Hello, I'm going to be speaking to you today on considerations in starting a cardiac PET program. My disclosures. So who benefits from PET? Of course, we know that the value of PET is in its high diagnostic accuracy, consistent high quality images, low radiation exposure, short acquisition protocols, and it's very strong prognostic power. But I think one of the greatest benefits of PET is the ability to quantify myocardial blood flow. And that really allows it to augment the scope of conventional MPI so that we are now able to delineate not just epicardial coronary disease, but really look for early atherosclerosis, microvascular dysfunction, and a more robust picture of focal and balanced reduction in coronary flow. For those that are interested and anyone at this conference knows the value of PET, however, people are worried about how do we get a program started and some of the fears and concerns include the planning that's required to get a cardiac PET program off the ground. Do you have the volume, the finances involved? How expensive is the equipment and the ongoing costs of the tracer? And how is the reimbursement picture? And of course, potential issues with the CT part and how you're going to deal with non-cardiac findings. And so what I'd like to go through with you today is a checklist that I've created of things to think about and what you want to look and address as you're planning a cardiac PET program. So we'll go through the planning stage, things to think about right up front, equipment, what you want to look for, how you want to think about your setup in the, both in terms of the room design and your space, some fiscal considerations, and then as you get started, some important things that you want to think about with your staff. So we'll start with your current state. You want to make sure you've taken a quick look, first of all, at where are you at right now with your myocardial perfusion imaging. So who, what, where, why, and how, who, where do your patients come from? Are you primarily an outpatient setting? Do you think that if you get a PET scanner, it would move to an inpatient or a hospital-based setting where then you might be able to have some leeway to do some inpatients as well? What is your current volume of pharmacologic spec? And of that, how much do you expect will shift to PET versus what new or incremental volume might you be able to bring in because you now have a test that is so much shorter or maybe there's no one in the regional area that could refer patients to you. Think about what you will perform. Do you want to be doing just high quality MPI and kind of be done with attenuation issues? Or do you want to ensure that your program has the ability to do calcium scoring concurrently and flow and flow reserve? Do you want to do the advanced PET imaging like viability and sarcoid? Thinking about where are you going to put the equipment, reviewing your existing space, the design and the shielding that you currently have to think about how much revamping of the space and the room is going to be required, or is there a possibility for a new space? Why? What is your primary goal in moving to PET, which I think most of us would say should always be from a patient perspective, patient safety and accuracy, but of course, fiscal considerations, throughput through the lab are a factor. And then how are you going to do this? Are you going to use existing equipment that might be upgradable or are you looking to buy new equipment? If so, what is your budget? If you have limitations with budget, considering whether you will share a camera with radiology or nuclear medicine, just at least get your foot in the door, or is this going to be a camera that is dedicated fully to cardiac studies because you have the volume? So first things first, I would say is what is your vision for your lab? Dream big. If you know you want to be doing all of this, you really need to have that vision and think, how am I going to get to that point where I can do all of these parts of the PET program? And you want to make sure that you consider your future needs to allow for growth. And that includes both volume as well as PET tracers. There are novel tracers coming out on the market, and I'll go through that later. But you want to think about what are the needs going to be, not just now, but five to ten years from now, so that my program can continue to grow. In addition, what are your constraints? We all have the ball and chain of maybe your institution contracts with a specific vendor, so you definitely have to buy your camera from that vendor. Maybe there's a space constraint, budget constraints. What do you need to be cognizant of? And remember that each lab has different needs, and one size does not fit all, and that's okay. I also think it's very important up front to have a champion and to have a team. So your champions should include your physician lead and your NMT lead. But your team, and in the planning stage is really important. You want to get input from your nursing staff, involving someone from your preauthorization or scheduling group, billing, and then, of course, including your physicist, if you have access to one, and radiation safety is really important. All of these people will give input that you may not have thought of, and we'll be able to see it from a different perspective to make sure that you're setting the program up well right from the start. First things first, educate yourself first. Make sure that you have a good understanding of all of the specifics of cardiac PET. ASNIC has a wealth of documents, more technical guidelines, imaging guidelines that go through the protocols, flow guidelines that go through the technical parts of flow. We now have reporting guidelines, and, of course, the cardiac PET intensive workshops. All of these are an excellent way to make sure you understand the technology, the physics, and the interpretation of these studies. Two other key points in the planning phase, PET-CT, which