All right, welcome everyone. Thank you for joining us on today's webinar. We're going to give it just a minute here to let people get registered and sign on. So please be patient. We'll be with you in just a second. Okay, it looks like we're having a few people starting to log on and register and log on and join us for today's webinar. So today's webinar is Improving Access and Throughput in a Community Setting Using Advanced Cardiac Imaging. Today's webinar is sponsored by one of our industry partners, Circle Cardiovascular Imaging. Before we get started today, I'd like to go through a few housekeeping items just so everyone can understand how to communicate with us. So if you go to the next slide. So here you're going to see there are a couple ways to contact us and chat with us. So there is a Q&A feature that you'll see on the bottom of your screen. That Q&A feature is where you're going to be able to pose any questions to the team. We'll be monitoring these questions throughout the presentation. Also in the chat function, there should be a link that you'll be able to access today's presentation. So with that, I think we're going to go ahead and get started. So again, today's presentation is Improving Access and Throughput in a Community Setting Using Advanced Cardiac Imaging. Today's presenters are Dr. Dabal, he's a cardiologist at Harrison Memorial Hospital. He completed his residency in non-invasive cardiology fellowship at Tufts Medical Center in Boston, which is where he also served as chief cardiology fellow and representative of the bylaws committee at the Mass Medical Society. Dr. Dabal specializes in general and structural echocardiography, nuclear cardiology, cardiac computer tomography, CT, and cardiac magnetic resonance imaging, MRI. Dr. Dabal also currently serves as the medical director of the imaging core lab services at Boehm Institute, previously Harvard Clinical Research Institute. Dr. Dabal has authored more than 100 original research publications, abstracts, and book chapters, including Topol's textbook of interventional cardiology, Bromwald's heart disease companion textbook for nuclear cardiology and multimodal cardiovascular imaging, and Springer's textbook on quality measures. He is a certified biostatistician with statistical expertise in survival analysis, regression models, and cost effectiveness analysis. He'll be joined by Dr. Matthew Shotwell, who is a board certified interventional cardiologist also at Harrison Memorial Hospital in Kentucky. He earned his medical degree from the University of Kentucky School of Medicine in 1994. Dr. Shotwell completed his residency in internal medicine in 1997 and a fellowship in cardiology in 2000 at the University of Cincinnati. He holds certifications from the American Board of Internal Medicine in 1999, cardiovascular disease in 2001, and interventional cardiology in 2004. Dr. Shotwell brings over two decades of experience in advanced cardiovascular care to the community. So we'll have a little bit of a discussion, but to get started, I'm going to turn it over to Dr. Dabal and let you get started with your presentation. So the floor is yours, sir. Thank you, Chris, and thank you all for attending today's presentation. The next few slides are just a 10-minute talk about talking a little bit about our experience from a rural hospital's perspective, starting a CCTA program and how we moved the program from just surviving to, you know, get the program running into now thriving, and hopefully share that experience with you for the next 10 minutes and drive the discussion after that in the Q&A session. Before we begin the talk today, I have nothing to disclose. So to begin with, I'd like to highlight a little about a few things regarding some of the significant challenges in rural hospitals in the United States in this day and age, and some of the unmet needs that we face in rural hospitals, which include limited access to specialists, a shortage of health care staff, a lot of the hospitals in rural settings lack advanced diagnostic imaging modalities, although there's a lot of care to be provided. There's not a lot of resources that can provide that care, which can eventually result in delayed response times, longer waiting times, and just a significant amount of volume of patients that require care when there's no either staff to provide that care or there's no availability of the right tests to allow that care to be done in a prompt and timely and accurate fashion. The other things that are facing rural hospitals in this day and age are educational barriers to preventative care, including addressing long-term primary and secondary preventative care. And of course, things that affect our nationwide, have nationwide implications are things related to regulatory and reimbursement challenges. One of these unmet needs is cardiac CT when it comes to heart disease and heart health. Cardiac CT is an emerging modality over the past 20 years that has grown substantially with regards to diagnostic accuracy in terms of its indications, its implications, and even its effect on outcomes. Although we see that substantial growth in the clinical trial context, it has still lagged behind in terms of growing in a real world setting, most notably in the rural setting. We see cardiac CTs growing substantially in big academic tertiary care hospitals, but rural settings where some of these cardiac CTs could be of most benefit, they're still lagging behind in terms of providing that modality. We do believe that establishing a cardiac CT program, especially in rural hospitals, could significantly improve early detection, timely intervention, and comprehensive management of cardiac conditions. That includes timely diagnosis of cardiac diseases, which would reduce the time, the waiting time, and also dependence on transfers to bigger hospitals. So small hospitals could take care of their own patients. Patients don't have to travel anywhere. Some of these travel times are hours and hours away from their home and their loved ones. Of course, CT programs have big implications in improving preventative care, especially the calcium scoring, for instance, and early detection of cardiac disease, and improving quality of care in general, and addressing the prevalence of cardiac disease in