Diagnostic imaging and spending review: extreme problems call for extreme measures.

The number of diagnostic imaging tests has increased dramatically over the past decade and about 5 billion diagnostic examinations are performed worldwide each year. According to Health Ministry, Italy, is in second place for the number of CT and MR tests per thousand inhabitants in 2014 with a score of 83.3 (only Germany has a higher score, 95.2) that is a long way off from the European average of 46.5. It has also the highest ratio of magnetic resonances per person with 24,6 machines per million inhabitants, followed only by Greece and Finland. The development of the New Health Information System (NSIS) in 2010 made uniformly readable the non-homogeneous clinical data from all the different Italian regions and permitted a detailed analysis of all diagnostic imaging within the public outpatient care setting in Italy in 2012. Despite that MRI examinations represented only the 10% of the total number of imaging tests performed, their cost reached 30% of the health-care expenditure for outpatient diagnostic imaging with an overwhelming contribution coming from musculoskeletal MR which accounted for the 73% of the performed MR tests. It is reasonable to assume that these phenomena are likely due to a lack of appropriateness in MR requests that is difficult to analyze due to an absence or invalid query on the prescriptions which together accounted for the 98.7% of cases. Taking into account the above-mentioned situation, this is possibly why the Ministry of Health decided to perform "linear cuts" in expenditure for some diagnostic examinations.

Secondary prevention at 360°: the important role of diagnostic imaging.

The aim of this paper is to underline the importance of the role of general practitioners (GPs) in distributing vital information about prevention to citizens, to highlight the importance of the so-called voluntary prevention programmes, both for conditions for which no organised screening programmes exist and for those for which they do exist but may well be obsolete or inefficient. Nowadays, voluntary prevention is made more effective thanks to the new sophisticated diagnostic technologies applied worldwide by diagnostic imaging. Epidemiological data about the incidence and causes of death among the Italian population have shown that screening programmes should be aimed first at fighting the following diseases: prostatic carcinoma, lung cancer, colorectal carcinoma, breast cancer, cardiovascular disease, cerebrovascular disease, aortic and peripheral vascular disease. GPs do not generally give good or adequate instructions concerning voluntary prevention programmes; GPs may not even be aware of this type of prevention which could represent a valuable option together with the existing mass screening programmes. Therefore, in the following analysis, we aim to outline the correct diagnostic pathway for the prevention of diseases having the highest incidence in our country and which represent the most frequent causes of death. If used correctly, these screening programmes may contribute to the success of secondary prevention, limiting the use of tertiary prevention and thus producing savings for the Italian National Health System.

PET-CT in oncological patients: analysis of informal care costs in cost-benefit assessment.

PURPOSE: The authors analysed the impact of nonmedical costs (travel, loss of productivity) in an economic analysis of PET-CT (positron-emission tomography-computed tomography) performed with standard contrast-enhanced CT protocols (CECT). MATERIALS AND METHODS: From October to November 2009, a total of 100 patients referred to our institute were administered a questionnaire to evaluate the nonmedical costs of PET-CT. In addition, the medical costs (equipment maintenance and depreciation, consumables and staff) related to PET-CT performed with CECT and PET-CT with low-dose nonenhanced CT and separate CECT were also estimated. RESULTS: The medical costs were 919.3 euro for PET-CT with separate CECT, and 801.3 euro for PET-CT with CECT. Therefore, savings of approximately 13% are possible. Moreover, savings in nonmedical costs can be achieved by reducing the number of hospital visits required by patients undergoing diagnostic imaging. CONCLUSIONS: Nonmedical costs heavily affect patients' finances as well as having an indirect impact on national health expenditure. Our results show that PET-CT performed with standard dose CECT in a single session provides benefits in terms of both medical and nonmedical costs.

Inappropriateness of breast imaging: cost analysis.

