Advances in nuclear medicine continue to extend the uses for this imaging modality. TechNation reached out to industry experts for the latest on nuclear medicine, including what to look for when purchasing a system or selecting service options. The panel of experts includes: Craig Diener, Senior Product Manager, Universal Medical Resources Inc.; Michael Eaton, Field Service Engineer at Southeast Nuclear Electronics; Jonathan Frey, Vice President of Product Management, Siemens Molecular Imaging; Kirill Shalyaev, Ph.D., Vice President and General Manager, Advanced Molecular Imaging, Philips; and Northeast Electronics Inc. CEO John Shaw.
Diener: The clinical utility of SPECT, SPECT/CT, PET/CT and general nuclear medicine remains a viable mainstay in assisting physicians and health care facilities with the care of their patients. Technical advances for nuclear medicine systems remain relatively the same. PET/MR is being investigated for clinical utility but is an expensive modality. Also, fusion imaging with SPECT/MR is being investigated. A primary advance for nuclear medicine lies with the development and implementation of radiopharmaceuticals that not only target specific diseases for diagnosis but also impact treatment of diseases, particularly cancer. The Accountable Care Act (ACA) has impacted nuclear medicine and the entire health care delivery systems. One of its directives transitions from a “fee for scan” to “value and patient focus” type reimbursement environment. This has stimulated nuclear medicine to be proactive in adapting to these forthcoming changes. One of these proactive adaptions is implementing Appropriate Use Criteria (AUC) that provides the right procedure for the right patient at the right time. Software advances that utilize existing nuclear medicine systems are being implemented to provide improved diagnostic information, reduced imaging times, and reduced radiation dose to the patient.
Eaton: There’s been a lot of buzz lately regarding solid state gamma detection. While computing and radio pharmaceuticals have advanced considerably over the years, gamma scintillation technology has remained mostly idle. Solid state detection is a significant technological leap, touting shorter acquisition times and better energy/spacial resolution. The downside is cost. The price point for solid state will render it out of reach for all but those departments with big budgets.
Frey: The adoption of SPECT/CT for clinical reasons and its replacement in the install base is a major recent development. Another SPECT/CT advance is quantification and the adoption of quantification for oncology and the growing application of radionuclide therapy. We’re also seeing new SPECT/CT visualization techniques such as for bone imaging. One final SPECT/CT advance is the introduction of solid state technologies, but they are principally for research purposes and have fairly narrow applications at present, for example organ imaging and specific tracers. On the PET side, we see new acquisition techniques that include continuous bed motion, which enables personalized acquisition and allows routine incorporation of respiratory motion correction. Another PET advance is the increasing adoption of large bore PET, approaching 80 cm. Those large-bore systems are being used for radiation therapy planning, which is becoming an increasing application for PET.
Shalyaev: As personalized medicine continues to influence how we deliver care, advances in nuclear medicine and molecular imaging technologies are making it more critical in the care continuum. First off, new radioisotope tracers represent a major development that will take nuclear medicine beyond the standard FDG (fluorodeoxyglucose), which will enable greater specificity to target individual tumors or disease processes. Second, advances in imaging equipment in digital technology such as digital PET/CT have demonstrated that they can provide approximately twice the volumetric resolution, sensitivity gain and quantitative accuracy when compared to analog systems. Finally, in order for physicians to deliver personalized treatment, they need quantitative data and advances in nuclear medicine have given providers more access to actionable information and analytics.
Shaw: Nuclear medicine has seen some updates including SPECT/CT and the trend to PET and PET/CT.
Diener: Lower reimbursement is making nuclear medicine purchase decisions very difficult these days, which means advancing the quality of medical imaging services and care extremely challenging. Purchasers are looking toward reconditioned nuclear imaging systems more and more as the cost of new equipment isn’t going down and service agreements are not free either.
Eaton: Since attenuation correction reimbursements have ceased, the source rods are mostly unused and in the way. To be effective, source rods must be replaced every couple years. Given the high cost of doing so, we’re beginning to see this option phased out with the absence of reimbursement.