is, I think, the way the field is going, but it really is desirable if you are planning on doing calcium scoring, inflammation, or infection imaging, but one thing you want to do ahead of time is discuss the responsibility for the interpretation of the non-cardiac portion, and you want to address this before you purchase a camera because there are legal ramifications here on, are your radiologist going to help and do an overread, are the cardiologist going to be responsible for the non-cardiac portions, or are you going to put a disclaimer in your note? You also want to think about your state-specific requirements for your nuclear medicine technologist and their ability to perform a diagnostic quality CT, so calcium gating now falls into diagnostic quality CTs, and in some states, your NMTs have to actually have CT training in order to even perform a calcium score. MBF quantification, I will say, is the other big consideration. It is the most significant benefit of PET, and I really feel should be the goal of every new cardiac PET lab. So now that we've gone through the initial planning criteria, let's move on to equipment. So hardware, tracers, and software are the three big categories. For cameras, first decision, I think, for many people is, am I getting a new camera or a refurbished camera? New cameras are ideal. If they're going to have the latest technology, they're going to be brand new, hopefully not have any repair or other issues, but they are, of course, much more expensive. There are purchasing and lease options available, and sharing a camera, such as with radiology or nuclear medicine, may help you facilitate a purchase into a newer camera or even a camera with CT and more advanced technology. Disadvantage there is you'll have less time on the camera, but this can be a beneficial way to get access to more advanced technology. Refurbished cameras, in general, tend to be older but less expensive. They're usually going to employ line source AC, although you can get refurbished CT cameras. They may have limited availability and support, and so I would encourage everyone to do their own research and make sure that you're getting a good quality system that will meet your needs. Know, though, that you won't be able to perform inflammation or infection imaging without that CT component. Attenuation is the other big thing to consider with the camera. Do you want a camera that has CT attenuation correction or line source nuclear attenuation correction? CT, in general, is preferred because it's the newest technology, but it also allows the ability to do calcium scoring. Now, it can be more prone to, of course, CT artifacts, but it does allow the full spectrum of imaging. At a minimum, if you are doing just CT for attenuation correction, you would need a four-slice scanner. If you plan on doing ECG gating for CAC, you're going to want eight to ideally 16 slices. And then again, discussing upfront who is going to have responsibility for the non-cardiac findings. Line source AC is generally, again, older cameras. And be aware there that if you're using line source, you will have a longer imaging protocol. So if efficiency and throughput is something you're really looking for, this may be a disadvantage. This is just a graph really encompassing a lot of what I've already said, but from a clinical perspective, dedicated PET or line source attenuation versus PET-CT will account for the majority of your imaging except for inflammation, infection and calcium. There is a big cost difference, though. Refurbished nuclear line source is going to be probably less than about $500,000. There is very limited, if not no new, line source cameras coming onto the market these days. PET-CT, if you want a brand new camera, is going to be upwards of a million, but you can get refurbished ones potentially for a little less. So advantages and disadvantages with both cameras. Other camera considerations are based on your volume. If you are a high volume place right off the bat, then you may want to consider investing in a camera that is dedicated to cardiac studies and will not be used for anything else. Again, a shared camera with radiology or nuclear medicine that's shared potentially with oncology or neurology imaging can be a great way to get into the game. And if you're truly a small volume place, mobile imaging options are going to be a great way to get into the game. So mobile imaging options are available. I would recommend meeting with as many vendors as possible or at least a few. I think talking to them, seeing what the different camera options are available and what the different, if you're thinking of it all, leasing, what are your options really is helpful when you've spoken to many people. Visiting or talking to an experienced PET center can be helpful. You may want to start out with your dream camera if budgetary constraints are there. And that's OK. I think it's all right to get your foot in the door and start with good quality imaging, show your value and upgrade in the future. A medical physicist is extremely helpful if you have access to this or can build that into your budget to get a consultant, both in terms of decisions of buying the camera, what camera works well with the tracer, what your needs are, and then setting up your budget is really important. And then there are turnkey services available that can facilitate everything from program setup, helping with the camera setup and the financials. But again, here you want to make sure that whatever service you're using aligns with your goals and that you're ensuring quality. Please note that when you're looking at cameras, although this can be overwhelming and there's so many choices, most currently available systems, whether using a newer or refurbished or whether you're using Linesource or CTAC, all produce good quality imaging for perfusion, function and myocardial blood flow. So be reassured that most of them do a good job for all of this. The differences really relate mostly to