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Noninvasive testing in cardiology may be used to control the initial diagnostic costs as well as to limit expensive testing to only those at highest risk. Outcome data may be used to profile accuracy for individual laboratories to assure quality of the nuclear test data in altering patient management.

Nuclear imaging is assuming an increasing role in the management of patients with cancer. A variety of new radiopharmaceuticals, several antibody or peptide based, as well as innovative uses of existing radiopharmaceuticals, mean that most nuclear medicine departments equipped with standard imaging devices can image the single photon imaging agents without difficulty.

The provision of nuclear cardiology services in private-practice settings is probably currently the fastest growing segment of nuclear medicine. One reason is that myocardial perfusion scintigraphy, by determining which patients require coronary angiography and revascularization, has the potential to help a cardiology practice complete more successfully in the managed-care environment. Private practices can establish their own patient databases to determine how scintigraphic findings correlate with patient outcomes and with findings if coronary angiography is performed. Based on these data, pressure can be exerted to modify clinical responses to optimize the relationship between scintigraphic findings, quality of clinical care, and cost-effective patient management. To succeed in a managed-care setting, nuclear cardiologists must demonstrate that, without their services, the quality of cardiac care would be lower and the cost of caring for patients with heart disease would be higher. As in other settings, nuclear cardiologists in private practice must be involved managerially so they will be active participants in the development of clinical-care guidelines and the negotiation of capitated and other types of managed-care contracts.

Many nuclear medicine procedures, originally developed more than 20 years ago, are now performed with new radiopharmaceuticals or instruments; it is therefore apposite to reappraise what we are doing and why we are doing it. The clinical utility of nuclear medicine is discussed with reference, by way of example, to gated blood pools scans and myocardial perfusion imaging; the importance of the referred population for the outcome of studies is stressed. Attention is drawn to the likelihood that the detection of ischemia would be enhanced by the administration of nitroglycerin prior to rest thallium injection. Emphasis is also placed on the increasing acceptance of dual-tracer studies. The significance of expression of p-glycoprotein by some tumors for sestamibi imaging is discussed, and advances in respect of fluorodeoxyglucose imaging are reviewed. The final section covers issues relating to the development of new procedures, such as the value of nuclear medicine in the detection and characterization of tissue oxygen levels and the possible future role of nuclear medicine in the management of sleeping and eating disorders.

Although there has been some anecdotal evidence regarding the demand for medical imaging personnel in the hospital setting, few statewide studies have documented the demand for such staff or compared data longitudinally. Using data from the North Carolina Council for Allied Health, the study reported in this article documented mean minimum hourly salaries and mean maximum hourly salaries, vacancy rates and time required to fill vacancies for nuclear medicine technologists, radiographers and ultrasonographers in rural and urban hospitals. Results indicated the vacancy rates were highest for ultrasonographers and lowest for radiographers. There were vacancy differences in rural compared to urban settings and for part-time compared to full-time employees.

A simple and inexpensive solution for the complete digital management of a nuclear medical institution is presented. The starting point was provided by five different gamma cameras, one of which was equipped with a PC-based ICON computer. The remaining cameras were first adapted to ICONs and subsequently integrated into a Macintosh LAN, of 15 computers, allowing the entire image acquisition, processing, interpretation, documentation and archiving to be performed on the same comfortable menu-guided surface. Complete patient management is accomplished by a specific commercially available data base to which a specially developed image and document archive was connected. The system described provides complete digital management without the conventional filing systems at the moderate price of approximately DM 11 x 10(4) plus the cost of the new camera computers.

The purchase of a new gamma camera is a major undertaking and represents a long-term commitment for most nuclear medicine departments. The purpose of tendering for gamma cameras is to assess the best match between the requirements of the clinical department and the equipment available and not necessarily to buy the 'best camera' [1-3]. After many years of drawing up tender specifications, this paper tries to outline some of the traps and pitfalls of this potentially perilous, although largely rewarding, exercise.

Significant changes in the medical environment in the United States pose difficult questions for small medical specialties such as nuclear medicine. How do we get our voice heard in the debates that surround the reform process? What type of information is required to demonstrate the efficacy of nuclear medicine procedures? The older measures of sensitivity and specificity do not carry the same weight in health planning circles as they do in science. Data demonstrating the impact on the outcome for the patient are preferred. American nuclear medicine has started producing outcome data. We have high hopes that we can demonstrate to health planners both the medical and economic benefits of our specialty. Cardiac procedures seem to have an excellent chance of withstanding the challenges of analysis. Some oncologic procedures such as bone imaging are likely to survive unscathed as well. However, where procedure costs are very high, and the gains marginal, such as oncologic antibody imaging, there are serious questions about how these procedures will be reviewed. Likewise, while PET systems still hold great promise, unless data showing a positive impact on medical and economic outcome can be presented, this area is also in jeopardy. Where there is little challenge to the procedure, such as lung scanning, in all likelihood the procedure will retain its current place in the diagnostic algorithm. In closing, clearly as resources become increasingly scarce in medicine, difficult choices must be made. In the past, many of these decisions were made by those with the loudest voices.(ABSTRACT TRUNCATED AT 250 WORDS)

There are many pressures on nuclear medicine physicians to keep costs down and to produce the most efficacious results for the money spent. A procedure is cost-effective if its benefits (correct diagnosis, effective treatment, etc.) are worth the additional costs (money, radiation dose, etc.). The benefits of diagnostic procedures are measured by test performance (diagnostic efficacy [efficacy-D]), which in turn depends on a specific task: detection, classification, localization, or quantitation. For the detection task, measures of test performance include sensitivity, specificity, predictive value, accuracy, diagnostic utility, posttest versus pretest disease probability, area under a receiver operating characteristic (ROC) curve, and others. Standard measures of test performance in the classification, localization, and quantitation tasks have not yet been developed. Efficacy-M (management efficacy) is a measure of the extent to which a procedure influences patient management appropriately. Efficacy-O (outcome efficacy) is a measure of the success of therapeutic procedures. Some publications illustrating these points are presented. Costs associated with nuclear medicine procedures include money, time, discomfort, possible drug reactions, radiation dose, and the hypothetical risk of radiation-associated cancer. The public's perception of these latter risks, or costs, is much higher than our knowledge would justify. Decision trees are useful for laying out all possible strategies, outcomes, costs, and benefits, and estimating the cost-effectiveness of each strategy. Some articles estimating cost-effectiveness in nuclear medicine are reviewed, although few articles in the literature make any detailed use of decision analysis. Much work remains to be done in forming a coherent, consistent procedure for assessing cost-effectiveness in nuclear medicine.

The Resource-Based Relative Value Scale (RBRVS) is finally here. A system designed to equate physician work across the specialties, it has its own peculiar and unique problems. Modeling of the system was based on the single physician-patient interaction; it may not work properly for laboratory specialties. There are other unique considerations concerning how the model was constructed. Although data were collected specifically for nuclear medicine, they were not used in the final computations. There is disagreement over whether those data would benefit or hurt nuclear medicine reimbursement. As presently implemented, the RBRVS poses grave dangers for the future of nuclear medicine. These dangers come not only in the professional reimbursement section of the rules but in the technical component areas as well. Estimates for reduction of income by 1996 range as high as 55% for nuclear medicine. When one factors the implementation of the RBRVS by independent insurance carriers into the equation, the entire economic future becomes muddy. A brief historical review of the RBRVS, as well as discussion of potential future implications of this type of reimbursement system, is presented. Prognostication is at least as inexact a science as reimbursement. Hopefully, the author's outlook on the future of nuclear medicine is more pessimistic than it need be.