a local community setting. Cardiac CTs have shown that they have implications on healthcare costs, including improving healthcare costs and length of stay of hospitalizations. And finally, having the right test in the right setting in a rural community really builds the trust between the healthcare provider and the community, and is really at the core of providing good access to medical care that the community needs. There are some limitations to starting a CCTA program, including high initial costs of equipment, installing these equipment, ongoing operational and maintenance costs, and of course, needing specialized and trained staff, which is one of the big limitations in a rural setting, finding the right person for the job, and of course, challenges in recruiting specialists such as cardiologists, radiologists, people who are going to be analyzing these studies, and of course, finding the patient volume for the tests that you are going to be implementing, and of course, eventually discuss a little bit about reimbursement, and if reimbursement will ever be a limitation to starting a CCTA program. So these are, in general, the limitations to starting any program, and you know, CCTA is not any different, and today we're going to be talking a little bit about how we can overcome some of these challenges, and if some of these challenges are really challenges to begin with, especially in the context of a cardiac disease, cardiac health, and CCTA program. So this map really highlights the unmet need in terms of providers and the availability of providers in the United States among people who can provide the service for cardiac CT. This is a slide from RSNA in 2017, which is the most updated version of this slide. It shows where CCTA providers are distributed in the United States, and we see the majority of providers are really on the coasts, in the East Coast and the West Coast, but really inland, and you know, this is where the majority of rural hospitals exist, they lack substantially the presence of providers that can perform the test and analyze these studies. And of course, when it comes to ECHOs and nuclear studies, there's much more availability for these tests, but when it comes to more advanced cardiac testing, namely CCTA and cardiac MRIs, we see a significant deficiency. In fact, some of these states are grayed out, they have no provider whatsoever to even provide that service. Where I am in Kentucky right now, as of 2017, there was only six providers who can analyze cardiac MRIs in the entire state, just six people, and 15 people can analyze cardiac CTs. So imagine the burden of healthcare, the burden of cardiac disease is basically on the shoulders of six people and 15 people when it comes to analyzing cardiac MRIs and cardiac CTs. With regards to, you know, the first question we need to ask ourselves is, is CCTA even worth it? You know, the answer to that has multiple layers. The first layer, which is the most important layer, is clinical outcomes. Is it going to benefit the patient? Before we talk about any administrative benefit, you know, the first question is outcomes for the patient. The answer is clear from the randomized clinical trials that have been done over the past decade. There are benefits to CCTA, including clinical outcome benefits, these are hard outcome benefits, and, you know, other softer endpoints, such as length of stays. For instance, the PROMIS trial showed that CCTA really identifies 88% of patients who have had death or MI at follow-up. So these patients were identified earlier, and they were identified at a much higher incidence compared to stress testing with CCTA in terms of allowing them to receive the care that they deserve. We were able to find more of these patients who are the right patient, who will get the right treatment, way higher, at a way higher incidence in CCTAs versus stress testing. Versus in the ROMICAT-2 trial in 2017, it showed that CCTAs really significantly reduced the length of stay compared to standard of care, and patients in the emergency department had to wait an average of 8.6 hours as opposed to 26.7 hours. So not just hard endpoints, but also length of stay, hospitalization, turnover, were all improved with CCTA. In other aspects of CCTA versus other imaging modalities, we know that CCTA performs better, especially when it comes to sensitivity. As in ruling out disease, CCTA has very high negative predictive value with a sensitivity of approaching 97%, and reasonably very high specificity, especially compared to other modalities. It performs much better, especially to rule out disease, than a stress test, which is at around 87% sensitive. So it's a much better test to rule out disease, and a faster test to perform, especially in an ER setting. So patients are being ruled out faster, they are leaving the ERs faster, and of course these tests are really sending the right patients home and keeping the right patients in the hospital at a better detection rate. So we know from validation cohorts is that CCTA really performs better than stress testing. You can see the area under the curve in the blue, the dark blue, is the CCTA versus the stress test, which is in yellow. CCTAs just perform better with much higher sensitivity and even better specificity. So the first, the most important question we want to ask in this talk is, okay, now that we know the benefits of CCTA, and I really want to start a CCTA program, how do I do this? How can I start this in a local, small institution? And this is not me talking about big hospitals, I'm talking to the person who's in a rural hospital setting that wants to start a CCTA program, just like our program. So this is who we are. This is me and Dr. Shotwell, who's joining me today at this webinar. And this is our hospital. It's called Harrison Memorial Hospital. We're a small local hospital in rural Kentucky. This is us on the United States map. We're in the middle of Kentucky, in central Kentucky. We like to call ourselves the Harvard of Harrison County. So Shotwell and I are basically providing all of the cardiac care when it comes to physician services at Harrison Memorial Hospital. And today we want to share a little bit of our experience and how we grew the CCTA program. To prove that we're a small hospital, I want to