efficiency, reader preference and the types of advanced technology you're going to have access to. Moving on to tracers. So there are two FDA approved and reimbursable PET radio tracers for myocardial perfusion imaging, rubidium 82 and N13 ammonia. And you can see some of the differences here. Rubidium is supplied by a generator, which you can purchase and have an infusion system on site. N13 ammonia requires a cyclotron. The half-life is very different. Rubidium is extremely short acting. First pass extraction is a little bit less for rubidium and its positron range is a little bit bigger. And so in general, ammonia will give you higher quality images, but because of the cyclotron can be harder to get access to. So going through these two in detail, rubidium is the most commonly used in the United States. It probably about 85% of sites in the US use rubidium. It is a potassium analog and it's made by the decay of strontium 82. It does require an onsite infusion system and a generator, but the nice thing is that you then have a dose that's continuously available. I believe that there are some mobile options now available as well. There are two commercially available FDA approved generators that you can see on the slide. And usually the generator is replaced every four to seven weeks. In addition, there are two different infusion models depending on the type of generator you pick, constant flow and constant activity. So when you're looking at rubidium, if this is the tracer you choose, you want to make sure you've looked at the infusion models and what you think is going to be best for your lab. And looking at these two companies, or if you really are a small volume place, again, there are mobile options available. N13 ammonia is only used currently in a handful of centers because it requires a cyclotron. And with the 10 minute half-life, you either need to have a cyclotron that is onsite or fairly close by with unit dose availability. Now there is a mini cyclotron company as well available. So that is an option. It's a single dose 10 minute production run. The advantages to ammonia is that it's excellent images because of the low positron range. There's no reliance on parent compounds. And because of the 10 minute range, it can allow you to do exercise. You're not limited to pharmacologic imaging alone. However, you will lose the quantification of flow. It does require more coordination and timing though on just getting the dose with the delivery, even if it's onsite and coordination with exercise can take a little bit more work on the imaging end. And the last pet radiotracer is F18 FDG. Now this is currently used for viability, sarcoid, and inflammation imaging. It is also cyclotron produced, but because of its longer half-life of 110 minutes, it is readily available in unit doses. Very short positron range with excellent image quality. Now know that there are future novel F18 agents that are currently in development for perfusion in particular that have the potential for exercise, will have unit dose availability again because of the longer half-life and may have the potential for other clinical applications. So you want to make sure you take that into consideration for future needs. Things to think about with the radiotracer when you're picking is going to be the cost and the availability of the tracers at your institution. What will your future needs be? And then know that each of these tracers has different shielding considerations, receiving and hot lab requirements, and staff protection needs. And the last equipment piece would be your software. So you'll want to look at whatever software program you're looking at and processing for PET, which is very similar to perfusion. So no major differences there. But a quantification of flow, of course, wants to be looked at. Now there are multiple different programs. I've listed just a few. There are others. You want to make sure that you understand the model that is being used by your flow software and the compatibility with your camera and with your particular tracer. Now there are studies that have looked at this, and I will say that there are fairly consistent results among the various software packages. So I don't think you should be worried too much about which package. There are subtle differences, but you want to take a look at what works well with the rest of your equipment. And then lastly, you'd want to make sure that your reporting program, whether you're using the existing one or looking at a new program, will acknowledge and account for PET tracers and activity. Will your report include, will it be able to include myocardial blood flow reporting? Calcium, if you're going to be doing a CT scanner. Potentially even adding in the non-cardiac findings into one report, whether it's interpreted by cardiology or radiology. And then will your reporting accommodate for viability, sarcoid, and infection reporting? Moving on now to your setup. So the cardiac PET room, you want to think about shielding and weight requirements. If you are planning on only doing rubidium and N13 MPI only, those require the least shielding. If you are adding F18 imaging, it needs more imaging, more shielding, I'm sorry. And if you're adding CT scanning to this, it will require even greater shielding as well as increased weight limits. So thinking about that with where is your room going to be in terms of the weight requirements and then how much shielding do you need? And I would also say that if you're thinking about using F18 agents in the future, or even for viability and sarcoid now, you're going to want to consider lining your prep area or your patient holding area because those patients, because of the F18 and the long half-life, will be radioactive in the holding area or in the patient waiting area. You want to think about your power and HVAC requirements for the cooling system. That could be air versus liquid, but that'll be something to ask with the camera company that you're looking at using. The