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Imaging with CARE Introduction Each year an estimated 17 million nuclear medicine and molecular imaging procedures are performed in hospitals and medical settings across the United States. With nuclear medicine and molecular imaging, physicians can obtain unique insights into a patient’s body that allow for a more personalized approach to the evaluation and management of heart disease, cancer and brain disorders. Yet despite the important implications these procedures can have for patients’ health, in many states technologists are not required to have certification or a license to perform these tests. Nuclear medicine and molecular imaging technologists are responsible for performing a wide variety of highly specialized procedures [see What Is Nuclear and Molecular Imaging? p.3]. Conducting these procedures entails, among other responsibilities: • preparing and administering radioactive chemical compounds; • performingpatientimagingproceduresusingsophisticated radiation-detecting instrumentation; • completingcomputerprocessingandimageenhancemen; • analyzingbiologicspecimensinthelaboratory; With nuclear medicine and molecular imaging, physicians can obtain unique insights into a patient’s body that allow for a more personalized approach to the evaluation and management of heart disease, cancer and brain disorders. Imaging with CARE • providingimages,dataanalysis,andpatientinformation to the physician for diagnostic interpretation; and • workingdirectlywiththepatientthroughouttheprocedure. It is essential that technologists perform these scans correctly to ensure that high-quality information is provided to physicians, that patients receive the lowest achievable dose of radiation and that health care costs are minimized. The Society of Nuclear Medicine (SNM) has created this report to bring light to the fact that mandatory, stringent education and certification standards must be enacted for technologists performing nuclear and molecular imaging scans to ensure excellent patient care, safety, and effectiveness. SNM and the SNM Technologist Section are committed to improving the quality and safety of medical imaging and therapeutic procedures. 2 What is Nuclear Medicine and Molecular Imaging? Nuclear medicine is a medical specialty that uses very small amounts of radioactive materials (radiopharmaceuticals) to diagnose, guide management and treat disease. Most nuclear medicine procedures are molecular imaging procedures that use radioactive substances to visualize the molecular processes through which the body functions. This provides physicians with molecular level—not only anatomical or structural level—data that can help personalize treatment. Nuclear and molecular imaging procedures are safe, painless, and cost-effective; they provide a way for physicians to gather medical information that would otherwise be unavailable, require surgery or necessitate more expensive diagnostic tests. Many times these procedures identify abnormalities very early in the progress of a disease, long before many medical problems are apparent with other diagnostic tests. With nuclear and molecular imaging physicians can determine—almost in real-time— the effectiveness of a treatment, allowing them to offer patients highly targeted therapies and to ensure that higher The Need for High-Quality Imaging Much depends on the quality of nuclear and molecular imaging procedures. When performed properly, a molecular imaging scan can provide unique information that allows doctors to better diagnose, guide management of and treat diseases; however, when performed improperly, the resulting scan can be useless. Before the nuclear or molecular imaging procedure takes place, a technologist must determine the appropriate dose of radioactive materials needed to obtain a high-quality imaging scan based on a patient’s height, weight and affected part of the body. Based on this information, technologists also calculate the length of time a patient should be scanned. Imaging with CARE doses of medicine are directed more precisely at problem areas. Common nuclear and molecular imaging technologies include: • Positron emission tomography (PET) scans: Commonly used in the staging of cancer and evaluation of treatment. • Single photon emission computer tomography (SPECT) scans: Used to diagnose brain and heart disease. • Magnetic resonance spectroscopy: Used to study metabolic changes in brain tumors, strokes, seizure disorders, Alzheimer’s disease, depression and other diseases affecting the brain. • Optical imaging: Uses light-producing molecules designed to attach to specific cells to identify cancer cells or brain chemicals. • Molecular ultrasound imaging: Uses microbubbles for both