated and how nuclear medicine diagnostic examinations can drive care and treatment. To create programs addressing the new focus on quality in nuclear medicine, an SNMMI-TS quality committee in collaboration with the McKinley Advisors firm developed a survey investigating how quality is viewed, measured, and learned by technologists in the nuclear medicine field today. The survey was administered to 27,989 technologists from July 28 to August 18, 2016. SNMMI partnered with the ARRT and the NMTCB to compile the distribution list, enabling the survey to reach a broader audience. The survey garnered 4,007 responses, for a 14.3% response rate. The full results were published in the June 2017 JNMT. The quality committee developed goals based on the survey to ensure technologists are prepared for the many clinical challenges they will face, and a 5-y plan toward achieving these goals was put into place. The objectives are to enhance quality through education and to use advocacy, leadership, public relations, outreach, and collaboration to help those outside the profession become more aware of the need for quality. Such objectives will arm technologists with the tools not only to provide patients with a good experience but also to demonstrate the high quality and safety of nuclear medicine procedures. The first 2 y of the 5-y plan focus on identifying avenues of collaboration among stakeholders, securing funding for ongoing and future initiatives, creating and implementing quality-education programs, developing an awareness campaign, and demonstrating quality as it relates to the continuum of care. The last 3 y focus on quality-related continuing education initiatives; collaboration with external stakeholders; Received Nov. 6, 2017; revision accepted Dec. 7, 2017. For correspondence or reprints contact: April Mann, Hartford Healthcare Corporation, 80 Seymour St., JB722 Suite M, Hartford, CT 06102. E-mail: april.mann@hhchealth.org Published online Dec. 22, 2017. COPYRIGHT© 2018 by the Society of Nuclear Medicine and Molecular Imaging. DOI: 10.2967/jnmt.117.204925