layout of the room, you want to ensure that you are optimizing patient safety as well as staff safety, and then of course, efficiency. You want to make sure that from the control room, you can visualize the patient and the vitals, the EKG machine, and the tracer infusion system, and in an ideal way, having everything from the control room so that everyone can be outside of the room and still optimizing patient safety. And last, you want to consider how long will the construction and the buildout of the room take as you're coordinating the lead time and purchasing your tracers, all of this. These are expensive pieces, and you want to make sure that you're not waiting too long for your room if everything else is in place. Now, this is our layout. We have our PET-CT, our control room is here on the left. The patient's head is here and goes into the PET-CT scanner and comes out the other side. We have put our GEK system for EKGs in the front so that we can see it from the control room, and we use rubidium. We've put our infusion in the back, along the back wall, and what we did was actually mounted a camera on this back wall so that we can see both the infusion system as well as the patient. So this is our control room. This allows, our setup allows our nurse to actually be outside of the room the entire time, and so minimizing staff radiation exposure. Our technologist sits here and can see through the window. The nurse sits here and has direct access to the EKG system as well as can watch the patient and watch vitals. And then in addition, our technologist has their eyes on the camera, which allows visualization of the infusion system, and of course the patient to make sure that there are no concerns with patient safety. The space should also be considered, where are you going to optimize this for efficiency in your lab as a whole? So proximity to the stress lab in general, if you are doing SPECT or stress echo or any other stress testing, in an ideal setup, you would have everything close together or right next to each other, so you'd have one MD supervising all of this. You're going to want to have one nurse in this pet control room, but if you have, obviously if anything goes wrong, having other nurses supply supervision and other healthcare professionals very close by is very helpful in the case of an emergency. The hot lab proximity is important. If you are using rubidium, the infusion system cart can be heavy, and so storing that close by and storing it safely is important because it will need to be either moved to the hot lab or have your pet room locked. And then if you are sharing a camera, ensuring that it is close to the other departments where it's going to be used. Also want to think about where are you going to be doing your patient setup? In an ideal room, you don't want to be doing your IV or your baseline EKG in the pet room so that you can maximize throughput and flow. So is there a holding area or a place to do consent and put the IVs in before you bring the patient to the pet imaging room? And where will you do your glucose monitoring for viability? Those can take a few hours. You want to make sure that you have an FDG room that is lead lined and safe for that patient. This is an example of ours. So our pet room here with our control room is adjacent to our stress lab. So we have four stress bays where we do our stress echo and ETT. So everything is nice and open. The room is closed off, but it is accessible if there is an emergency. Our nuclear aspect imaging rooms are along this back wall. Our nuclear medicine reading room is right here. And we have a holding area just to the left, a very large holding area where we do our consents and IDs, patient prep, and to really maximize efficiency. And our hot lab is right back here. So everything's very close. Lab staffing and throughput. I would recommend one nurse and one NMT team per patient and cardiac pet. So we have one team that runs the lab and stays basically in the room. For a high volume lab, an additional team to facilitate the patient prep, getting the next patient ready while you're imaging one. And then in particular processing, having an additional NMT to help with the processing, which does take some time, will help you get started with your reading faster. Remembering again that some NMTs may need additional training in CT if a pet CT is being used and depending on your state regulations. Scheduling. I would recommend that you start with one hour time slots for rubidium. If you're using N13 or line source AC, it might require even more imaging time. You can always ramp up once you're comfortable, but as you get started, allow yourself a little bit of extra time. If you are hospital-based, are you going to be allowing inpatient or ER add-ons? Something to consider. And then how are you going to handle scheduling for viabilities and sarcoid scans? Now viabilities in particular can be unpredictable in how long the glucose manipulation can take. And then if you're sharing a camera, considering if you're going to cross-train your NMTs I think is very helpful. If you're sharing with oncology or neurology, making sure that the NMT is versed in all of those imaging modalities and the protocols for specific to cardiac versus the other areas. Again, the MD supervision of the stress test and then how making sure that you have a nursing or an MD present for glucose manipulation if you're going to be doing viability studies. This is our scheduling protocol. So we are now at 45 minutes. We actually can do faster than that, but we've left it at 45 minutes so that we give ourselves some wiggle room if we need to do some add-on cases. We are a hospital-based program. So you can see we built in an optional ER slot at the very beginning of the day and at the very end of the day with two additional slots. So we have seven outpatients, add-ons for four on an average day, but we've easily been able to accommodate 12 to 13 on a normal kind of work hour day. Last, I will say in