imaging and therapy for a wide variety of diseases and disorders, including cancer, heart disease and inflammation. Scan quality is affected by the positioning of the patient and the scanning device. Scanners must be placed over the appropriate body part, with the height and angle of the scanner precisely measured. Based on the body part to be imaged, technologists adjust the controls on the scanner to account for density, detail and contrast. If a scan is performed incorrectly, a poor-quality image may be produced. This can result in the misdiagnosis of disease, delays in treatment and needless anxiety for the patient. If additional testing is required, patients are exposed to an increased amount of radiation. While imaging can be an invaluable tool, the procedures do carry a potential health risk, and radiation can be harmful if administered improperly. 3 Reducing Health Care Costs going registration in nuclear medicine is managed by two Poor-qualityimagingaffectsnotonlyindividualpatientsbut national organizations—the American Registry of Radiologic also the U.S. health care system as a whole. Repetition of Technologists (ARRT) and the Nuclear Medicine Technology medical imaging examinations due to improper positioning Certification Board (NMTCB). To be certified by the ARRT, nuclear medicine technoloor poor technique costs the U.S. health care system millions of gists must have—within the past five years—successfully dollars annually in needless medical bills. According to the Radiologic Sciences of North America completed an educational program that is accredited by a journal Radiology, approximately 130 million diagnostic ra- mechanism acceptable to the ARRT. After meeting the ARRT diology procedures—including X-rays, magnetic resonance Standard of Ethics, candidates must then pass an ARRT eximaging (MRI), computed tomography (CT) scans and nucle- amination,whichassessestheknowledgeandcognitiveskills ar medicine scans—are performed on 30 million Medicare underlying the intelligent performance of the tasks typically enrollees a year.[i] Approximately $2.4 billion was spent required of staff technologists practicing at entry-level within by Medicare on medical imaging in 2006, according to the the discipline. Government Accountability Office Medicare Part B Imaging Prospective technologists who graduate from approved Services report.[ii] An estimated four to seven percent of these nuclear medicine technology programs or meet alternative procedures are repeat procedures due to poor imaging.[iii] requirements(e.g.,relatedcourseworkorclinicalexperience) Thus, by extrapolation, by ensuring high quality imaging and are eligible to take the NMTCB certification examination. avoiding repeat scans, the federal government could possibly Candidates who pass the examination receive certification. Currently, 30 states, as well as the District of Columbia, generate $132 million each year. have licensure or regulatory provisions for nuclear medicine technologists that require them to be certified by either the Figure 1. Cost of Nuclear Medicine ARRT or the NMTCB. The remaining 20 states do not regulate and Molecular Imaging (Medicare) this profession at all. Total federal funds per year spent on nuclear medicine and molecular imaging scans Estimated percentage of all repeated medical imaging exams $2.4 billion 5.5% Potentialfederalfundssavedeachyear $132million by avoiding repeat nuclear medicine and molecular imaging scans Current Requirements for Nuclear Medicine and Molecular Imaging Technologists Nuclear medicine and molecular imaging technologists are regulated on a state-by-state basis. Certification and on- Imaging with CARE Improving Medical Imaging Across the United States, it is possible that individuals with little or no training are performing sophisticated medical imaging procedures that, if performed improperly, could harm patients and—further—cost the health care system millions of dollars. To improve the quality of medical imaging, the Consistency, Accuracy, Responsibility and Excellence in Medical Imaging (CARE) bill has been introduced on Capitol Hill. If enacted, this bill would establish minimum education and certification standards for personnel who perform nuclear medicine and molecular imaging procedures. As a result, institutions that provide medical imaging or radiation therapy to Medicare patients would be required to employ personnel who meet or exceed the standards set by the federal govern- 4 Figure 2 RegulatoryProvisionsforNuclearMedicineTechnologists States that regulate nuclear medicine technologists *List complete as of April 10, 2012 ment. The CARE bill is supported by the Alliance for Quality Medical Imaging and Radiation Therapy, a group co-founded by SNM, its Technologist