show you a little bit of the New Year's Eve celebrations that the big cities do. You can see Dubai in the upper left corner, big celebrations on New Year's Eve. Sydney, same. New York, big major celebrations. And this is who we are in the bottom right corner, two firecrackers at the Harrison Memorial Hospital, and we were home. So it doesn't get any more rural than this. So we're proud, we're happy, and we're here for it. So today I want to share with you a five-step guide. This is almost like a checklist where we, these are some of the things, the lessons that we learned, whether it's just things that we learned as we went performing what we're doing, or things that we kind of learned as in these are the mistakes that we have to teach other people not to fall, you know, and make the same mistakes. So this is the Harrison Memorial Hospital's five-step guide that you need to know basically to start your CCTA program. Step number one is just like any investment, like any initiation of any project, you need a needs assessment and budgeting. When it comes to cardiac CT, it's actually the easiest thing because we know that every community needs some sort of diagnostic testing for cardiac care. Cardiac disease, cardiovascular disease is the most prevalent, the most common disease worldwide. Heart attacks happen every 42 seconds in the United States. So there is no deficiency in the need, especially when it comes to community settings, that do I need better cardiac testing? The answer is always going to be yes. Otherwise, you're going to, of course, assess the financial feasibility in your local institution and engage the stakeholders, whether that's the hospital leadership, staff, partners, donor. A lot of this is community-based, so you're going to see a lot of community-based engagement. These are the individuals that are going to be involved in some of the decision-making when it comes to investing into the program. Eventually, you're going to develop a budget, which includes the purchasing or leasing of the CT scan or some of the facility modifications, staffing and training, and, of course, the budgeting for the ongoing maintenance and supplies. So make sure you factor all of these into the budgeting. It actually helps moving forward, managing expectations, and setting the right budget for the right tests. Step number two is, really, this is where it starts materializing. And this is where you're going to start looking at what's out there. And this comes in two flavors. Number one is the hardware, where you're going to be working with vendors. And this is tip and trick number one. I really, when it comes to starting or installing equipment, make sure you capitalize on the fact that vendors and third-party individuals have a lot of reach when it comes to, you know, they've done this before. So make sure you use their services when it comes. And they have available services that are provided to you at no cost, unless, of course, you end up purchasing, in terms of making sure, you know, addressing some of the feasibility questions that you have, whether allocation of resources, or whether it's the physical space feasibility, or even what kind of CT scanner you need for the services that you're going to provide. So not all of these questions you're going to have to answer yourself. Make sure you use the services of the people around you. And that includes the vendors. For instance, in the picture on the right side, this is me and Anastasia and Abby, who are radiology technologists. Basically, this is at one of the vendors' sites. We were visiting the site and actually looking at their CT scans. So, you know, it is a very active effort where you're going to go visit sites. They're going to, you know, there's going to be a lot of back and forth with vendors. And this is good. This is healthy. You want to see what's out there. And you want to see if they are able to provide the service that you're really looking for. Number three is going to be, you know, one of the most important thing is installing really the post-processing workstation. And these are the right workstations, the right post-processing software that you need to actually get the job done. You could have the greatest scanner in the world, but if you don't have the right workstation, it's almost like you have the engine of a Ferrari, but you're running a Honda. So, you know, make sure you match that your Ferrari with a Ferrari workstation. And, you know, in our institution, we use Circle. It's tremendously been helpful in terms of making the workflow easier and making our job easier. The efficiency, the efficacy has been substantially improved with a lot of the AI technologies and the capabilities of the software. So I really, you know, I think of post-processing softwares and, you know, the software that I have, it's almost like my fellow. So I have a fellow with me that is very, you know, provides a reproducible job and very good, accurate work. Obviously, as a human, I will always overlook the, I will have an oversight in terms of what the software is generating, but it does make my life substantially easier. And it makes the technologist's life substantially easier in terms of how much work they have to do to make the pictures look good, to even provide the initial measurements, the initial reporting before I look at the picture. So having a good process, post-processing software really goes a long way in terms of investing in the right devices. And it almost, it feels like you have an extra human with you that is providing a good service. Number three is staff recruitment, training, and of course, protocol development. So once you have the software and the equipment, you want to make sure that your staff is adequately trained. We have, for instance, used a lot of the colleagues that we work with in other states. And these are the people who, some of the individuals who trained, you know, trained me personally. We reached out to these individuals as, and we want to make sure our personnel, our techs are learning from the best. So we flew our techs to other states, to big tertiary hospitals. They learned a lot about, you know, how they do the things and they brought that information back home. So we're now performing at a level of a big tertiary care hospital