terms of your protocol setup, having a physicist in-house or as a consultant is a very big advantage and very helpful. They will help you look over the safety considerations of your camera and set up with radiation safety and also your protocol. They can really help ensure the tracer quality control and the camera settings are all optimized in order to get proper and accurate myocardial blood flow and will help you refine your protocols. Next, moving on to physical considerations. Now, I'll start off with the primary motivator for starting a PET program for all of us really is patient-centered imaging, high quality images, high diagnostic accuracy. And I think that really accentuating that point, it should be the motivator for all of us from a patient perspective, but also for our hospitals. But of course, physical considerations are important. They're important and they're practical. Budget considerations need to be looked at, whether this is what are your volumes, what are your costs and what does the reimbursement in your area look like. And if you're a hospital-based program, one thing that you can also look at is what are the downstream effects of PET? If this is going to improve throughput through the hospital and help your ER and your inpatient length of stay, if this will help with your catheterization, so you have a better cath to PCI program, then those are harder to quantitate, but can really be a great pushing point for your administrators to say that this can really improve things downstream. Some unique considerations you want to consider is your regional practice style at your facility or your area, your organizational structure, referral patterns that are going to be unique, the growth potential, and then geographic variation. There are differences in how PET is practiced across the country and how PET is reimbursed across the country. Costs that you want to think about. So, fixed costs will include your camera, your hardware, and your software. You'll pay for those up front, and the room structural modifications. Reoccurring costs monthly or every year will be the tracer and its related expenses. So, some of the infusion systems require special proprietary IV lines, will need saline. Of course, thinking about equipment maintenance as well as upgrades, and then your staffing. Of course, you need at least one full-time NMT and nurse daily with a backup coverage for when they are unavailable or vacation times. You want to think about your current volume. Again, how much pharmacologic spec will you shift to PET and how much incremental new volume, which really dictates your reimbursement. Especially if you're using rubidium, the more volume you do above the baseline cost is incremental benefit. The downstream costs, again, as I've already said, looking at the benefits to your institution in terms of calf volume, ED and inpatient length of stay can really be an advantage to some hospital systems. Here are some overarching reimbursement considerations. Because there is so much geographic variation, it's really hard to give concrete numbers, but I will say that in average, PET reimbursement is one and a half to two and a half times higher than that of SPECT, but of course varies geographically. Private payers vary significantly in terms of reimbursement and in terms of their preauthorization eligibility for PET. CPT codes are separate for line source now versus CTAC PET. In general, CT attenuation and correction studies reimburse higher. Although the cost of acquiring a CT-based camera is going to be more expensive, the reimbursement is also much higher. You want to look at these CPT codes and the average reimbursement in your area before you get started, and it may be worth talking with the payers as well ahead of time. In terms of your payers, for Medicare, you want to consider that Part A is bundled reimbursement, which applies in general to hospital-based imaging centers. Medicare Part B is multi-segment reimbursement, where each element is billed separately, and this applies to most outpatient practices. In general, for outpatient practices, the multi-segment may reimburse higher. Now, know that if you're a hospital-affiliated outpatient, you may end up in the end having to bill under Part A. Private payers, the things to think about is preauthorization. This requires good documentation of the indication for the study and good supporting documentation. Eligibility requirements vary from payer to payer, so you'll want to look at those contracts and kind of know what are they looking for to qualify for a PET versus a SPECT. I would recommend considering developing a peer-to-peer team to help your referring physicians. This might be one or two MDs or one or two nurses who are versed in the indications for PET and what are the eligibility requirements and can really help with that peer-to-peer process. And you really want to avoid denials if you can, because once a denial, I think, has gone through, it's really hard to reverse that. And engage your payers up front. So, I would recommend that you talk to your payers even before you start your program, negotiate your contracts, and make sure that you're aware of what their eligibility and indications for PET are and educating them on the benefits of PET to ensure that you're on the same page on where the benefits and reimbursement should be. Preauthorization. Documentation is critical. You want to make sure that, again, the test indication and supporting documentation is there. And this is important from your referring physician. So, educating your referring physicians on having this in their notes or in your orders are really important. Now, the PAMA mandate, which we're still not sure what's going to happen with, but is a mandate that we all need to be using clinical decision support mechanisms for advanced imaging modalities, which includes PET. So, if you are not looking at this, something you need to be aware of for the future. Think about your ordering process. How do you