The number of hospitals offering CT colonography, sometimes referred to as virtual colonoscopy, rose slightly between 2005 and 2008, despite lack of Medicare coverage, a new study shows.
The researchers led by Dr. Megan McHugh, director of research at the Health Research and Education Trust, surveyed 3,980 nonfederal hospitals of all sizes across the U.S. about whether they offered computed tomography for diagnosing colorectal cancer. The 2008 survey showed that 669 (16.8 percent) offered the service as an alternative to or as an adjunct to conventional optical colonoscopy. This represented a 4 percent increase over the 2005 survey despite the fact that Medicare does not cover the procedure. Only 11.6 percent provide both CT colonography (CTC) and optical colonoscopy.
“Although we show that use of CT colonography is growing, I don’t want to give the impression that this study shows some new wave that is about to sweep healthcare,” McHugh told The Hub in a phone interview. “While use is increasing, the majority of the hospitals offering CT colonography in our study were doing less than 50 per year.”
In 2008 the American Cancer Society, the American College of Radiology, and the US Multi-Society Task Force on Colorectal Cancer (a group that comprises representatives from the American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, and American College of Physicians) for the first time recommended CT colonography every 5 years as a cancer screening tool.
At the same time, the U.S. Preventive Task Force, the guidelines body of the U.S. Department of Health and Human Services, concluded that there was insufficient evidence of benefits vs. risk to recommend CT colonography.
In a 2009 review of the efficacy of CT colonography, the Centers for Medicare and Medicaid Services (CMS) declined to cover CTC for its beneficiaries citing inadequate evidence to support approval for reimbursement.
The researchers compared the responses to a question about CTC included in the American Hospital Association annual surveys conducted in 2005 and 2008. The survey is sent to all non-federal, private, for-profit and non-profit hospital CEOs in the U.S. A total of 84 percent of the hospitals responded to the survey in 2005 and 86 percent returned completed surveys in 2007. In addition, the researchers conducted exploratory interviews in 2009 with representatives from radiology departments at nine hospitals; six that provided CTC and three that did not. Their study appears in the March issue of the Journal of the American College of Radiology (www.jacr.org).
One surprising result was that CT colonography was more likely to be offered at second tier hospitals in terms of financial resources, than at larger hospitals with the highest financial resources. At the same time, cost was not an issue in deciding to offer CT colonography. The survey showed that all of those that offered it had CT scanning machines already installed that were capable of performing CT colonography, although half of those did have to install the software required for colonography, but those $5,000 to $20,000 costs were considered a minor consideration in deciding whether to offer the colorectal scans or not.
However, all respondents said that reimbursement was an important consideration. Respondents to the exploratory interviews from five of the six hospitals providing CTC said that they performed fewer than 50 CTC studies per year and that the service is primarily for patients with failed optical colonoscopy. Such patients are typically eligible for third-party reimbursement for CTC.
One notable exception was a medium-sized hospital that performs more than 1,000 CT colonographic scans per year. The researchers found that one radiologist at that hospital had actively gone to insurance carriers in the hospital’s service area and convinced them to include coverage of CTC for their covered members. As a result, CTC is used for general screening in that community.
“That’s the first time that I had heard of that happening before,” said McHugh who is now research assistant professor at Northwestern University Institute for Healthcare studies. “And it may be something that can be reproduced in other communities, but our study didn’t look into that.”
CTC was more commonly offered in the Northeast with 27.1 percent of respondents offering CTC with hospitals in the Midwest trailing that with 17.4 percent of them adopting CTC. A total of 15 percent of hospitals in the West offered CTC as do 13.8 percent of hospitals in the South.
All those offering CTC said that it took less than 6 months from the time the decision was made to offer CTC, and implementation. Radiologists received training on performing CTC readings typically through a continuing education class that involved reviewing 50 or more cases. Technicians were also trained, although often in-house.
McHugh and her colleagues noted that one of the disadvantages of CT colography is that if a suspicious polyp is identified, then a second colonoscopy procedure must be scheduled, and if it cannot be done the same day, the patient must undergo the unpleasant preparation for the procedure a second time. In contrast, if a suspicious polyp is seen with conventional optical colonoscopy, it can be excised and biopsied at the same time.
This is one of the reasons CT colonography has not been adopted by Medicare. Despite several studies showing that CT colonography can be an effective, less invasive screening test for colorectal cancer, the lack of ability to sample and biopsy tissue at the time of the scan, negates one of CTC’s advantages.
The cost of a CT colongraphy is between $400 and $800, according to Scan Directory.com, which is considerably less than the typical $1,800 for an optical colonoscopy if no suspicious polyps are found. If any suspicious masses/polyps are detected, however, the cost of CTC is additive. In addition, because CTC cannot detect small polyps less than 5-7mm, current guidelines suggest that CTC be performed every 3 years. By contrast current guidelines for a negative regular colonoscopy call for repeating the procedure every 10 years.
“It is concerning that more than 30 percent of hospitals that offer CTC do not also offer optical colonoscopy,” McHugh’s team wrote. “These radiology departments would need to establish partnerships with other organizations that could accommodate same day follow-up appointments for optical colonoscopy to spare patients the need to undergo the rigorous colon preparation required by both procedures a second time.”
Overall, the researchers concluded that widespread implementation of CTC, together with expansion to a broader group of patients, may be difficult under current reimbursement policies.
By: Michael O'Leary, contributing editor Health Imaging Hub
