Conflicting recommendations from two national guideline setting bodies regarding CTC have spurred a debate over the role this relatively new technology should play in moving the nation toward higher colorectal cancer screening rates. While this debate continues, our study finds that the number of U.S. hospitals providing CTC is modest but growing, from 13% in 2005 to 17% in 2008. Our findings are consistent with previous studies showing that imaging services are expanding [15
]. However, the rapid growth of imaging services is often attributed to inaccuracies (i.e., overpayment) in Medicare reimbursement for those services. Our study is unique in that we show expansion even in the absence of Medicare reimbursement for CTC for general screening.
Our results are also consistent with other studies finding that early adopters of new technologies tend to be major teaching hospitals, hospitals with higher patient volume (i.e. large hospitals), and hospitals located in states with higher average income (i.e. hospitals in the Northeast) [17
]. Past studies have shown that hospitals acquire new technology for many reasons, including the desire to improve clinical care, competitive pressure from neighboring hospitals, profit seeking in an environment of favorable insurer reimbursement, and availability of capital to adopt new technologies [18
]. Among the small number of hospitals we interviewed for the qualitative component of our study, the desire to improve clinical care—particularly for patients who cannot complete optical colonoscopy—and the enthusiasm of radiologists for CTC sparked by promising results of clinical trials were strong motivating factors. Since those hospitals already had CT scanners, implementation of CTC required little additional capital.
Should a future goal be to expand the number of hospitals that offer CTC, our preliminary findings offer some good news. The individuals we interviewed reported a relatively quick and easy implementation of the service. Assuming that hospitals implementing the service already have a suitable CT scanner, additional resource needs include appropriate software and a CO2 insufflator. The cost of those purchases, while not negligible, represents a relatively small investment for a new service. Importantly, technologists and radiologists must receive appropriate training to prepare and position the patient and interpret the images, respectively (Johnson et al., 2008).
A potential benefit of the growth of CTC is that frail, elderly patients and those who cannot complete an optical colonoscopy have access to a suitable alternative for screening. However, the availability of CTC at a local hospital does not necessarily indicate widespread access for the community. Although the qualitative component of our study was exploratory and results are not generalizable, our findings suggest that some hospitals focus their CTC programs on the subset of individuals who qualify for reimbursement (i.e. patients with a failed optical colonoscopy and patients whose private plans cover CTC). This is not necessarily surprising, especially considering that most hospitals with CTC also offer optical colonoscopy. It follows that these facilities would direct other patients to optical colonoscopy, which is typically a covered benefit, since the hospital and physician will be paid, and the patient has little out-of-pocket cost. Also, the relatively narrow focus of CTC programs on covered patients means that radiologists and gastroenterologists do not compete for patients. This might explain why gastroenterologists were generally in support of CTC adoption at the hospitals we interviewed.
It is concerning that more than 30 percent of hospitals that offer CTC do not also offer optical colonoscopy. 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 prep required by both procedures a second time. Patients with an abnormal CTC finding might be reluctant to complete the recommended follow-up care if resource or scheduling constraints necessitate that they undergo a second colon prep.
There are several limitations to this study. The AHA data simply indicate whether a hospital, including its affiliated outpatient centers, provides CTC services. There is no information currently available about the volume of procedures performed. Additionally, CTC may be performed by imaging or outpatient centers that are not affiliated with a hospital, and those organizations are not represented in this analysis. Also, we do not have information on who completed the AHA Survey. It is possible that the individual completing the survey may not have known whether the organization provides CTC, particularly if the service was recently added. Additionally, our interviews were exploratory. We used a convenience sample and our results are not generalizable.
Despite these limitations, the study provides important baseline data on availability of CTC among U.S. hospitals. Radiologists are likely to continue to conduct research on CTC in order to address many of the concerns raised by CMS in the memo outlining its reimbursement decision (e.g., concerns about radiation exposure, miss rates for small polyps, detection of incidental extracolonic findings, variability in performance) and to further advance the technology (e.g., development of “prepless” CTC). Radiology groups, such as the American College of Radiology and the Radiological Society of North America, are well positioned to coordinate the collection of data from hospitals, outpatient centers, and imaging centers to track, monitor, and report CTC utilization. These data would be beneficial to public health researchers and policy makers as they consider strategies for increasing colorectal cancer screening rates, and the role that CTC should play.
Widespread implementation of CTC, though, and its expansion to a broader group of patients, may be difficult under current reimbursement policies. The impact of Medicare’s recent decision on future adoption of CTC is uncertain. Although more information related to procedure outcomes is needed, CTC’s relatively easy implementation coupled with improved patient acceptance makes CTC a tool that holds promise for the future of colorectal cancer prevention.