Scott Jerome

Patient-Centered Imaging: Shared Decision Making for Cardiac Imaging Procedures With Exposure to Ionizing Radiation

The current paper details the recommendations arising from an NIH-NHLBI/NCI-sponsored symposium held in November 2012, aiming to identify key components of a radiation accountability framework fostering patient-centered imaging and shared decision-making in cardiac imaging. Symposium participants, working in 3 tracks, identified key components of a framework to target critical radiation safety issues for the patient, the laboratory, and the larger population of patients with known or suspected cardiovascular disease. The use of ionizing radiation during an imaging procedure should be disclosed to all patients by the ordering provider at the time of ordering, and reinforced by the performing provider team. An imaging protocol with effective dose ≤3 mSv is considered very low risk, not warranting extensive discussion or written informed consent. However, a protocol effective dose >20 mSv was proposed as a level requiring particular attention in terms of shared decision-making and either formal discussion or written informed consent. Laboratory reporting of radiation dosimetry is a critical component of creating a quality laboratory fostering a patient-centered environment with transparent procedural methodology. Efforts should be directed to avoiding testing involving radiation, in patients with inappropriate indications. Standardized reporting and diagnostic reference levels for computed tomography and nuclear cardiology are important for the goal of public reporting of laboratory radiation dose levels in conjunction with diagnostic performance. The development of cardiac imaging technologies revolutionized cardiology practice by allowing routine, noninvasive assessment of myocardial perfusion and anatomy. It is now incumbent upon the imaging community to create an accountability framework to safely drive appropriate imaging utilization.

2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR appropriate utilization of cardiovascular imaging in heart failure: A joint report of the American college of radiology appropriateness criteria committee and the American college of cardiology foundation appropriate use criteria task force

Peter Alagona, MD[⁎][1] Gerard Aurigemma, MD[‡][2] Javed Butler, MD, MPH[§][3] Don Casey, MD, MPH, MBA[∥][4] Ricardo Cury, MD[#][5] Scott Flamm, MD[¶][6] Tim Gardner, MD[⁎⁎][7] Rajesh Krishnamurthy, MD[††][8] Joseph Messer, MD[⁎][1] Michael W. Rich, MD[‡‡][9] Henry

Current worldwide nuclear cardiology practices and radiation exposure: results from the 65 country IAEA Nuclear Cardiology Protocols Cross-Sectional Study (INCAPS)

Aims To characterize patient radiation doses from nuclear myocardial perfusion imaging (MPI) and the use of radiation-optimizing ‘best practices’ worldwide, and to evaluate the relationship between laboratory use of best practices and patient radiation dose. Methods and results We conducted an observational cross-sectional study of protocols used for all 7911 MPI studies performed in 308 nuclear cardiology laboratories in 65 countries for a single week in March–April 2013. Eight ‘best practices’ relating to radiation exposure were identified a priori by an expert committee, and a radiation-related quality index (QI) devised indicating the number of best practices used by a laboratory. Patient radiation effective dose (ED) ranged between 0.8 and 35.6 mSv (median 10.0 mSv). Average laboratory ED ranged from 2.2 to 24.4 mSv (median 10.4 mSv); only 91 (30%) laboratories achieved the median ED ≤ 9 mSv recommended by guidelines. Laboratory QIs ranged from 2 to 8 (median 5). Both ED and QI differed significantly between laboratories, countries, and world regions. The lowest median ED (8.0 mSv), in Europe, coincided with high best-practice adherence (mean laboratory QI 6.2). The highest doses (median 12.1 mSv) and low QI (4.9) occurred in Latin America. In hierarchical regression modelling, patients undergoing MPI at laboratories following more ‘best practices’ had lower EDs. Conclusion Marked worldwide variation exists in radiation safety practices pertaining to MPI, with targeted EDs currently achieved in a minority of laboratories. The significant relationship between best-practice implementation and lower doses indicates numerous opportunities to reduce radiation exposure from MPI globally.