because we sent our people to learn and they became skilled personnel. And now they're teaching the new personnel. So make sure you recruit and you invest in the right individuals, you establish training programs and continuing medical education programs. And of course, part of the process itself is to develop good protocols. So the technologist always has the right roadmap in terms of what tests needs to be done and in which imaging protocol, which modality and which phases, which views. So if these personnel, if these staff are taught, you know, or they have the right protocols, then the test will always be the right test and patients will always leave there with the right answer. So make sure you, as also part step number three is, this is kind of building now the integrating the workflows into the existing workflow and the electronic medical records. And eventually what you really want is down the road is to start establishing quality control measures and measuring some of these key metrics and making sure we're meeting these key metrics. And of course that includes real-time feedback and then aggregated feedback. So for instance, in this picture, I'm just standing with Abby while we're scanning. And this is one of the early scans. It was just part of our testing scanning where we're just going over the, you know, the quality of the scan, the imaging protocol, the pictures, the right phases, the right amount of contrast. So all of these things, you know, can be evaluated in real time, especially at the beginning when the program is being established. Number four is to develop partnerships and community outreach. What you don't want is to be in isolation. And although you're a rural hospital and a lot of these rural hospitals, you know, are in isolation, but you know, you can, you do have access to other providers and you will, you will be surprised by how many non-specialists will be interested in the service that you're providing. And I'm talking here about urgent care offices, about primary care offices, and even specialists. So other cardiology offices that don't have the service that you're providing, which is a CT scan now, they would want to work with you and collaborate with you too. So you can provide that service on their behalf and they can now offer it to their patients through your institution. So make sure you're collaborating with local physicians and make sure you're using the network that you have available to you, to your advantage in terms of community, in terms of partnerships. And the other group of individuals or the other aspect of this is really the community. You want to reach out to the community directly. So you want to be out there, you want to be in the community with the, with, with the people, the, the people that you're providing the service to and teaching them a lot of what cardiac CTs are, what heart disease looks like and how you can prevent heart disease. For instance, these are some of the pictures from my presentations in the community. We just, we go into the community and we, we have these talks and, you know, they're very educational. They're very helpful. People appreciate them. And we do see a lot of the return on that where patients just come and, you know, now they have questions. What, what's a CT scan? You taught us that last time. Do I benefit from this? And a lot of the times the answers are yes. Of course, going on podcasts, local radio stations, newspapers, all of these, you know, help promote preventative care, help promote the service that you're providing. And at the end of the day, you're doing it for the right reason. So make sure you use that to your advantage. And finally, of course, initiating the program, selecting a few cases that are test protocol that are tests to look, to look for, you know, the workflows and making sure your, your, the protocols that you set in place are being tested and are being implemented appropriately. Make sure you're monitoring the quality and the efficiency and the key metrics, as we said earlier, feedback, and eventually you're going to scale the program and you're going to want to measure some of these metrics, including clinical outcomes, correlating the findings with other findings, such as the cardiac catheterization findings, looking at patient satisfaction outcomes, such as wait time, such as, such as their efficacy of the test to actually help in terms of symptom relief, in terms of outcome relief. And of course, eventually you're going to look at that from a financial perspective and evaluate if this was the right investment for you, which in our case has been a tremendous help for our institution. So what are the most important questions that providers and administrators and hospitals can ask, you know, is we are a small hospital and is the patient volume even, even there to provide, to need that service? You know, we learned actually it's, it's almost paradoxical is that in a rural setting, it's really where the patient volume is the highest. You are providing a service to a big catchment area, and you want to make sure that you, if, if, if people know that you are providing that service, then you will realize that that service will be used. And patient volume actually is, is the opposite. It's, it's not a problem. It's actually, it's, it's, it's more than you can imagine to be in a rural setting. So it's definitely not a problem. In our institution, when we started the program in October, 2022, we started the first month or two with just testing mode where we did only one study per month, but you could see our trajectory is growing very nicely in a very linear fashion, upward fashion over the past year and a half, couple of years now, where we're seeing just growth and growth over time. We're performing anywhere between 40, 50 CT scans a month, which is equivalent to big tertiary care hospitals. And, you know, we're, we're a small hospital, but we're providing that level of, of care in a rural setting. That's actually, that's actually incredibly surprising in a very pleasant way. And the other question that people usually ask is, okay, now I have a, I have a nuclear scanner in my office or in my hospital. If I get a CT scan, am I going to lose the utility of a nuclear scanner? We, we, this was one of the hypotheses that