Frey: Reimbursement trends are driving purchasers to focus on clinical, operational and financial efficiencies. They aren’t looking for “gee-whiz” features. Instead, they want to know how they can make a clinical, operational or financial difference. So they ask the question, “How can this product provide the same performance in less time with less total cost of ownership?” For instance, can features such as continuous bed motion for PET offer a significantly improved clinical workflow, increase efficiency and provide more data in less time? With reimbursement declining, purchasers need more clinical, operational and financial bang for their buck.
Shalyaev: Despite some slowdown in overall imaging volume due to the changing reimbursement landscape, advanced imaging modalities (CT, MRI and PET) will show significant growth. There are ongoing studies and data that demonstrate the value of nuclear medicine solutions in both traditional and new use cases. Today, the value in these innovations and the added confidence they provide in informing better patient care is more widely recognized. As a result, PET volume is expected to rise steadily over the next 10 years, driven by new indications, novel tracers and expanded insurance coverage.
Shaw: In the past seven years, we have seen the private cardiology doctors either dropping nuclear cardiology or selling the practice to the hospitals due to the decrease in reimbursements. Since the Supreme Court made its decision two years ago, the physicians have learned how to make a profit and offer nuclear cardiology again. Hospital scan numbers are down all around, most departments have forced the employees to go part time or they send people home if there is not enough work. Equipment sales are down to private practices and hospitals because of the decrease in reimbursements.
Diener: Health care facilities should definitely consider more options other than PET/CT. SPECT systems are much more cost-effective than PET/CT. SPECT gamma cameras cost a fraction of what PET/CT scanners do – $400,000 to $600,000 versus upwards of $2 million. SPECT radio tracers also last much longer and are much more inexpensive – ultimately increasing throughput.
Eaton: That all depends on the facility, the budget and the need. While PET is excellent for detecting abnormalities, combining it with CT greatly assists physicians in determining if a treatment or course of action is effective. The initial investment is astronomical, as is the operation and maintenance. I’d say much the same for PET/MR. SPECT is still the only modality that illustrates function, and not just structure. Additionally, SPECT tracers have a half life of around 6 hours, allowing ample scan time. Comparatively PET tracers have a half life closer to 75 seconds. SPECT tracers are also more widely available and less expensive.
Frey: Health care facilities should focus first on the clinical needs that they are trying to address. Then, you worry about the technology. For example, if the facility needs cardiology and general oncology, like thyroid and bone and organ function, SPECT/CT is probably best. If the facility is focusing strictly on cardiology, a dedicated SPECT system is likely the best choice. If, on the other hand, the facility wants to support radiation therapy and management of lung, lymphoma, breast, head and neck cancer, PET/CT is probably the way to go.
Shalyaev: With health care facilities seeking new, better ways to enhance diagnostic confidence, we’re seeing a growing demand for technologies that enhance image quantification. In looking at the options outlined above, they each have unique benefits and functions. SPECT is an established and widely-used modality, but it involves long scan times and low resolution images. SPECT/CT brings in CT imaging that can sharpen the image, providing attenuation corrected data and anatomical information for diagnostic purposes. PET/CT has become part of the standard of care for oncology, adding a layer of diagnostic confidence to disease staging and localization by combining PET’s ability to determine metabolic activity of tissues and CT’s high-resolution anatomic information for an integrated rich, actionable data set. PET/MR combines the power of PET with MR’s advanced soft tissue contrast, diffusion-weighted imaging and dynamic contrast-enhanced imaging, making it conducive for robust imaging evaluation in certain clinical settings that are disease or organ specific.
Shaw: In more rural hospitals the PET/CT market doesn’t seem to be a big seller. Most small hospitals hire a truck to come in once a week and they end up doing 2 or 3 scans all day. Big city hospitals will often have multiple PET/CT scanners. The nuclear medicine departments offering SPECT and planar imaging are steady, but the scan numbers are down from eight years ago. Insurance policies require a high co-pay and that seems push people to decline the scan even though a doctor has ordered it. Other forms of hybrid imaging don’t seem to be discussed at all in the smaller rural hospitals.
