1

Donna Newman B.A. RT( R) CNMT PET CNTSanford Health Fargo , North Dakota

Why Now???Pet Cardiac :

Program OutlineProgram OutlineSPECT vs PETCardiac PET agentsTechnical AspectsCurrent ProtocolsCase StudiesCase StudiesPlanning/Implementation Start-Up CostsReimbursement Marketing

SPECT

Attenuation artifacts– Soft tissue

• Diaphragm• Breast

Lateral fat pad

Disadvantages:Disadvantages:SPECT SPECT

• Lateral fat pad

Gastrointestinal uptakeProtocol, start to finish: 2-2.5 hours

Tc-99m shortages

2

Improvement with CT/ SPECT Camera’s

Evolution resolution recovery ½ time acquisitionAccurate attenuation correction

How Solid State detectors have changed SPECT Imaging

Scan Faster with less patient motion

Achieve near-perfect positioning every time

Better resolution and 10X sensitivity

CT/ Spect Gamma Cameras:

3

Solid State CZT detector technology:

Roger Maris Cancer Center :Houses our CT/PET Scanner:

CT/PET Scanner Housed in Cancer Center

Typical Schedule5 - ½ hour slots for

Pet oncology5- ½ hour slots for

CT planning 3 hours Table time still open on scanner losing opportunity for Revenue.

4

PET

Attenuation correction: alwaysImproved diagnostic accuracy for

– Obese patients– Large breasted women

B l h t d

Advantages: Advantages: PET PerfusionPET Perfusion

– Barrel chested menImproved resolutionLower radiation exposureWorkflow efficiency

– Protocol, start to finish:30-45 minutes

Ventricular function: stress, rest (peak stress added value)

Program OutlineProgram OutlineSPECT vs PETCardiac PET agentsTechnical AspectsCurrent ProtocolsCase StudiesCase StudiesPlanning/Implementation Start-Up CostsReimbursement Marketing

Breast attenuation Case:

Case example Breast Attenuation67, Female– Atypical sharp chest pain associated with arm movement.– No other cardiac history.– History of sleep apnea.– Risk factors: HLD, quit smoking 10 yrs ago.

Physical exam: Hgt: 5’2”, Wgt: 228 BMI 42Adenosine cardiolite ordered, cardiology referral.

5

RW - 5291158

66, Male– CABG in 2003.– Exertional dyspnea with chopping wood.– Risk factors: Type II DM, HLD, Obesity, – Chronic A FibChronic A. Fib.

Stress test: Submaximal, inconclusive.Adenosine cardiolite ordered.Physical: Hgt. 5’ 9 ½’’ Wgt. 233 BMI 34

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PET Myocardial Perfusion TracersPET Myocardial Perfusion TracersAGENTAGENT HALFHALF--

LIFELIFEDOSEDOSE

RANGERANGE

MEAN (+) MEAN (+) RANGERANGE

(mean (mean free path)free path)

PRODUCTIOPRODUCTIONN

METHODMETHOD

ABSOLUTE ABSOLUTE QUANTITATION OF QUANTITATION OF

MBFMBF

Rb-82 75 sec75 sec 2020––60 60 mCimCi

2.4 mm2.4 mm GeneratorGenerator In In developmentdevelopment

N-13 Ammonia

9.8 9.8 minmin

77––20 20 mCimCi

0.7 mm0.7 mm CyclotronCyclotron YesYes

O-15 Water

2.0 min

60–100 mCi

1.1 mm Cyclotron Yes

MBF = myocardial blood flow.

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Logistics: RubidiumLogistics: Rubidium--82 Generator82 Generator

Generator is replaced every 28 daysFixed price (~29K to 31K/month): the more you do, the more cost-effective AND vice versa“Unlimited” usage

Indications for Cardiac PETIndications for Cardiac PET

Pharmacologic stressObese patientsLarge breasted womenNondiagnostic or equivocal SPECT studiesHospitalized patientsER patients in the future– Atypical chest pain

Viability studies

Artifacts and False Positives produced from SPECT imaging

Patient motionGastrointestinal uptakeSoft tissue attenuation– Breast– Diaphragm– Lateral fat pad

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PET Image: No Bowel Uptake PET Image: No Bowel Uptake InterferenceInterference

PET: Improved Interpretive Certainty PET: Improved Interpretive Certainty vsvs SPECTSPECT

40

50

60

tain

ty (%

)

29

43

53 53P = 0.03

0

10

20

30

Inte

rpre

tive

Cer

t

SPECTPET

DefinitelyNormal

Probably Normal

Equivocal ProbablyAbnormal

DefinitelyAbnormal

29

70

60

5 4

P = 0.004

P = 0.007

Bateman TM et al. J Nucl Cardiol. 2006;13:24-33.