Section and the American Society of Radiologic Technologists in 1998. Since then, an additional 20 organizations have joined the alliance; together, the 23 groups represent more than 500,000 health care professionals. These groups include: • AmericanAssociationofMedicalAssistants • AmericanAssociationofMedicalDosimetrists Imaging with CARE States that do not regulate nuclear medicine technologists • • • • • • AmericanAssociationofPhysicistsinMedicine AmericanCollegeofMedicalPhysics AmericanRegistryofRadiologicTechnologists AmericanSocietyofEchocardiography AmericanSocietyofRadiologicTechnologists AssociationofEducatorsinImagingandRadiologic Sciences • AssociationofVascularandInterventional Radiographers • CardiovascularCredentialingInternational 5 A Technologist’s Perspective Ann Marie Alessi, BS, CNMT, NCT, RT(N) SNM Technologist Section President Having worked as a nuclear medicine technologist for over 26 years, I am fascinated by how much the field has changed. While PET and SPECT are common imaging techniques, modalities like hybrid imaging with PET/MR and optical fluorescence imaging are the new wave of the future. With new technologies upon us every year, it’s critical that nuclear medicine and molecular imaging technologists are up to date on the techniques required to appropriately perform the imaging scans. To maintain licensure or certification, technologists must complete a defined number of continuing education hours each year to keep their skills and knowledge current. Without this education, a technologist may be relying on knowledge that was acquired during his or her initial training, which can quickly become out of date. SNM has several initiatives in place to help technologists remain current on the latest technologies, including continuing education courses, opportunities for advanced education, and publications on new modalities. The society also has a road show in which it travels to its chapters throughout the country promoting the importance of radiation safety. We take keeping our patients safe seriously; that’s why it’s important for there to be minimum education and certification standards for technologists. With the enactment of the CARE bill, we can make great progress in ensuring that patients receive the best care possible. • Joint Review Committee on Education in Cardiovascular Technology • Joint Review Committee of Education in Diagnostic Medical Sonography • Joint Review Committee on Education in Radiologic Technology • Joint Review Committee on Educational Programs in Nuclear Medicine Technology • Medical Dosimetrists Certification Board • Nuclear Medicine Technology Certification Board Imaging with CARE • Section for Magnetic Resonance Technologists of the International Society of Magnetic Resonance in Medicine • Society for Radiation Oncology Administrators • Society for Vascular Ultrasound • Society of Diagnostic Medical Sonography • Society of Invasive Cardiovascular Professionals • Society of Nuclear Medicine • Society of Nuclear Medicine Technologist Section The bill is also supported by many consumer and medical organizations such as the American Cancer Society, the Cancer Research Foundation of America, Help Disabled War Veterans, the National Coalition for Cancer Survivorship and others. In June of 2011, the CARE bill (HR 2104) was introduced in the House of Representatives by Rep. Ed Whitfield (R-KY). As of April 13, 2012, it has 89 cosponsors. It is expected that a companion bill will be introduced in the U.S. Senate as well. What Does It All Mean for Patients? Individuals undergoing nuclear and molecular imaging studies should know that even in states that don’t have formal requirements, many technologists do hold certifications and are skilled in their profession. Patients should be encouraged to discuss with their physician what the recommended imaging procedure entails and other pertinent details, as an informed patient is the best patient. Examples of potential questions include: • Does my state require licensure for nuclear medicine technologists? • Does the facility performing my scan require certification for nuclear medicine technologists? • What type and dose of radiopharmaceutical will I receive as part of my examination? • Are there any side effects of the radiopharmaceutical of which I should be aware? Regardless of whether a state has licensure or regulatory provisions, all individuals should contact their Congressional representatives to encourage them to support the CARE bill. References I Radiology 2005; 234:824-832, Sunshine and Bhargavan, Utilization of Radiology Services in the UnitedStates: Levels and Trends in Modalities, Regions and Populations. II US Government Accountability Office. Medicare Part B Imaging Services. June 