Nationwide Laboratory Adherence to Myocardial Perfusion Imaging Radiation Dose Reduction Practices: A Report From the Intersocietal Accreditation Commission Data Repository.

OBJECTIVES This study sought to examine current laboratory practices for radiation effective doses for myocardial perfusion imaging (MPI) and laboratory adherence to guideline-directed radiation reduction practices. BACKGROUND A recent focus on radiation dose reduction for cardiovascular imaging has led to several published guidelines and consensus statements detailing performance metrics for laboratory practices. We sought to examine laboratory adherence to optimized radiation dose protocol recommendations among 5,216 submitted cases from 1,074 MPI laboratories evaluated for Intersocietal Accreditation Commission accreditation. METHODS Eligible imaging centers included MPI laboratories enrolled in the Intersocietal Accreditation Commission data repository of accreditation applications from 2012 to 2013. Accreditation requires submission of 3 to 5 cases for evaluation of a range of representative cases. Based on standard dosimetry for rest and stress MPI, an effective dose (in millisieverts) was calculated. Model simulations were performed to estimate guideline-directed effective doses. RESULTS The average effective dose was 14.9 ± 5.8 mSv (range 1.4 to 42.4 mSv). A 1-day technetium Tc 99m protocol was used in 82.9% of cases, whereas a 2-day technetium Tc 99m and dual isotope protocol was used in 7.5% of submitted cases. Only 1.5% of participating imaging centers met current guidelines for an average laboratory radiation exposure ≤9 mSv, whereas 10.1% of patient effective doses were >20.0 mSv. A model simulation replacing the radiation exposure of dual isotope MPI with that of a 1-day technetium Tc 99m protocol reduced the proportion of patients receiving an effective dose >20 mSv to only 2.7% of cases (p < 0.0001). CONCLUSIONS Mandatory laboratory accreditation for MPI allows for examination of current radiation dosimetry practices. Current guidelines for reduced patient-specific radiation exposure are rarely implemented, with few laboratories meeting recommendations of ≤9 mSv for 50% of patients. Increased educational efforts and the development of performance measures for laboratory accreditation may be required to meet current radiation dose-reduction standards.

How Do Noninvasive Imaging Facilities Perceive the Accreditation Process? Results of an Intersocietal Accreditation Commission Survey

The Intersocietal Accreditation Commission (IAC) accredits vascular, echocardiography, nuclear medicine, computed tomography, and magnetic resonance imaging laboratories. How facilities involved in the accreditation process view accreditation is unknown. The objective of this study was to examine the perception of laboratory accreditation from those who had undergone the process. An electronic survey request was sent to all facilities that had received IAC accreditation at least once. Demographic information, as well as opinions on the perceived value of accreditation as it relates to 15 quality metrics was acquired. Responses were obtained from 2782 facilities. Of the 15 quality metrics examined, the process was perceived as leading to improvements by a majority of respondents for 10 (67%) metrics including: report standardization, adherence to guidelines, test standardization, report completeness, identification of deficiencies, improved staff knowledge, report timeliness, distinguished facility, correction of deficiencies, and image quality. Overall, the perceived improvement was greater for hospital‐based facilities (global 66% vs 59%; P < 0.001). Survey data demonstrate that the accreditation process has a positive perceived impact on the majority of examined metrics. These findings suggest that those undergoing the process find value in accreditation.

HOW DO NON-INVASIVE IMAGING FACILITIES PERCEIVE THE ACCREDITATION PROCESS? RESULTS OF AN INTERSOCIETAL ACCREDITATION COMMISSION (IAC) SURVEY