was suggested, but we actually learned that's the opposite. So, you know, the, the dark blue line is the CT, CT scanning. And as you can see, it's the linear growth that I showed you earlier. And then in the light blue line is really the stress testing where it's almost a horizontal line. That's actually, you know, sloping a little upward as in it's also growing. We learned that, you know, one modality does not replace the other. It's actually the opposite. They, they go hand in hand. When people come to the office, when CT scans are happening, other tests might need to happen. Not everybody needs a CT scan for instance, but they're coming to explore, you know, the heart disease that they heard about. And, you know, some people have had stents before where CT scans might not be adequate if their stents are small in size, or they might have some contraindication to CT scan. Their kidney function might not be great. So providing the additional service of a stress test, we learned that actually has not been compromised. In fact, they grew together and one test just complemented the other test. So we saw almost a double effect when it comes to providing one test and the other test just naturally organically grew with it. And the last question I'm going to address, you know, before we take the Q&A session, is reimbursement a problem? This is actually an excellent question. A lot of people hear that reimbursement for CT scans has been a problem. It's not reimbursed at the level that you would want. That actually has just changed as of November 1st, 2024. So less than two weeks ago, the CMS has agreed to double the reimbursement for CCTAs for Medicare patients. And actually we're going to see a lot of reimbursement changes. There's a lot of coding changes when it comes to CCTAs and CTFFR, and a lot of the payment rates are going to change, including things for artificial intelligence enabled QPA services. So CTA is growing, not just organically and at a clinical level, but obviously the decision makers when it comes to reimbursement are recognizing the utility of this and are recognizing the services that it's providing, not just for outcomes, but also for length of stays and all the benefits that it's providing. And they're now reimbursing more adequately and we're expecting to see a more favorable reimbursement rates down the road. So thank you for attending. And I would love to take your questions now. I'm going to be joined by my colleague, Dr. Shotwell, who's the interventional cardiologist at Harrison Memorial Hospital. And the both of us will happily take your questions. Dr. Shotwell, I'd like to get some of this conversation started if I could. I mean, I thought that was a great presentation. Again, thank you to your team and also to Circle Imaging for bringing this to our attention. It was great news about the CCTA reimbursement that just came out last week. So as a reminder, if anybody wants to download this presentation, just go into the chat feature, there's a link there and you can do that. So a few questions. First of all, it's obvious that the two of you are very, very busy. The program is shouldered by you as the non-invasive and interventional specialist. So being so busy, can you talk to us about the importance of collaborating with each other? And if any of our members are looking to establish a cardiac imaging program, what would you suggest to them about collaboration? Yeah, I mean, there's, you know, cardiology has two aspects, the non-invasive aspect and the interventional aspect. And, you know, they clearly complement each other. And I think historically, there was a lot of kind of load on the interventional arm where people just used to be, you know, calved frequently. But that was because we lack the technology to evaluate patients non-invasively. But, you know, over time, we're learning that the non-invasive cardiologist is really, is just complementing the job of the interventional cardiologist. And, you know, a lot of cardiac care is just going to depend on both. So the diagnostic portion of it will be heavily dependent on the non-invasive portion, but a lot of it is also going to depend on the interventional arm. So I think to provide the full service, the diagnostic and the therapeutic aspect of it, you really need both. And I think this is, you know, where Dr. Shotwell and I really do well, as in we work well together and we're providing the full spectrum of the care. Dr. Shotwell, anything to add to that? Yeah, I concur. It's been an excellent addition having Dr. DeBolt here. The CCTA is, I think whenever we lower the threshold for catching the leading cause of death in the United States, allowing practitioners to order these tests and screen these diseases and bring them in, it always enhances the entire program. What we're finding is we're having more patients come into the cath lab that actually have bona fide disease and require interventions. So we've seen, while we've seen a fewer of the normal or non-occlusive heart caths maybe go down, there's been a far higher compensation or compensatory increase in the patients that are coming in with true bona fide disease. And that always makes it nice for the interventionalists because as interventionalists, we like to intervene. And that's what we're seeing. So it's been a very pleasant surprise. We're seeing much more, you know, and not subjecting a normal, a patient to a normal heart cath is, you know, that's always something we want to do. We have to remember it's an invasive test. And there are some risks associated with invasive tests. But when we have a higher pretest likelihood for having interventional disease or bona fide disease, these patients are coming to us with that higher pretest likelihood, which, you know, makes us happy. One of the slides you showed, Dr. Dalton, was really interesting. It showed that the CTA program did not reduce the volume for the existing Newt Med program. And I know you also do cardiac MRI procedures. So my question is, how does your CTA program relate to this CMR work? And specifically, how do you manage the caseload and workflow differences between these two modalities? Yeah, good question. So CCTA and MRI are both, you know, advanced imaging modalities. The thing about them is that they provide a different