2008. http://www.gao.gov/new.items/d08452.pdf IIIAmerican Society of Radiologic Technologists. http://www.asrt.org/content/GovernmentRelations/CAREBill/faq_legislative.aspx. 6 Appendix A: Listing of State Requirements State Licensure Requirements* Continuing Education Requirements Reference: Certification Reference: Continuing Education (if different) Alabama None None N/A N/A Alaska None None N/A N/A Arizona Successful completion of state examination or NMTCB or ARRT certification 24 hours every 2 years http://www.azleg.state.az.us/FormatDocument.asp?inDoc=/ars/32/02812. htm&Title=32&DocType=ARS http://www.azleg.state.az.us/FormatDocument.asp?inDoc=/ars/32/02815. htm&Title=32&DocType=ARS Arkansas Successful completion of state examination, NMTCB examination or ARRT examination 6 hours of http://www.healthy.arkansas.gov/programsServices/ continuing education hsLicensingRegulation/RadiationControl/Pages/Radiologiacquired within the cLicensing.aspx year preceding the date of renewal http://www.healthy.arkansas.gov/programsServices/ hsLicensingRegulation/RadiationControl/Pages/RadiologicContinuingEducation.aspx California Successful completion of state examination, NMTCB examination or ARRT examination 5 hours every 5 years per scope. There are 4 scopes. This totals 20 hours every 5 years. http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/ cdph8435.pdf http://www.cdph.ca.gov/certlic/radquip/Pages/RHBCEC-Renewal.aspx Colorado None None N/A N/A Connecticut None None N/A N/A Delaware Successful completion of state examination or NMTCB or ARRT certification Per licensure require- http://regulations.delaware.gov/AdminCode/ ment title16/4000/ 4400/4466.shtml See Certification Reference District of Columbia NMTCB or ARRT certification Per licensure require- N/A ment N/A Florida Successful completion of state examination or NMTCB or ARRT certification 12 hours every 2 years http://www.myfloridaeh.com/radiation/radtech1.htm See Certification Reference Georgia None None N/A N/A Hawaii NMTCB or ARRT certification 24 hours every 2 years http://hawaii.gov/health/environmental/noise/index. html/radiationsection/radiationsection/pdf/rai.pdf http://hawaii.gov/health/environmental/noise/index. html/radiationsection/radiationsection/pdf/radtechrenewal.pdf Idaho None None N/A N/A Illinois NMTCB or ARRT certification 24 hours every 2 years https://iema.illinois.gov/radiation/pdf/IEMA%20 091%2012-04.pdf See Certification Reference Indiana NMTCB or ARRT certification 24 hours every 2 years http://www.in.gov/legislative/iac/T04100/A00052.pdf See Certification Reference Iowa Successful completion of state examination or NMTCB or ARRT certification 24 hours every 2 years http://www.legis.state.ia.us/aspx/ACODOCS/ DOCS/641.42.pdf See Certification Reference Kansas Successful completion of state examination or NMTCB or ARRT certification 12 hours every year http://www.ksbha.org/statutes/booklets/radiologictechnicians.pdf See Certification Reference Kentucky NMTCB or ARRT certification 24 hours every 2 years http://chfs.ky.gov/dph/radiation+operator.htm http://www.lrc.state.ky.us/kar/902/105/020.htm Imaging with CARE 7 Appendix A: Listing of State Requirements, continued State Licensure Requirements* Continuing Education Requirements Reference: Certification Reference: Continuing Education (if different) Louisiana Successful completion of state examination or NMTCB or ARRT certification 24 hours every 2 years http://www.lsrtbe.org/documents/Louisiana_Radiologic_Technologist_Licensing_Law.pdf http://www.lsrtbe.org/documents/ce_rules_and_regulations_for_the_web.pdf Maine Successful completion of NMTCB or 24 hours every 2 ARRT examination or NMTCB or ARRT years certification http://www.maine.gov/sos/cec/rules/02/chaps02.htm See Radiologic Technology Board of Examiners Maryland Successful completion of NMTCB or ARRT examination and NMTCB or ARRT certification 24 hours every 2 years http://www.dsd.state.md.us/comar/comarhtml/10/10.32. 10.04.htm http://www.dsd.state.md.us/comar/comarhtml/10/10.32.10.13.htm Massachusetts Successful completion of state examination, or NMTCB or ARRT certification 20 hours every 2 years http://www.mass.gov/Eeohhs2/docs/dph/ regs/105cmr125.pdf See Certification Reference Michigan None None N/A N/A Minnesota None None N/A N/A Mississippi NMTCB or ARRT certification 24 hours every 2 years http://msdh.ms.gov/msdhsite/_static/resources/140. pdf See Certification Reference Missouri None None N/A N/A Montana None None N/A N/A Nebraska None 24 hours every 2 years N/A N/A Nevada None None N/A N/A New Hampshire None None N/A N/A New Jersey Successful completion of state, ARRT, None or NMTCB examination http://www.state.nj.us/dep/rpp/RPRP_Rules/sub24.pdf See Certification Reference New Mexico Successful