order studies and how will you help guide a referring physician on when to order a PET versus a SPECT? Physicians that order PETs appropriately because they know the indications are much more likely to get a study approved. Again, how to handle peer-to-peers, avoid denials, and then I think it's important to track insurance issues as you go along. If you see that there's one particular payer that is giving you a hard time and has a lot of peer-to-peers, it may be worth another visit with that payer as well as collecting data on insurance issues. So, if you're particularly having issues, you want to track those and let ASNIC know. Developing a program financial analysis or pro forma is important and I think helpful if you're pitching this in particular to your administrators. If you're doing this, you want to know your CPT codes for PET, MPI, viability, and sarcoid. You want to know your top payers' reimbursement rates. So, it's worth looking at who are the four or five top private payers. This is just an example of some of our numbers and, again, this is going to have wide geographic variations. Most pro formas, though, utilize Medicare reimbursement rates. Know that. And you want to think about what's your break-even point. So, if you're going to be using rubidium, for example, typically you would need to do about four PETs per day to break even and above that would be more profitable. You also want to think about what's the opportunity cost of not doing PET. Consider the downstream benefits and that's something you can really pitch. As you're pitching this to administrators, I like to think of the P's of PET. This is a patient-centered approach which improves patient satisfaction and improves our ratio of appropriate caps that actually lead to PCI. It promotes value, the power of flow reserve, the potential for future growth, and productivity of the lab. And lastly, moving on to what do you need to know as you get started with your program. So, training your staff is very important. In regards to new year nuclear medicine technologists, you want to begin training prior to program initiation and it really should include on-site training. Now, much of this will come from both your camera and your isotope vendors, but encouraging your NMTs to be reading and learning and training them yourself on the things that you want to be doing with your protocol and technology-specific issues I think is very important. That training should include the specifics of the PET and the CT camera technology and the system, transmission and emission alignment, which is critical to getting good quality images. From the isotope vendor looking at understanding the specifics of the radiotracer, you're using the infusion system and the daily quality control procedures that are necessary. You want training on the timing of the infusion and the acquisition, which is really important in the dynamic imaging required for myocardial blood flow. You want to make sure that you are getting the full spectrum of flow. So, the timing of the camera and when you're acquiring all of this data is very important. PET has slight differences in processing from SPECT. Patient counseling here is very important to prevent motion. Motion is in general is less of an issue with PET because it's such a shorter study, but when it happens, it becomes more of an issue in interpretation and a lot of that can be mitigated by counseling the patients properly. And then, of course, having your NMTs being very worst in artifact recognition so that they can help anticipate any problems or change their technique to prevent any artifacts. From your nurses, they need to be taught how to screen for study safety. Again, here, counseling the patients up front before they're even brought into the room in regards to motion. And then, that timing, the coordination with the nuclear medicine technologists for dynamic imaging is important during the training phase. From the physician's standpoint, image interpretation is different from SPECT. And, of course, like the PET intensive can really help with this, but you want to be versed in what are the normal variants. For example, rubidium has apical thinning, which is a normal variant, and 13 ammonia can have lateral wall changes. Your physicians need to be trained on quality control. Although your technologists will be excellent at transmission emission alignment, of course, we also need to be double checking all of that and looking for motion or other artifacts. High risk markers on PET are slightly different than SPECT. The drop in EF from rest to stress, because it is a true stress ejection fraction, is prognostically significant. TID cutoffs are slightly different, and how to incorporate myocardial flow and flow reserve. Your physicians will need training on calcium and the non-cardiac portions, potentially, of the CT. Flow is a whole other area, which I'll get to in a moment, but artifact recognition, then, of course, if you're planning on doing FDG imaging, you need to ensure that your physicians are trained on how to interpret and report sarcoid and viability studies. Now, understanding and reporting CFR is very important. You want to make sure that you review the educational materials. ASNIC, again, has quite a few documents on quantification of flow and now the reporting of flow. I will say that performing flow is one thing, but reporting it, you really want to make sure that you've initiated, I would say, your flow program a few months after you've began your PET perfusion. You want to make sure that you're doing this well and the quality is right on par before you start reporting these. The protocols do require special attention to the timing of the acquisition to ensure that you're imaging both the total tracer activity to get accurate quantification, and then, in particular, for stress that you're imaging at both maximum hyperemia and sustained hyperemia, and your vendors can help with this, but there is also vendor-specific training that you'll