answer to the clinical question. An MRI is really addressing the structural, the functional heart when it comes to, you know, what the heart is functioning like, and, you know, anomalies related to the heart structure versus the CCTA is an anatomic assessment of the coronaries for the most part. In addition to some structural aspects of it, especially when looking at valves, but the bulk of it is really looking at the coronaries. So if we want to simplify it in the easiest way possible, the CCTA is looking at the plumbing problem. The MRI is looking at the motor problem. So, you know, they're giving us two different answers to the same puzzle. But when a patient comes to us, you know, with chest pain or breathing issues, they might end up needing both because we still don't know at that level what's the underlying issue. Is it a plumbing problem or is it a motor problem? And, you know, a lot of the times they complement each other and they're both necessary. And of course, you know, in addition to other modalities such as echo or, you know, whatever tests that can be done before that, but a lot of the times they end up needing to do both just because, you know, the symptoms are still nonspecific and, you know, the diagnosis has not been made. So they complement each other by providing different answers to the clinical question. Having one system that, you know, the one post-processing system, for example, Circle, we have the same post-processing software that really analyzes both is very helpful in terms of improving the workflow, the efficiency of the workflow, especially from a technologist perspective, but also from the physician perspective, I have the same software that can run both and you can go back and forth and navigate between both imaging modalities. And you learn a lot by looking at one modality when you're really trying to look at the other one. So having the availability of both at hand in just one software is really helpful in terms of improving efficiency, but also efficacy. And also, you know, what you really need when it comes to efficiency is, you know, simple and something that works. And the fact that, you know, the software provides simple, is a simple tool to make that work. You know, we don't need to complicate it with more softwares. Dr. Schott, want anything to add to that? Anything specific? You know, it's pretty all on your point. We've been very happy with the, with the CCTA. I know I find myself, I find myself even pushing some of the CTA, CCTAs, for example, some of the kind of sicker inpatients, maybe with coagulopathies, liver disease, ventilators are on septic pneumonia that have positive proponents. These are the patients that we're not real excited about bringing into the cath lab, but we still have a fairly high pretest suspicion, ischemic disease. So now that we're much more experienced, we have experienced technologists, we're able to take these sicker patients and do a non-invasive assessment of their coronary arteries without having to subject them to an invasive heart cath during a coagulopathy. So, you know, it's been a, when we start initially with kind of the healthier cardiac patient, we're now advancing to the sicker heart patients. And as an interventionist, I'm actually, you know, running these CCTAs before the patients even come to the cath lab. And just to follow up, you also mentioned AI and the AI tools, obviously, you know, they're not aware that you're in a community hospital setting. So just, I'm curious, my question would be, you know, what's the value that you found out of the AI models, you know, specific to your community hospital setting and what kind of benefits do you recommend or do you see that your colleagues in this same setting might be able to get from these type of tools, the AI tools? Yeah, no, that's an excellent question. So, you know, I think utilizing AI to your advantage goes a long way. And if you're not using it to your advantage, then you're missing out on a lot when it comes to, you know, providing efficient and good care. So in a rural setting, especially, you know, you don't have a necessary, you're not in a big tertiary care hospital where you have a resident and a fellow and, you know, 10 fellows looking at the images and measuring things before you show up. Well, you know, a lot of it is just you. So, you know, having AI really is like having another, as the name mentions, it's just having another intelligent brain that is doing some of the work for you. I don't think it should ever replace, you know, the physician as what we do, but it really facilitates our job and it cuts down our time consumption. You know, it takes away a lot of the scut work that you have to do when it comes to measuring small things or looking at tiny details that are part of the protocol that you have to measure. It takes that away from you. And, you know, you end up just doing the thing that you signed up to do, which is, you know, looking at the actual images and analyzing the images without having to do, you know, what a trainee was meant to do. Now you have just an AI doing it for you very reproducibly, very accurately. And it just helps, you know, improve the workflow. We can, you know, there's a lot of room to use it even further. And, you know, this has been in discussion with me and Dr. Shotwell in terms of, you know, for research purposes, because a lot of this is still under research investigation. You know, we have the capability to provide the AI service and we have the patient volume. You know, we can scale this technology that we have into research purposes and take our CT scanner and our expertise into not just the clinical aspect of, you know, providing care, but also the research aspect of providing care, where we have the technology to characterize plaque, to quantify plaque. A lot of it is based on AI to just advance research and, you know, help answer the next, you know, future questions in terms of, you know, what cardiac CT scan provide. Okay. So I do have a few questions here that have come from the audience. And let me take the first one here. So it says, thank you for the presentation. Can you discuss the role of CTFFR in your plan to add plaque analysis? I'm not sure if that's something that we should ask the circle team, or if you're aware