PURPOSE: The aim of this study was to assess how an incorrect indication for an examination may affect the diagnostic workup and diagnosis as well as healthcare expenditure. MATERIALS AND METHODS: We considered all the requests for breast imaging (mammography, ultrasound and magnetic resonance imaging) received by our radiology department between October 2010 and December 2010, and assessed their appropriateness based on the patient's age and the clinical question, if present. We then analysed the unnecessary costs resulting from inappropriate requests. RESULTS: Out of a total of 1500 requests for ultrasound examination, the request was appropriate in 855 (57%) cases; out of a total of 2350 requests for mammography, the request was appropriate in 493 (21%) cases; out of a total of 100 requests for magnetic resonance imaging, the request was appropriate in 83 (83%) cases. The cost deriving from inappropriate requests was 51,235.04 Euros. CONCLUSIONS: Improving the timeliness of diagnosis is an important goal to be pursued by enhancing the available health services, improving communication and coordination of the different professionals involved and optimising diagnostic pathways in order to reduce healthcare spending.

Cost-effectiveness of percutaneous vertebroplasty in osteoporotic vertebral fractures.

A retrospective study was conducted in 179 consecutive patients (48 males, 131 females; mean age: 72.0 +/- 8.59 years; range: 51-93) with single symptomatic acute amyelic osteoporotic vertebral fracture presenting between September 2004 and September 2005 to the Santa Lucia Foundation in Rome, Italy. Vertebral fractures usually become manifest due to pain which can be debilitating. Treatment depends on the presence or absence of spinal cord involvement. In the first case, surgical stabilization is mandatory. In the second case, treatment may be performed either by conservative medical therapy (CMT) or percutaneous vertebroplasty (PVT). The aim of this study was to evaluate the effectiveness, costs and cost-effectiveness of percutaneous vertebroplasty. After 2 weeks of analgesic therapy, 153 patients presented refractory pain and were offered treatment by PVT. A total of 58 patients accepted and underwent PVT (PVT group), while 95 refused and underwent conservative medical therapy (CMT group). Follow-up was performed by specialist consults, spine radiography and MRI and a self-assessment questionnaire evaluating pain using a Visual Analogue Scale (VAS) and function using an ambulation and an Activities of Daily Living (ADL) scale. A 12-month follow-up was obtained in 86 of 95 (90.5%) CMT group patients and 54 of 58 (93.1%) PVT group patients. Significant reduction of VAS and improvement of ambulation and ADL was observed in both groups at 1 week and 3 and 12 months (P < 0.05; Wilcoxon signed rank test), however, these results were significantly superior in the PVT group at 1 week and 3 months (P < 0.05; Mann-Whitney U test). Average cost per patient at 1 week and 3 and 12 months were respectively 755.49 +/- 661.96, 3791.95 +/- 3341.97 and 4299.55 +/- 3211.53 euros (CMT group) and 3311.35 +/- 0.32, 3745.30 +/- 3.59 and 4101.05 +/- 755.41 euros (PVT group). PVT resulted significantly more cost-effective than CMT with regards to the three scales at 1 week (P < 0.05; Mann-Whitney U test). At 3 months PVT was more cost-effective than CMT with regards to the three scales, however, the difference was significant only with regards to ambulation. No significant differences in cost-effectiveness where found between the two groups at 12 months. PVT should be considered the treatment of first choice in symptomatic acute amyelic osteoporotic vertebral fractures with refractory pain after a short period of analgesic therapy.

Hospital organization and importance of an interventional radiology inpatient admitting service: Italian single-center 3-year experience.

In June 2005 a Complex Operating Unit of Interventional Radiology (COUIR), consisting of an outpatient visit service, an inpatient admitting service with four beds, and a day-hospital service with four beds was installed at our department. Between June 2005 and May 2008, 1772 and 861 well-screened elective patients were admitted to the inpatient ward of the COUIR and to the Internal Medicine Unit (IMU) or Surgery Unit (SU) of our hospital, respectively, and treated with IR procedures. For elective patients admitted to the COUIR's inpatient ward, hospital stays were significantly shorter and differences between reimbursements and costs were significantly higher for almost all IR procedures compared to those for patients admitted to the IMU and SU (Student's t-test for unpaired data, p < 0.05). The results of the 3-year activity show that the activation of a COUIR with an inpatient admitting service, and the better organization of the patient pathway that came with it, evidenced more efficient use of resources, with the possibility for the hospital to save money and obtain positive margins (differences between reimbursements and costs). During 3 years of activity, the inpatient admitting service of our COUIR yielded a positive difference between reimbursements and effective costs of 1,009,095.35 euros. The creation of an inpatient IR service and the admission of well-screened elective patients allowed short hospitalization times, reduction of waiting lists, and a positive economic outcome.