Background: The Intersocietal Accreditation Commission (IAC) accredits vascular, echocardiography, nuclear medicine, PET, CT and MR imaging facilities. How those involved in the accreditation process view accreditation is unknown. We sought to examine the perception of accreditation from those who underwent the process successfully. Methods: An electronic survey was sent to all IAC accredited facilities. Demographic information, as well as opinions on the value of accreditation as it relates to various quality metrics were acquired. Results: Responses were obtained from 2782 (7%) facilities including 1004 (36%) echocardiography, 832 (30%) vascular, 641 (23%) nuclear/PET, 164 (6%) CT and 141 (5%) MR facilities of which 42% were hospital-based and 58% office-based. Of the 15 quality metrics examined, the process was perceived as leading to improvements by a majority of respondents for 10 metrics (Table) including: report standardization, adherence to guidelines, test standardization, report completeness, identification of deficiencies, improved staff knowledge, report timeliness, correction of deficiencies, facility distinction and image quality. Overall, the perceived improvement was greater for hospital-based facilities (global 65% vs. 59%; p<0.001). Conclusion: Results of the IAC survey indicate that the accreditation process has a positive perceived impact on the majority of examined metrics. These findings suggest that those undergoing the process find value in accreditation. : Category (Complete): 15. Non Invasive Imaging: Echo Prevention Pathway Abstracts (Complete): My study will help enable cardiovascular clinicians to . . . . : Not applicable. None of the above statements relate to the research described in my abstract. Clicking this answer will not jeopardize the review of my abstract. Keyword (Complete): Quality ; Diagnostic performance ; Practice management Institution Information (Complete): *Responsible Institution 1: : Intersocietal Accreditation Commission *City: : Ellicott City *State: Maryland *Country: USA * : No * : No Page 1 of 2 Oasis, The Online Abstract Submission System 11/19/2013 http://www.abstractsonline.com/submit/SubmitPrinterFriendlyVersion.asp?ControlKey=... Need Technical Assistance? OASIS Helpdesk American College of Cardiology 2400 N Street, NW Washington, DC 20037 Leave OASIS Feedback Powered by OASIS, The Online Abstract Submission and Invitation System SM

Accreditation Is Perceived to Improve Echocardiography Laboratory Quality: Results of an Intersocietal Accreditation Commission Survey:

The Intersocietal Accreditation Commission (IAC) began accrediting echocardiography laboratories in 1996 to improve quality in diagnostic imaging facilities. With no existing data linking accreditation to improved outcomes, the aim of this study was to examine the perceived value of accreditation among individuals who have successfully achieved IAC echocardiography accreditation. An electronic survey was sent to accredited facilities soliciting demographic data along with questions regarding the perceived value of accreditation related to 15 quality indicators; 10.455 emails were sent with 999 responses (9.6%), and 63% of respondents reported improvement in results due to accreditation. Of the 15 quality indicators, the process was perceived as leading to improvement by a majority for 10 of the quality indicators. Nonphysicians tended to report more improvement compared with physicians (64% vs. 54%, P = .056). The perceptions from hospital-based respondents were more favorable than nonhospital-based respondents (67% vs. 59%, P < .001). More than 90% of respondents reported that maintaining accreditation was important for improved quality and better reimbursement. The study showed that IAC echocardiography facility accreditation is perceived by most facilities to improve operations for most quality indicators, particularly regarding study quality and reporting.

Nuclear cardiology practices and radiation exposure in Africa: Results from the IAEA Nuclear Cardiology Protocols Study (INCAPS)

Summary Objective: While nuclear myocardial perfusion imaging (MPI) offers many benefits to patients with known or suspected cardiovascular disease, concerns exist regarding radiationassociated health effects. Little is known regarding MPI practice in Africa. We sought to characterise radiation doses and the use of MPI best practices that could minimise radiation in African nuclear cardiology laboratories, and compare these to practice worldwide. Methods: Demographics and clinical characteristics were collected for a consecutive sample of 348 patients from 12 laboratories in six African countries over a one-week period from March to April 2013. Radiation effective dose (ED) was estimated for each patient. A quality index (QI) enumerating adherence to eight best practices, identified a priori by an IAEA expert panel, was calculated for each laboratory. We compared these metrics with those from 7 563 patients from 296 laboratories outside Africa. Results: to that of the rest of the world [9.1 (5.1–15.6) vs 10.3 mSv (6.8–12.6), p = 0.14], although a larger proportion of African patients received a low ED, ≤ 9 mSv targeted in societal recommendations (49.7 vs 38.2%, p < 0.001). Bestpractice adherence was higher among African laboratories (QI score: 6.3 ± 1.2 vs 5.4 ± 1.3, p = 0.013). However, median ED varied significantly among African laboratories (range: 2.0–16.3 mSv; p < 0.0001) and QI range was 4–8. Conclusion: Patient radiation dose from MPI in Africa was similar to that in the rest of the world, and adherence to best practices was relatively high in African laboratories. Nevertheless there remain opportunities to further reduce radiation exposure to African patients from MPI.