of what that next step would be, Dr. Dunn or Dr. Shah. Yeah, so CTFFR is of course, you know, a technology that is very helpful. And in fact, you know, we are in active communication with some of the vendors to provide that service. This is kind of part of our, you know, we are at that, you know, step five of our program scalability and kind of always tweaking and improving. So we're now at the level of having the conversations about CTFFR and, you know, in our program, it is now part of the recommendations in the society of cardiac CT guidelines for moderate lesions. So we wanna make sure that we're providing the standard of care, you know, the best level of care for our patients. And, you know, we're actively communicating with the vendors for that. So I think it's just a matter of time before it happens. And I think, you know, it should be part of every CT, you know, CT programs plan to get it done. It doesn't necessarily have to be the first thing that you do, but it definitely should be part of the planning. And it does help with quantifying stenosis, with also improving sensitivity and specificity. And again, this is, you know, going back to Dr. Shotwell's point, we wanna send the right person to the cath lab. We don't wanna send the person with normal coronaries or somebody who doesn't need the intervention to the cath lab. So I think, you know, this is where CTFFR comes, the role is pretty crucial here. Okay. Another question coming through the Q&A. And again, to the audience, please feel free to add your questions here, but do you perform a high number of diagnostic cath and angiograms? If so, was that volume impacted by the implementation of CCTA? I think this is just another concern that I am struggling to account for when putting together a budget proposal. Yeah, I guess I can answer that. So, you know, naturally, that was a concern of mine. Were we going to see a drop in the cardiac catheterizations? And as I kind of touched on before, whenever you cast a wide net and you start screening the leading cause of death in the United States, like coronary artery disease, especially in a rural area where there's a higher prevalence, life expectancy is lower, and you cast that wider net, you're going to bring in a lot of people and when you cast that wider net, you're going to bring in more patients and screening them for the coronary artery disease. What we have found is the number of cardiac catheterizations since Dr. DeBolt started is actually we've climbed exponentially. And from the interventional standpoint, what I've seen, I've seen fewer normal heart caths because we don't have to bring those patients into the lab, which is good. We don't really want to do a cath on a normal patient. It's still an invasive procedure. And while it's a safe procedure, there still are risks associated with an invasive procedure. So if we never have to subject a patient with normal coronary arteries to an invasive heart cath, I mean, that's a win-win for everybody. So the CCTA is eliminating these normal heart caths. Instead, what's coming to the cath lab are patients pretty much with bona fide disease. And the question is, is this interventional disease? Is it disease that we're going to be sending for bypass? Or is it medical disease? So while initially there might be some concern that the cath volume is going to be reduced, paradoxically, it actually increases. And more importantly, it's sending us patients that have intravenous coronary disease. So we've been very pleasantly surprised. And I will tell you just on a side note, some of the more difficult lesions to find, for example, angiographically looking for an osteo-LAD or an osteocircumflex artery, sometimes the way the heart is kind of configured during the cardiac catheterization, we may even miss it. It might be something that we would otherwise miss on coronary angiography. But knowing in advance that this patient has an osteo-LAD lesion, as an interventionalist, I pay particular attention to make sure I'm doing all the views to specifically lay out that osteo-LAD. Because if Dr. DeBool has already identified a critical lesion in the proximal LAD, I better make darn sure that I'm evaluating it. So anytime I think you add a modality in a tool, you're just getting improved care, finding more disease and then being able to treat. So if there's a concern about the lower number of normal caths, while that may occur, you're going to find a much higher compensatory increase in interventional disease. Thank you. Now that your service is up and running, what impact do you foresee the reimbursement changes having to your program? Say that question again, sorry, what? Now that your service is up and running, what impact do you foresee the reimbursement changes having? Yeah, I mean, the reimbursement changes that are starting in 2025, they're expecting to double the reimbursement. I think that's mathematically, we're expecting to double the reimbursement from that perspective. And I think it's appropriate. The test is very helpful and is very useful. But at the same time, a lot of the reason why it has not been implemented, especially in rural hospitals, is because of the incentives to have it done has not been there. So I think the reimbursement rates are just now matching the importance of the test. And I think that's going to go a long way in terms of seeing CT programs growing and new programs being established. So hopefully, as these are growing, we're going to learn more about the benefits of CT, and especially that we're already learning the indications for CT are expanding over time. So we're anticipating even further growth and even better reimbursement rates. So I think now it's going to be doubled, but I think it's going to improve further. Okay, another question. Can you speak to the agreement for READS, 24-7 stat or business hours? Excellent question. So I think CT scans, a lot of the benefits of CT scans are, of course, in the emergency care setting where a patient comes on a Sunday night where it's not business hours. And the question is, can he or she be discharged now, or do they have to wait till Monday morning when the cardiologist comes in? So I think when you're initiating the program, it might be helpful to start easy and slow and see what business hours look