Patients with BMI >30 kg/mPatients with BMI >30 kg/m22: MeritCare : MeritCare Health System Experience (2005 Health System Experience (2005 –– 2006)2006)

r of P

atie

nts

185 patients (73%) with abnormal SPECT were found to have normal PET

Num

ber

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Prognostic Value of PET MPIPrognostic Value of PET MPINormal SSS

Mild SSS

Moderate and Severe SSS

ed S

urvi

val*

0 85

0.9

0.95

1

SSS = summed stress score.*Free from cardiac death and nonfatal myocardial infarction.Yoshinaga K et al. J Am Coll Cardiol. 2006;48:1029-1039.

Follow-Up (Years)

Ris

k-Ad

just

e

P = 0.016

0 0.5 1 1.5 2 2.5 3 3.5 40.7

0.75

0.8

0.85

MeritCare’sMeritCare’s Experience With Positive Experience With Positive Predictive Value of PETPredictive Value of PET

MeritCare’s research results match Yoshinaga’s research that patients with a normal PET MPI have mortality rate of <1% per year

MPI = myocardial perfusion imaging.

Breast Attenuation: CaseBreast Attenuation: Case

59-Year-Old-Female– Atypical CP, DOE– AS, AVA 0.9, paroxysmal AF, poorly tolerated– DM, HTN, SLE, autoimmune hemolytic anemia

asthma on cyclosporine and prednisoney p p– Abnormal stress Tc-99m in Bemidji– Referred to cardiology– Exam: Hgt 5’2” Wgt 272 BMI 50

AF = atrial fibrillation; AS = aortic stenosis; DM = diabetes mellitus; DOE = dyspnea on exertion; HTN = hypertension; SLE = systemic lupus erythematosus.

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Courtesy of Sandford Health System.

Courtesy of Sandford Health System.

Sample Inquiry Letter to Sample Inquiry Letter to PayorPayor to Determine to Determine Coverage for PET and RubidiumCoverage for PET and Rubidium--8282

Medical policy clarification regarding positron emission tomography using the tracer rubidium-82 in lieu of SPECT Study used for the diagnosis and management of patients with known or suspected CAD

(Insert insurance carrier)Medical Policy DepartmentCity, State

Medical Policy Clarification RegardingPositron Emission Tomography (PET) Health Care News 248, August 2004

(Insert clinic/hospital name) asks that (insert insurance carrier) clarify the above bulletin to address the benefit coverage of a PET scan, using the tracer rubidium -82, in lieu of single-photon emission computed tomography (SPECT) for non-invasive imaging of the perfusion of the heart. This study is used for the diagnosis and management of patients with known or suspected coronary artery disease using the FDA approved radiopharmaceutical, rubidium-82.

Medicare Part B covered diagnosis– PET scan is used following a

SPECT that was found to be inconclusive

Request for payor to indicate intention and timeline for updating this bulletin

(Insert clinic/hospital name) references Medicare B News issue 206, August 25, 2003, as containing the criteria to perform this PET:

1. Medicare Part B covered diagnosis are: 410.00-414.9 and the PET scan, whether at rest alone, or rest with stress, is performed in place of, but not in addition to, a SPECT; HCPCS code series G0030-G0047 with the tracer of rubidium (Q3000) or

2. The PET scan, whether at rest alone or rest with stress, is used following a SPECT that was found to be inclusive. In these cases, a PET scan must be considered necessary in order to determine what medical or surgical intervention is required to treat the patient.

Please indicate your intention and timeline for updating this bulletin to include this information so ( insert clinic/hospital name) can assess whether any (insert insurance carrier) subscribers would qualify for this efficient diagnostic tool.

Please contact me with any additional questions.