completion of state examination or NMTCB or ARRT certification 24 hours every 2 years http://www.nmcpr.state.nm.us/nmac/parts/ title20/20.003.0020.htm See Certification Reference New York NMTCB or ARRT certification 12 hours every year http://www.health.state.ny.us/environmental/radiological/radon/docs/part_89.pdf See Certification Reference North Carolina None None N/A N/A North Dakota None None N/A N/A Ohio Successful completion of state examination or NMTCB or ARRT certification 12 hours every 2 years http://www.odh.ohio.gov/ASSETS/D4B8854092F6411CBB73B88621972A4D/Fr72_02.pdf See Certification Reference Oklahoma None None N/A N/A Oregon NMTCB or ARRT certification 24 hours every 2 years http://arcweb.sos.state.or.us/pages/rules/oars_300/ oar_337/337_010.html See Certification Reference Pennsylvania Successful completion of NMTCB or None ARRT examination or NMTCB or ARRT certification http://www.portal.state.pa.us/portal/server.pt/ community/state_board_of_medicine/12512/licensure_information/599413#forms See Certification Reference Rhode Island NMTCB or ARRT certification http://sos.ri.gov/documents/archives/regdocs/released/ See Certification Reference pdf/DOH/6514.pdf Imaging with CARE 24 hours every 2 years 8 Appendix A: Listing of State Requirements, continued State Licensure Requirements* Continuing Education Requirements Reference: Certification Reference: Continuing Education (if different) South Carolina Successful completion of state examination or NMTCB or ARRT certification 24 hours every 2 years http://www.scrqsa.org/associations/3460/files/ Final%20Rules%20and%20Procedures%20July%202000. pdf http://www.scrqsa.org/displaycommon.cfm?an=3 South Dakota None None N/A N/A Tennessee None None N/A N/A Texas Successful completion of NMTCB or 24 hours every 2 ARRT examination or NMTCB or ARRT years certification http://www.dshs.state.tx.us/mrt/mrt_rules.shtm See Certification Reference Utah Successful completion of NMTCB or ARRT examination 16 hours every two years http://www.dopl.utah.gov/laws/R156-54.pdf http://www.dopl.utah.gov/licensing/forms/applications/022_radiology_tech.pdf Vermont Successful completion of state examination or NMTCB or ARRT certification 24 hours every 2 years http://vtprofessionals.org/opr1/radiology/rules/Radiologic_Technology_Rules.pdf See Certification Reference Virginia None 24 hours every 2 years for radiography and radiation therapy N/A N/A Washington Successful completion of state examination or NMTCB or ARRT certification None http://apps.leg.wa.gov/WAC/default.aspx?cite=246-926 See Certification Reference West Virginia Successful completion of state examination or NMTCB or ARRT certification 24 hours every 2 years http://www.wvrtboard.org/LinkClick.aspx?fileticket=1q2 D7z97OX0%3d&tabid=338 http://www.wvrtboard.org/LinkClick.aspx?fileticket=T2 RLfNioRIE%3d&tabid=322 Wisconsin None None N/A N/A Wyoming NMTCB or ARRT certification 24 hours every 2 years http://plboards.state.wy.us/radiology/pdf/RadiologyRulesRegsChapter2.pdf See Certification Reference *ARRT is the American Registry of Radiologic Technologists NMTCB is the Nuclear Medicine Technology Certification Board Imaging with CARE 9 Appendix B: Glossary of Terms Computed tomography (CT): A medical imaging technique that uses a computer to acquire a volume of x-ray based images, generally reconstructed as two-dimensional or threedimensional pictures of inside the body. These images can be rotated and viewed from any angle. Each CT image is effectively a single “slice” of anatomy. Contrast agent: A compound or other substance introduced into the body in order to create a difference in the apparent density of various organs and tissues, making it easier to delineate adjacent body tissues and organs. Diagnostic imaging: Imaging that uses technologies such as x-ray, CT, MRI, ultrasound, PET and SPECT to provide physicians with a way to look inside the body without surgery. Diagnostic imaging is considered a non-invasive diagnostic technique, as opposed to a biopsy or exploratory surgery. PET, SPECT and some types of MR imaging also provide information about how certain tissues and organs are functioning. FDG (F-18-fluorodeoxyglucose): A frequently used radiotracer in PET scanning. FDG is a compound in which a radioactive fluoride atom is attached to a molecule of glucose, or sugar. Once in the body, the FDG molecule is absorbed by various tissues. Radiation from the fluorine is used to create pictures of how the radiotracer is distributed within the body. Gamma camera: A specialized camera that is capable of detecting gamma rays—the byproduct of a radiotracer, a combination of a radioactive atom, called an isotope, and another substance. The gamma camera creates two-dimensional pictures of the inside