Diener: When looking to purchase a piece of nuclear medicine equipment, buyers need to understand that it is all about their clinical and financial needs – nothing else. There are many things to think about. Look at the region you would be drawing scans from, what is the demand like? What’s the potential for reimbursement for a scan? Does the provider’s installation schedule make sense for your facility? Make sure the system fits your specifications, not the vendors. Does it fall within your budget?
Eaton: Purchasing a system is a sizable investment and should never be done hastily. Don’t refrain from asking questions, researching the company and checking references. Another trap to avoid is the mind set that the OEM is the best. Third-party service and equipment providers do not have the luxury of assumed superiority in quality like the OEM. Take the time and do the research, you’ll be glad you did.
Frey: Consult with someone who has purchased from the company and determine whether that entity will service the equipment. I wouldn’t recommend purchasing equipment from a third-party or eBay type of vendor because you don’t know what you will get. Will they service what they sell – and if they do, what is the geography of their service area? Is it California? Is it global?
Shalyaev: When looking to invest in new technology from a vendor, it is important to choose the right equipment for your organization, which will meet the needs of the technicians, environment and patients. In working through contracts with an OEM, your readers will want to take usage and the end users into account – looking at the skill level and training along with how often the equipment will be used, etc. It is worth noting to your readers that the most common platform, hybrid PET/CT, offers the convenience of a single exam with both functional and anatomic data.
Shaw: Equipment purchasing is largely based on quality of the equipment and the reputation of the company and their service organization. The user needs to make sure the system they are looking at will do all the studies that their department is asked to do. Overbuying because it is the greatest unit available will turn into a higher cost in purchase and service when they don’t need all the bells and whistles. Purchasing what is necessary, and not more, and the reputation of the service department would be first on my list.
Diener: Just like purchasing a piece of equipment, there is much to consider when selecting service. Obviously there is cost, but there are many other factors as well. Does that independent service provider have field-service engineers specifically trained in nuclear medicine? Are they qualified to service this particular system? You’ll also want to know if they know the normal maintenance schedule. What is the average time-frame between putting in a call and someone arriving to perform service? Without answering these questions, you’ll likely be over-paying for services that you don’t need or won’t get the preventive maintenance required to maximize uptime.
Eaton: The first attribute that comes to mind when choosing a service company is experience. Aside from being complex and delicate, nuclear medicine systems can be very dissimilar from one another, even within the same OEM. Second is inventory. You’ll want to avoid downtime due to shipping, and the potential of costly restocking fees. For these reasons, having immediate access to parts is crucial. Third is response time, take measures to assure you’re not being over promised when it comes to response time. Whoever you decide to use should have a local presence.
Frey: Consider three key points. Number one: Do they offer both remote and on-site service plus backup? (The geography question comes into play there, too.) Number two: Do they offer updates to performance and new safety standards? I would add cybersecurity to that, as well as upgrade options for the latest innovations. And finally: Do they have a proactive monitoring system or remote diagnostic, predictive failure detection?
Shalyaev: In addition to the capital investment for the devices, your readers should consider their facility needs, operating costs and annual service options. In the case of service options, annual service contracts generally run around 8-12 percent of the purchase price. Also, some referring physicians may still be unfamiliar with PET utilization for these new devices, so it is also important to develop an active education and outreach program to communicate the new device’s availability and value can build confidence in the reports being provided.
Shaw: There are many service organizations available. OEMs obviously support their systems but don’t always take care of the needs of the individual customer. ISO groups usually have an easier path to take care of the customer both in the delivery of service and that they can adjust the program to fit the end user’s needs. The reputation of the service organization is most important. The purchaser should call around to other users and get their opinion of the service provider. Asking for a reference list from the service provider is one way, but you can be sure you will get the customers who like the service provider best. You would be best to call around to other departments.