Sincerely,

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Policy Language: Insurance that Policy Language: Insurance that Covers PETCovers PET

Minnesota Blue Cross Blue ShieldCardiology

– Rb-82 PET or ammonium N-13 PET for:• Assessment of myocardial perfusion in the diagnosis of

coronary artery disease, following an inconclusive SPECT; or• Assessment of myocardial perfusion in the diagnosis of

coronary artery disease in obese patients with a body mass index (BMI) of greater than 35

Policy Language: Insurance that Does Policy Language: Insurance that Does Not Cover PETNot Cover PET

MedicaCardiology

– Myocardial perfusion imaging for diagnosing and determining the severity of suspected CAD due to the presence of associated signs or symptoms when all p g y pof the following criteria are met:

– Stress testing contraindicated– SPECT unavailable– Angiography is contraindicated– Results will be used to determine definitive treatment

Establish Core Committee One Year Establish Core Committee One Year Prior to Adding PET to Practice Prior to Adding PET to Practice

Nuclear medicine departmentCT departmentReferral and managed care coordinatorReimbursement specialistRadiologistCardiologist Senior management

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PET StartPET Start--Up TimelineUp Timeline

Coding Licensing, Space,Marketing

Equipment,

Logistics

Training

12-9 9-6 6 3 1 Months

PET Practice –Go Live

Payorassessment

Reimbursementprocess

Logistics

q pMarketing,Referral base

Training,Policies & procedures

SandfordSandford Health System Patient Mix Health System Patient Mix

MeritCare had a growth in cardiac patients of 19%

Property of MeritCare Health System.

PayorPayor Assessment: 9 Months Before Assessment: 9 Months Before PurchasePurchase

Patient Mix by Payor – MeritCare Health System

Payor Patient Mix

BCBS ND (CAD) 21%

Medicare (CAD) 27%

Cross reference ICD-9 codes that are covered in both SPECT and PET cardiac insurance policies in your state

– Examples:• CAD, chest pain 786.50-786.51 • Chest pain, other 786.59 • Shortness of breath, ischemic heart disease 410.00-414.9 DOE

Medicare (CAD) 27%

BCBS MN (CAD) 15%

DOE = dyspnea on exertion.Property of Sandford Health System.

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National Reimbursement

78492- multiple study

2010-$1,429.36

78492- multiple study

2005-$735.77$1,429.36

Proposed 2011-$1099.16

( includes Scan and Pet radiopharmaceutical)

$735.77

2006$2,484.88

Diagnostic procedure offered at Meritcare:2005 /2006

Cardiac PET started Feb 2005

Nuclear SPECT 13% increase

Stress Echo’s Started Jan 2006530 exams

CTAC’ sStarted in July 2007200 exams

Heart Cath’ s 4% increase

23% increase Bruce Stress 2% increase

TEE’ s1% increase

Cath Interventions 18% increase

Reimbursement Process: CodingReimbursement Process: CodingICD-9 Code Diagnosis410.0 Acute myocardial infarction of anterolateral wall

410.10 – 410.12 Acute myocardial infarction of other anterior wall

410.20 – 410.22 Acute myocardial infarction of inferolateral wall

410.30 – 410.32 Acute myocardial infarction of inferoposterior wall

410.40 – 410.42 Acute myocardial infarction of other inferior wall

410.50 – 410.52 Acute myocardial infarction of other lateral wall

410.60 – 410.62 Acute myocardial infarction, true posterior wall infarction

• Diagnosis – Indicate one of the following

NOTE: (Rubidium Pharmacological) PET scans (G0030--G0047) are covered under Medicare when furnished for the

410.70 – 410.72 Acute myocardial infarction, subendocardial infarction

410.80 – 410.82 Acute myocardial infarction of other specified sites

410.90 – 410.92 Acute myocardial infarction of other unspecified sites

411.0 – 411.89 Other acute & subacute forms of ischemic heart disease

412 Old myocardial infarction

413.0 – 411.9 Angina pectoris

414.00 – 414.03 Coronary atherosclerosis

414.06 Coronary atherosclerosis of native coronary artery of transplanted heart

414.07 Coronary atherosclerosis of bypass graft (artery)(vein) of transplanted heart

414.10 – 414.19 Aneurysm of heart

414.8 Other specified forms of chronic ischemic heart disease

414.9 Chronic ischemic heart disease, unspecified

furnished for the following conditions:

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Coding and ReimbursementCoding and Reimbursement

Cardiac PET CPT Codes

78491 Cardiac PET stress or rest single study

78492 Cardiac PET stress and rest multiple study

78459 Cardiac imaging, PET, metabolic evaluation

A9555 Rb-82 per dose (bundled)

A9552 FDG, per dose (bundled)

Coding and ReimbursementCoding and Reimbursement

Stress Testing

93015 Cardiovascular stress testing (global)

93016 Physician supervision only

93017 Tracing only (hospital)

93018 Interpretation and report only

J1245 Dipyridamole per 10 mg

J0152 Adenosine per 30 mg

The Pro Forma: Cardiac PETThe Pro Forma: Cardiac PETNew Camera Refurbished Camera

Patients Per Day 3.00 3.00 Patients Annually 756 756 Ave Rev per Patient (rubidium – 82) $2,363 $2,363 Revenue $1,786,216 $1,786,216 CTA Patients Per Day 1.00 1.00 CTA Patients Annually 252 252 CTA Ave Rev per Patient $400 $400 CTA Revenue $100,868 $100,868 Gross Revenue $1,887,084 $1,887,084 Less Bad Debt ($56,613) ($56,613)

First yearassumptions• New camera =$1,250,000• Refurbished =$500,000• Patients/day

• 3 cardiac• 1 CTA ($ , ) ($ , )

Net Revenue $1,830,472 $1,830,472 Capital Equipment Costs $561,317 $265,327 Administrative Tech. $20,000 $20,000 Nuclear Med. Tech. $80,000 $80,000 Registered Nurse $30,000 $30,000 Rubidium - 82 Cost $401,375 $401,375 Contrast Media $7,560 $7,560 Supplies $22,680 $22,680 Camera Service Agreement $0 $0 Infusion System Service Agreement $24,000 $24,000 Marketing $20,000 $20,000 Insurance $25,000 $25,000 Utilities $20,000 $20,000 Other $10,000 $10,000 Expenses $1,221,932 $925,942 PRE-TAX Income/(Loss) >>>>> $608,540 $904,530

• 0 oncology

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Reimbursement ProcessReimbursement Process

Prior authorization– Physician to physician review

Denied PET claims– Reprocess with additional documentation

• Letter of medical necessity• Letter of medical necessity• Invoices• Other

Policy Policy SandfordSandford Submitted To Submitted To Insurance Insurance

Anthem BCBS– Cardiology– Rb-82 PET

• To assess myocardial perfusion performed at rest or with pharmaceutical stress in the diagnosis of coronary disease. PET scanning is used to diagnosis and/or determine the severity of coronary artery disease when any of the following are present:

– Body habitus or other conditions for which SPECT may have attenuation problems ( eg, BMI ≥30%, large breasts, left mastectomy, breast implant, chest wall deformity, left pleural or pericardial effusion, circulatory problems in inferior- septal areas of the heart) or other technical difficulty (extensive prior myocardial infarction) or

– Conditions for which angiography may be technically challenging, (eg, low to intermediate probability of coronary artery disease, borderline stenosis) or associated with high risk for morbidity (allergy to contrast medium, poor arterial access, renal dysfunction for which angiography increases the likelihood of renal failure)

Property of Sandford Health System.

Blue Cross Blue Shield

Dear Medical Director:

I am writing in response to your proposed revised DRAFT Policy on Positron Emission Tomography (PET) regarding FDG PET Cardiology Applications. We are asking you edit #1 to say “diagnosis of coronary artery disease or determine the severity of coronary artery disease when there has been a recent inconclusive nuclear cardiac or stress echocardiography study in patient with at least an intermediate risk of coronary artery disease.”

In addition, please edit #2 to reflect the following; “Diagnosis of coronary artery disease or determine the severity of coronary artery disease in obese patients (BMI>30).” Bateman’s research from the ASNEC Journal January 2006, supports doing rubidium cardiac PET for patients who are obese with a BMI >30. This research confirms the artifacts that show up on SPECT

edit #1 to say “diagnosis of coronary artery disease” or determine the severity of coronary artery disease when there has been a recent i l i l di t

Payor Policy Amendment: Payor Policy Amendment: PET Provider Request Letter PET Provider Request Letter

rubidium cardiac PET for patients who are obese with a BMI 30. This research confirms the artifacts that show up on SPECT imaging. ____________ has had success in performing cardiac rubidium PET imaging on patients with BMI’s between 30 and 40. Allowing us to do a cardiac PET on these types of patients will help reduce overall health care costs, in addition to, eliminating a heart catheter in many cases. We are, therefore, asking you to change the BMI to reflect the standard of care that best reflect our patient population.