of the body from different angles. Hybrid imaging: The combination of the two imaging techniques, such as PET/MRI or PET/CT, that allows information from two different studies to be viewed in a single set of images. Imaging agent: A substance introduced into the body as part of a diagnostic procedure. In nuclear medicine, imaging agents are typically a compound consisting of a drug or a Imaging with CARE natural substance, such as glucose, and a small amount of radioactive material, which can be detected by an imaging device to produce pictures of the inside of the body. Ionizing radiation: Subatomic particles or electromagnetic waves that are energetic enough to detach electrons from atoms or molecules, a process called ionization. Radiation on the short-wavelength end of the electromagnetic spectrum, such as x-rays and gamma rays are ionizing. Ionizing radiation is produced by radioactive decay, nuclear fusion and particle accelerators. Isotope: Atoms of a single element that have differing masses. Isotopes are either stable or unstable (radioisotope). Radioisotopes are radioactive: they emit particulate (alpha, beta) or electromagnetic (gamma) radiation as they transform or decay into stable isotopes. Magnetic resonance imaging (MRI): A diagnostic scan that uses high-strength magnetic fields rather than radiation. MRI techniques are used primarily to study anatomy, but a special type of MRI scan, functional MRI (fMRI), can be used to map blood flow for functional studies. Molecular imaging: An array of non-invasive, diagnostic imaging technologies that can create images of both physical and functional aspects of the living body. It can provide information that would otherwise require surgery or other invasive procedures to obtain. Molecular imaging technologies include traditional nuclear medicine, optical imaging, magnetic resonance spectroscopy, PET and SPECT. Ultrasound, traditionally an anatomical imaging technique, uses microbubbles to create molecular images. Nuclear medicine: The use of very small amounts of radioactive materials (called radiopharmaceuticals or radiotracers) to evaluate molecular, metabolic, physiologic and pathologic conditions of the body for the purposes of diagnosis, therapy and research. Nuclear medicine procedures can often identify abnormalities very early in the progress of a disease— 10 Appendix B: Glossary of Terms, continued long before many medical problems are apparent with other diagnostic tests. Optical imaging: A molecular imaging procedure in which light-producing molecules designed to attach to specific cells, such as cancer cells or brain chemicals, are injected into the patient’s bloodstream. Imaging is then performed using devices that are able to detect these molecules inside the body. The two major types of optical imaging are bioluminescence imaging, which uses a natural chemical—such as luciferase, the substance that enables fireflies to glow—to trace the movement of certain cells or to identify the location of specific chemical reactions within the body, and fluorescence imaging, which uses proteins that produce light when activated by an external light source such as a laser. Single photo emission computed tomography (SPECT): Imaging that uses a gamma camera to detect radioisotopes that emit high-energy radiation. The gamma camera, which rotates around the patient, works with a computer to create three-dimensional images of the distribution of the tracer in the body. For a complete listing of nuclear medicine and molecular imaging terms, visit www.discoverMI.org. Positron emission tomography (PET): A medical imaging technique that uses radiopharmaceuticals that emit positrons (positively charged electrons). A radiopharmaceutical such as FDG is injected into the patient. The fluorine emits positrons, which react with the first electron they come in contact with, annihilating both and producing energy according to Einstein’s famous E=MC2 formula. This energy takes the form of two photons (particles of light) with a very specific energy level that shoot off in opposite directions. When these photon pairs are detected by the PET scanner, the location of the original fluorine atom can be extrapolated. Although positron/electron annihilation is one of the most powerful reactions known to science, the amount of mass involved is so small that the actual energy produced is not harmful to the patient, and the fluorine decays rapidly into harmless oxygen. Radiopharmaceutical: A type of imaging agent used in nuclear medicine, a branch of molecular imaging. It is a compound consisting of a drug and a small amount of radioactive material that localizes in specific organs or areas of the body and can be detected by an imaging device. Imaging with CARE 11