Diener: The process of ensuring access to viable parts and service should take into consideration the provider’s ability to provide both excellent, cost-effective service as well as quality parts that are tested on operating camera systems to assure that parts are viable and will be able to get your camera system operational in a timely manner. Purchasers should take time to qualify and confirm that a service and parts provider will meet the demands and needs of their nuclear medicine services offering.
Eaton: Again, this is where research and legwork pay off. Don’t be afraid to ask direct questions about specific concerns. A reputable company should have a list of customer references.
Frey: Work with established vendors – it’s that simple. Siemens, for example, plans to support our products for 10 years after the shipment of the last system. So if our company introduced a system in 1995 and ended its run time in 2005, it would support that system for another 10 years after that end date. And that’s the policy of any established vendor in this market that plans to be around a long time.
Shalyaev: As nuclear medicine and imaging technology is constantly evolving, it is also important to understand what technical support and system updates are often bundled in the terms and conditions with the purchase of a service contract, as well as availability of parts for repair. For purchasing organizations still building expertise, it is important to look at training options in the form of fellowship programs, vendor-supported programs and use of overreading services that can help to provide the highest standards of quality in exam interpretation.
Shaw: Usually purchasing departments never ask these questions. Many smaller hospitals do not have a biomed department or the purchasing department knows nothing about the nuclear medicine equipment so these questions are not asked. Again the OEMs are pretty much stuck with one plan fits all where the ISO can be creative and work with the department and offer plans that might fit the hospital’s needs better. We are often asked about the biomed doing a first look and that idea has worked very well if the biomed is willing to actually take the time to learn the system. Some ISOs will offer training for biomed engineers as part of the service agreement. Parts are usually readily available for systems older than five years for ISO groups. OEMs will end of life systems and they will stop stocking parts for the older cameras. Many ISO companies will work together to help each other with parts and technical support which will benefit both the hospital and the ISO.
Diener: Nuclear medicine devices/systems add to the portfolio of imaging systems that biomeds/clinical engineers are now becoming responsible to maintain. The responsibility to maintain a variety of imaging devices within the health care facility is daunting to say the least. However, by developing a mutually beneficial relationship with an independent service provider this responsibility can be shared. In addition to a collaborative relationship with a quality independent service provider that can provide support, parts, and escalated service offerings, the clinical engineering department should research the independent service provider’s ability to provide training programs.
Eaton: Listen to your technologist! These men and women spend more time with the systems than anyone. Too often service and maintenance requests are downplayed or ignored and this can prove to be a costly mistake. I’ve also noticed a trend in biannual PMs morphing into annual PMs and then progressing to calling when it breaks. Many expensive replacements could have been avoided by something as simple as clearing dust from cooling fans.
Frey: What is the platform history of the product being purchased? Has it been upgraded? Can people who bought this platform 10 years ago fully upgrade it? And is it a forklift, or have features been added? At Siemens, we pride ourselves on being able to take the product from serial number 1 to look as good as the latest factory shipment, so there are a series of upgrades. Also, what is the status of that vendor on cybersecurity? No one really discusses this topic, which is an important and growing area of concern for health care in general and for imaging in particular.
Shalyaev: With access to more data, biomedical professionals are looking for ways to customize treatment for patients, based on their anatomy and specific molecular and cellular patterns of disease. They should understand that nuclear medicine and molecular imaging provides the most detailed view of how disease functions in the body, combining data with digitally advanced imaging tools to help make faster and more confident diagnosis and treatment decisions. Molecular imaging has also shown to be helpful in improving the drug discovery process by giving a clear and detailed picture of how the drug is interacting with a target.
Shaw: Each individual biomed department would have to decide how involved they want to be in the actual servicing of the equipment. Many ISOs will offer on-site or off-site training. Learning the function and some minor repairs of the system might save the department some downtime. Some biomed departments are so busy that to learn the nuclear systems is not cost effective.
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