We can’t stress how important it is to add or determine the severity of coronary artery disease. As a cardiologist, once a patient has bee diagnosed with CAD, we will continue to follow them throughout their life. The best practice would be to perform a non-invasive test, i.e. PET, rather than do a heart catheter. The way the current policy is written, you will only allow us to do a PET scan once, when we’re diagnosing the CAD. It is current standard of care to perform a Cardiac SPECT study when a patient is symptomatic. The way the DRAFT Policy is currently written, we would not be able to perform a PET scan.

Thank you very much for your consideration in this matter. As always, our goal is the best possible care for our patients. We look forward to your response.

Sincerely,

edit #2 to reflect the following:“Diagnosis of coronary artery disease ordetermine the severity of coronaryartery disease in obese patients (BMI>30).”

inconclusive nuclear cardiac or stress echocardiography study in patient with at least an intermediate risk of coronary artery disease.”

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Supporting Documentation for Cardiac Supporting Documentation for Cardiac PET: PeerPET: Peer--Reviewed Journal ArticlesReviewed Journal Articles

MYOCARDIAL PERFUSIONMerhige ME et al. Impact of myocardial perfusion imaging with PET and (82)Rb on downstream invasive procedure utilization, costs, and outcomes in coronary disease management. J Nucl Med. 2007;48:1069-1076.Machac J et al. Positron emission tomography myocardial perfusion and glucose metabolism imaging. J Nucl Cardiol. 2006;13:e121-151. Yoshinaga K et al. What is the prognostic value of myocardial perfusion imaging using rubidium-82 positron emission tomography? J Am Coll Cardiol. 2006;48:1029-1039.Jacklin PB et al. Cost-effectiveness of preoperative positron emission tomography in ischemic heart disease. Ann Thorac Surg. 2002;73:1403-1409.Patterson RE et al. Comparison of cost-effectiveness and utility of exercise ECG, single photon emission computed tomography, positron emission tomography, and coronary angiography for diagnosis of coronary artery disease. Circulation. 1995;91:54-65.Bateman TM et al. Diagnostic accuracy of rest/stress ECG-gated Rb-82 myocardial perfusion PET: comparison with ECG-gated Tc-99m sestamibi SPECT. J Nucl Cardiol. 2006;13:24-33.Machac J. Cardiac positron emission tomography imaging. Semin Nucl Med. 2005;35:17-36.Gould KL. PET perfusion imaging and nuclear cardiology. J Nucl Med. 1991;32:579-606.Crean A et al. Cardiac imaging using nuclear medicine and positron emission tomography. Radiol Clin North Am. 2004;42:619-634.

List of Insurance Policies That List of Insurance Policies That Support Change Support Change

Blue Cross/Blue Shield 2007 – 2008 PoliciesPolicy Number State(s) Specifics6.01.29 NY Positron emission tomography (PET)

oncologic application06.01.13 (rev March 2008) Wellmark

SD & IA PET scan, oncologic applicationsWellmark04-78000-17 (rev Jan 2008) FL PET scan, oncologic applications

RAD.00002 (rev Jan 2008) Anthem

CO, CT, IN, KY, ME, NH, NV, OH, VA

PET and PET/CT fusion

34 (rev July 2007) Regence OR, UT Cardiac applications of PET scan

RAD 605.001 (rev Mar 2008) IL, TX PET scan

358 (rev May 2008) MA PET scan

2:2007; sec. Radiology; issue 1:2007

ID Oncologic application of PET scan

Letter In Response to Letter In Response to PayorPayor Draft Coverage Draft Coverage Policy: Public CommentPolicy: Public Comment

Re: Blue Cross/Blue Shield Policy on Cardiac PET

Dear Medical Director:

I reviewed the BC/BS policy on cardiac PET. Per our telephone discussion, I would suggest the following modifications: FDG PET is considered medically necessary in the following clinical situations: Diagnosis of coronary artery disease or assessment of severity of established coronary artery disease when there has been a recent (within the past 60 days) inconclusive nuclear cardiac or stress echocardiography study in patients with at least an intermediate risk of coronary artery diseasewith at least an intermediate risk of coronary artery disease.Diagnosis of coronary artery disease or assessment of severity of established coronary artery disease in obese patients (BMI >30).In item #2, I recommend we remove the morbidly obese term and replace it with obese. Furthermore, I suggest we use a BMI of 30 as the cut-off for when to use PET. Attached is our data which supports this recommendation. As you will see, at _________ we were able to achieve a significant cost reduction when using PET at a BMI of 30 or greater. In addition, I have attached 3 articles from the literature supporting this position. The article by Bateman, et al, especially, cites a significantly higher accuracy of PET vs SPECT in patients with BMI >30.

Thank you so much your attention and consideration of these issues. I look forward to your response.

Best regards,

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Overall Healthcare Cost Savings Overall Healthcare Cost Savings

A) 981 Total Patients that presented with Chest Pain as indication for SPECT432 Number of Patients that are Medicare (44%)112 Number of Medicare Patients that had BMI 30% or greater (26%)67 Number of Medicare Patients that had normal Cath following abnormal SPECT (60%)

B)Expected Reimbursement for SPECT exam on 112 patients that had chest pain and BMI =>30% E t d R i b t f PET 112 M di ti t f b

All Patients that presented with Chest Pain and had SPECT followed by Cath

Financial Impact for Medicare

vs Expected Reimbursement for PET scan on 112 Medicare patients from aboveIncreased Reimbursement Medicare would reimburse for PET vs SPECT

Expected Reimbursement for Cath on 67 patients that had abnormal SPECT with normal outcome on Cath

Overall savings to Medicare program by allowing PET for chest pain and BMI => 30%(Savings of Cath reimbursement subtracted by increased reimbursement of PET vs SPECT)

* Data extrapolated from calendar year 2006

Referral PathwayReferral Pathway

Understand the specialty referral patterns (cardiologists, GPs, OB/GYNs)

– Specific relationship marketing based on THEIR patient populations

– Focused educational dinner meetings to address their gneeds and concerns

– Outpatient versus inpatient

Decision Tool for Ordering Nuclear Decision Tool for Ordering Nuclear Stress TestingStress Testing

Property of Sandford Health System.

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Logistics: StartLogistics: Start--Up ConsiderationsUp ConsiderationsCamera

– PET or PET/CT– New or refurbished– Share with existing oncology practice– Lease

Rubidium generatorgInfusorECG monitorCode cartSoftware/computers Forms/templatesStaffing

Logistics: Equipment and Associated Logistics: Equipment and Associated CostsCosts

Rb-82 generator$31K/ (fi d)

< $1M for PET alone~1.1–2.6 M for PET/CT

$31K/mo (fixed)

Infusion System$2K/mo lease

Logistics: Software and HardwareLogistics: Software and Hardware

For existing or new PET or PET/CT– Workstation

• Expand memory• ImagenPro™ software installed• EC Toolbox Normal PET

– ImagenMD™ QC• Onsite version• Offsite version

– Misregistration • CVIT software – equipment dependent

– Computer monitor requirements

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Logistics: Infusion SystemLogistics: Infusion System

Required to administer rubidium-82Fully automated for infusion and dosimetryPermits accurate dosing with minimal operator interfaceMinimal operator radiation exposure Contains shielding vault for rubidium-82 generator and waste containerLeasing options available

PET/CT

620 sq ft (includes tech control room)Contrast injectorContrast warmer

SPECT

No need for radiation control280 sq ft for SPECT room

– No control room

Logistics: Space RequirementsLogistics: Space Requirements

HVAC requirements intense; temp sensorECG monitor in roomGenerator in room

– “Hot-lab” security– Homeland security

(strontium)

– No CT extras

190 sq ft for treadmill room

– ECG monitor– No control room

SPECT

Rotational patient schedule

– 2-3 hours– Exercise room

PET/CT

Linear patient schedule– 60 minutes initially– 30-45 minutes with

experience

S / ff

Logistics: Scheduling and StaffingLogistics: Scheduling and Staffing

– Scanner room

Stress/prep room staffing (2 FTE)Scanner staffing (1 FTE)LIP required to supervise in most states

Stress/prep room staffing and scanner staffing can be combined (2 FTEs)LIP required to supervise in most states

FTE = full-time employee; LIP = licensed independent practitioner.