need for your MDF software. Physician education on flow quantification, you want to confirm that you have excellent time activity curves and reliable data that is not inaccurate. If it's not accurate because of motion, those are not flows you want to be reporting. You want to make sure that your physicians are knowledgeable about the clinical factors that may alter the rest flow, the stress flow, or the reserve fraction values. You want to make sure that they know the diagnostic and the prognostic value of flow so that then they can communicate that well, and I really believe that an integrated assessment on PET that integrates the history, ECG, perfusion function, and if you're doing calcium and flow, gives the best data and how you're going to report the flow and your overall impression to your referring physicians in a manner that they will understand, so in a clinically meaningful manner that they can actually act on. You have to educate your community as well. PET offers a bunch more information in terms of data that we're presenting in our reports, and so our referring physicians need to be educated on the indications of PET and its value. Why would you order it? How do you document this indication appropriately to allow good pre-authorization so your studies get approved? Make sure they're aware of the safety benefits to our patients with the low radiation and the short imaging time, how it may affect downstream procedures, and of course the clinical and prognostic significance of flow, and educating your staff on pre-authorization process, the billing and CPT codes, and scheduling so that everything is seamless. We did this in our lab, and I would also encourage you to think through the entire process from the perspective of the system first. How is an order placed? Does it go through EPIC or another EMR? How does it go through scheduling, pre-authorization, and then finally the report, and how does that get to the physician? Think of it from the perspective of the ordering physician. What do they need to do to order to ensure that their studies are scheduled appropriately, especially if it's an urgent study? What are you going to do to facilitate pre-authorization and getting the report to them, and making sure that the report is a friendly report to the ordering physician, and even now the patients now that they get the reports, and then of course from the patient perspective. From when the order is placed, when does the patient get pre-visit instructions? What will they be told before the day, and you're on the day of the study, and what is your patient flow on the day of? Where do they check in, get prepped, do their study, and where are they going to be post-study? Lastly, we'll move on to ongoing assessment of quality. I think this is really important. You want to make sure that you continuously do quality imaging, so you after you get started, reassess your protocols and your processing. As you hire new staff, staff turnover, whether it's your nurses or your technologists, you need to be continually making sure that that quality is maintained. Consistency in lab interpretation is very important. I feel strongly that all of your physicians need to be trained and trained as a group, that you are consistent in how you are putting this information together and out there. Using standardized reporting and standardized language as a lab ensures that you're giving the same message to your referring physicians, that they know on every report what to look for in terms of the language you're using to know what's a high risk or a low risk study. Ongoing assessment of cath correlation. I spent a lot of time when we started our lab looking at the patients that went on to cath and looking at their flows and correlating it specifically with cath, looking at what volume of our caths from PET actually led to a PCI which should improve, and then partnering with your interventionalists. There are points now where we, you know, the interventionalists will call me either before or even during a case to say, take another look at this, look at the flow in that area. I'm not sure about this equivocal lesion. Ongoing evaluation with your payers and looking at any pre-authorization issues and then demonstrating your value from a business case perspective as well as the impact that you're providing on patient care will allow you some leverage to upgrade your equipment in the future. Cath correlation, I'll lastly say on this, PET has been shown to improve cath and PCI ratio. There are a number of studies, not a lot, but there's a few that have looked at this. And so again, looking at follow-up in your own lab, I think is important. The most recent study looked at PET MPI versus SPECT. And if you had a low risk study versus a high risk, what was the resource utilization in terms of referral to cath and specifically the need for revascularization. And lastly, I would tell you to go slow when you first get started. It's very exciting. Make sure that your protocols are set and that you're doing high quality imaging. Key takeaways today, knowledge is power. Become an expert before you make purchasing decisions so that you know that what you are buying in the lab that you're setting up will account for your current needs, your constraints, but what you want in the future for your growth and what you want for the vision of your lab, both now and 10 years from now. Put your emphasis on quality imaging and reporting, which is critical for accurate results and ensuring that you're referring physicians are happy and that you're doing the best that you can for your patients. Ongoing cath correlation and program review and showing your value to upgrade your program if you've started with your less than ideal equipment, but also showing your value to continue to improve and optimize. Thank you for your attention.

cardiac PET program

diagnostic accuracy

myocardial blood flow

program planning

equipment selection

staff training

PET tracers

quality assessment