like for you. And a lot of it will be allocated hours on a non-urgent basis. So you don't have to start and rush the program into an emergency care setting where you're adding on patients to expedite discharges. But down the road, as you improve the workflow, and a lot of it is really the technologist's capabilities and their expertise in terms of providing a quick, efficient service that answers the question. So I think down the road, I think every CCTA should really be looking towards becoming an extension of the emergency care department, because this is where a lot of the utilities and the benefits, especially for hospitalization stays and turnover in the ERs can be seen. So in our institution, we are now actually working on the protocol to expand the service from just a business hour service to a 24 hour service. That would include having the physician on call, whether it's a cardiologist or a radiologist to be available. The good news is that the scanner itself and the majority of the technologists that we have are all trained to do the study. So it's not going to be a limitation of the technologist's availability because the ER will have a scanner and will have 24 hour service anyway. The limitation has been at the level of the physician reading the study. So making sure that you have a 24 hour coverage. If you have at least two people providing, who can provide the service, whether it's a local physician or a remote physician, especially that applies to radiology groups. I think you can easily do this as a 24 hour, seven day service without any interruption. Okay, I've got another question from a member. It sounds like on average you perform two to three CCTAs per day. Do you have carved out reading time in your day or do you read in between clinic patients? Curious about how we need to design provider templates to accommodate for expansion of CCTA. Yeah, good question. So, you know, we started as doing this as one or two studies every other day, Monday, Wednesday, Friday. As the volume grew, we started doing it every day and now we added an extra slot. So there is a dedicated, you know, three or four studies per day that happen for outpatients. And now we're starting to add on some of the inpatients and the, you know, the emergency care setting, the patients in the emergency care department. So we're averaging now around four and we might be hitting, you know, the fifth CCTA per day as our numbers continue to grow. When it comes to reading CCTAs, some of these are time sensitive. So CCTAs will need to be read in a timely fashion, especially when we're looking at emergency care reads because this is, you know, the purpose of the test is the time sense, it allows you to just, you know, or to cut down on some of these times. So usually a lot of the reads happen for me in the morning and my clinic patients are in the afternoon. So I dedicate basically the mornings to reading all the imaging modalities that I have, including ECHOs, CCTAs, nuclear studies. And then in the afternoons, if there are additional cases that need to be read, it would happen between clinic patients or a little later in the afternoon if I'm still around. And occasionally I do have a remote workstation at home and if I'm not physically available in the hospital, then, you know, some of this can be read even remotely at home, which is a big benefit. You don't have to be physically present at the scanner to work at the workstation. Okay, another question. Does your team have any insight to share on increasing their throughput and efficiency? And have you switched to nitro patches instead of PO nitro? Yeah, good question. Actually, nitro patches have been a little debatable, especially with regards to, you know, the release of the active ingredient. What we really want with the nitro is the fast instantaneous vasodilation because the scanner just, you know, is a few seconds and then the study is done. Nitro patches, a lot of the times is just an extended release of, you know, vasodilation where sometimes we can miss the optimal time point to see the vessel lumen, you know, in its best form. So, you know, we tend to stay away from nitro patches and actually sublingual nitro has, you know, either one or two tabs, you know, 0.4 milligrams or 0.8 milligrams right before the procedure, you know, has had very good outcomes in terms of lumen diameter, lumen visualization. So I would, you know, and this is kind of in line with a lot of the experts that I asked around when we were building the protocol in place because we did ask about nitro and some of the other questions were related to heart rate reduction, such as, you know, using ivabradine. So when it comes to nitro specifically, you know, I got a lot of feedback and which I agree to, you know, use the short acting fast sublingual nitro, not the patches just because it helps the image quality. Okay, we're coming up at the top of the hour here and I think we've answered all of our questions. And again, I wanna thank Circle Cardiovascular Imaging for sponsoring this webinar. Dr. DeVol or Dr. Shotwell, any closing comments before we close down the webinar? Yeah, I'd like to mention about the throughput. When we first started with this program, you know, there was still some of the radiology anxiety, some of the technician anxiety. And then the more we start doing the cases, suddenly now it's just, it's nothing. Ordering a CCTA is kind of like ordering a chest X-ray or just a regular CAT scan. So the more experienced and more confident than these tests just become just another test. So don't allow the initial anxiety of doing a CCTA. That is not gonna continue. The staff become very desensitized very quickly and then start doing these just like any other modality. That's terrific. Okay, if anybody has any questions or comments, you can feel free to reach out to the MedAxiom team here and we'll pass those along or you can contact Dr. DeVol or Dr. Shotwell directly. But with that, thank you all for taking the time to join us today. Again, we wanna thank Circle Cardiovascular Imaging for sponsoring this webinar. Thank you all. Have a great day.

cardiac care

advanced imaging

rural hospitals

cardiac CT

CCTA reimbursement

AI tools

diagnostic capabilities

community engagement

cardiologist collaboration