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Schedule Oncologic PET and Cardiac Schedule Oncologic PET and Cardiac PET and CT Planning PET and CT Planning

Oncologic PET Cardiac PET CT PlanningArrival Injection Table Time Arrival Table Time

8:00

7:30 8:00 9:00 8:30

8:00 8:30 9:30

Table open at 10:00

9:00 9:30 10:30

9:30 10:00 11:00

10:30 11:00 12:00 11:30

11:45 12:30 1:10

12:55 1:40 2:20

2:30

3:00

2:45 3:30 4:10

Schedule Oncologic PET and Cardiac Schedule Oncologic PET and Cardiac PET PET

Oncology Cardiac PETArrival Injection Table Time Arrival Table Time

7:00 7:30-8:30

7:00 7:30 8:30

7:30 8:00 9:00

9:00 9:30 10:30

PET/CT Camera Schedule for 8 oncologic and 5 cardiac PET

9:00 9:30-10:30

9:00 9:30 10:30

10:30 11:00-12:00

10:30 11:00 12:00-13:00 1 hour

11:30 12:00 13:00

1:00 1:30-2:30

12:30 1:00 1:30

1:30 2:00 3:00-4:00 1 hour

3:30 4:00-5:00

3:00 3:30 4:00

Logistics: Staff TrainingLogistics: Staff TrainingPlan in start-up

– Infusion system – Infusion cart quality control– Vendor equipment– Software applications

Miscellaneous– MiscellaneousTrain on site

– Super-userNuclear/PET technologists

– Training for 4 days• Two days with vendors and applications specialists• Two days with limited number of patients

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Types of scanning:

DynamicStaticGated

Rest Imaging Stress Imaging

Elapsed Time: 2.5-4 hours

Imaging time: 30 minutes

Rest/Stress SPECT Protocol, Rest/Stress SPECT Protocol, Circa 1991Circa 1991--20092009

Time(min) 0 45 60

Radiopharmaceutical Injection

(rest)

120 135

Radiopharmaceutical Injection

(peak exercise/pharmacologic stress)

90

2 55 1

Rb-8255 mCi

2

Pharmacologic Stress

35-40

Rb-8215 mCi

2

Rb-8255 mCi

RbRb--82 PET MPI Protocol 82 PET MPI Protocol

Transmissionscan

Emission scan

Transmissionscan

Emission scan

35-40 minutes

Scout scan

22

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PET StartPET Start--Up TimelineUp Timeline

Coding Licensing, Space,Marketing

Equipment,

Logistics

Training

12-9 9-6 6 3 1 Months

PET Practice –Go Live

Payorassessment

Reimbursementprocess

Logistics

q pMarketing,Referral base

Training,Policies & procedures

Author Sensitivity Specificity # Patients

Gould 95% 100% 50

Demer 94% 95% 193

Go 93% 78% 202

Sensitivity & Specificity Sensitivity & Specificity

Schelbert 97% 100% 45

Yonekura 93% 100% 49

Williams 98% 93% 146

Stewart 84% 88% 319

Weighted Avg. 93% +/- 8 92% +/- 5 766

Case: RSCase: RS64-year-old-male– History of CAD, NSTEMI in 1995– Atypical chest pain over past year, worse over past 3

months– Other cardiac history: CHB, s/p ppm in 1998

Ri k f t HTN it ki 15– Risk factors: HTN, quit smoking 15 years ago– Gastric bypass in 1999

Physical exam: Height: 5’8”, Weight: 213 lb, BMI 32 kg/m2

Adenosine cardiolite ordered

NSTEMI = non-ST segment elevation myocardial infarction; CHB = complete heart block; s/p ppm = status post previous pacemaker.Property of Sandford Health System.

24

Property of Sandford Health System.

Property of Sandford Health System.

Property of SandfordHealth System.

25

Property of Sandford Health System.

Information LocationsInformation Locations

www.cms.hhs.gov/HospitalOutpatientPPS/www.cms.hhs.gov/PhysicianFeeSched/Society of Nuclear Medicine (www.snm.org)American Society of Nuclear Cardiology (www.asnc.org)