Reconciling discordant myocardial perfusion imaging and coronary angiography

A common clinical conundrum presents itself in the discordance between nuclear stress testing and invasive coronary angiography (ICA) in the patient presenting with angina. A patient with an abnormal perfusion scan and “normal coronary angiography” may result in the patient’s symptoms being dismissed as “non-cardiac.” Alternatively, a patient with a “normal perfusion study,” who nonetheless undergoes ICA and is found to have significant coronary artery disease may confound efforts to risk stratify and potentially treat patients with angina. This paper will review the current evidence to explain these apparent paradoxical scenarios.

It’s about time we think about lowering radiation dose in obese patients too

Medical technology has advanced at a rapid pace, particularly, the diagnostic imaging tools relied upon daily to care for patients. Myocardial perfusion imaging (MPI) uses advanced technology and radiopharmaceuticals to detect, assess, and risk-stratify ischemic heart disease. The level of radiation exposure from these scans is often higher than other diagnostic imaging procedures. Patients and health care providers are increasingly more aware of and concerned about the potential health risks associated with radiation exposure. It is, therefore, prudent that the radiation dose from diagnostic imaging scans be kept as low as possible while maximizing image quality. Therein lies the problem. If we were to construct the ideal radiation reduction strategy, it would be adaptable to patients of all ages, body habitus, ambulatory status, and admission state. Protocols should be flexible for both patients and laboratories while hopefully improving workflow. Expensive hardware and software would not be required, and there should be associated cost savings. All of this must be accomplished while concomitantly producing highquality images that can be confidently used to make the correct diagnosis. To address concerns related to radiation, the American Society of Nuclear Cardiology (ASNC) published several recommendations for reducing radiation dose. Suggested approaches include utilization of appropriate use criteria, stress-only imaging, limited use of a dual isotope protocol, and PET imaging, where appropriate. Other approaches rely on recent improvements in camera hardware and software such as highsensitivity cadmium zinc telluride (CZT) solid-state detectors and iterative reconstruction resolution recovery algorithms, which can allow injection of less radiotracer and/or decrease image acquisition time. Along with specific techniques for lowering radiation dose, the many recommendations emphasize patientcentered imaging that tailors the imaging protocol specifically to each patient. ASNC specifically advocated reducing radiation exposure such that [50% of a facility’s MPI patients receive a total effective dose B9 mSv. A recent study published by Jerome et al. reviewed 5216 MPI studies performed at 1074 Intersocietal Accreditation Commission accredited facilities in 2012 and 2013. They found most facilities were not meeting this radiation dose goal. They reported the average effective dose was 14.9 ± 5.8 mSv, far above the B9 mSv goal. Only 1.4% of all laboratories administered B9 mSv in [50% of cases. Additionally, they found that only 0.4% of studies performed were stress-only, and 7.5% of facilities continued to use the dual isotope protocol. These findings suggest that laboratories still encounter difficulties in routinely lowering radiation dose effectively. One particular struggle in reducing radiation exposure is obtaining quality images in obese patients at a lower radiation dose. Considering there are over 300 million obese people in the United States and with the number growing, better options to imaging obese patients are promptly needed. Increased body mass results in photon attenuation which decreases the signalto-noise ratio and increases scatter. The outcome is image noise, artifacts, and nondiagnostic results. See related article, pp. 1912–1921