The role of laboratory medicine in a value-based healthcare system: the example of heart failure patient management in the Italian context.

OBJECTIVE: As of today, healthcare systems worldwide face severe challenges that undermine their sustainability. The value-based healthcare (VBHC) approach has been proposed as a strategic and methodological framework to ensure the delivery of the best patient outcomes with economic efficiency. Through the illustrative example of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) for heart failure (HF) patient management in the context of the Italian National Healthcare system, this article explores the role that in vitro diagnostics (IVDs) can play in enabling value-based care models. SUBJECTS AND METHODS: 14 healthcare professionals representing the relevant professional figures involved in HF patient management met to revise the current HF patient journey and design a new care pathway that, leveraging on BNP/NT-proBNP, reflects the VBHC principles. RESULTS: The literature recognizes the dosage of BNP/NT-proBNP as the gold stan-dard for diagnosing HF. However, as of today, these IVDs are not employed at their full potential regarding HF patient management. A new patient journey is proposed so that patients are diagnosed early and properly monitored in the aftermath of hospitalization, improving outcomes at contained costs. CONCLUSIONS: As testified by the example of HF patient management in Italy, laboratory medicine can represent a lever for adopting value-based care models. Still, large-scale adoption of VBHC will call for structural reforms that revise how healthcare delivery is organized, measured, and reimbursed.

Percutaneous ablative treatment of metastatic bone tumours: visual analogue scale scores in a short-term series.

INTRODUCTION: The aim of this study was to examine the role of palliative percutaneous secondary lesions bone treatment by comparing the visual analogue scale (VAS) scores of cryoablation plus vertebroplasty versus radiofrequency (RF) plus vertebroplasty so as to determine their feasibility, reliability and efficacy in a short-term series. METHODS: Combined RF thermal ablation plus osteoplasty or cryoablation plus osteoplasty was performed in osteolytic secondary bone localisations in 30 consecutive patients who were suffering from pain refractory to conservative therapies. We evaluated pain with the VAS during the preoperative period and at four hours, 24 hours, one week, one month, three months and six months post procedure. RESULTS: There were no statistically significant differences in the VAS score between patients treated with cryoablation plus osteoplasty and those treated with RF ablation plus osteoplasty at one week (p-value is 0.34), one month (p-value is 1), three months (p-value is 0.68) and six months (p-value is 0.65) post procedure. Patients treated with cryoablation plus vertebroplasty have less pain at four hours (p-value less than 0.001) and 24 hours (p-value less than 0.001) than patients treated with RF ablation plus vertebroplasty. CONCLUSION: Both RF ablation and cryoablation are optimal techniques in the treatment of painful bone metastatic cancer. Cryoablation achieves less treatment-related pain during the early period of follow-up and better volume control by real-time depiction of ablation margins.

Future directions in percutaneous vertebroplasty.

The first percutaneous vertebroplasty, used to treat a painful cervical haemangioma, was performed by a French team in 1984 and reported in the literature in 1987. This technique has rapidly become the standard of care for treatment of medically refractory painful vertebral compression fractures. Vertebral fractures usually become evident because of pain of varying intensity that reduces the patient's quality of life, producing functional limitations, depression, disability, height loss, spinal instability and kyphotic deformity associated with impaired lung capacity. Many diseases may underlie vertebral compression fractures, such as osteoporosis, trauma, neoplasms and haemangioma. Vertebroplasty, as derived from our experience and a review of the literature data, has more than 70%-90% effectiveness for short-term pain reduction and return to activity. The aim of this paper was to describe the state of the art of this spinal interventional radiology procedure and to examine the future directions of percutaneous vertebroplasty.

Malignant renal neoplasms: correlation between ADC values and cellularity in diffusion weighted magnetic resonance imaging at 3 T.

PURPOSE: This study aimed at exploring the feasibility of high-field diffusion-weighted magnetic resonance imaging (DW-MRI) (3 T) and to correlate apparent diffusion coefficient (ADC) values with tumour cellularity in renal malignancies. MATERIALS AND METHODS: Thirty-seven patients (ten healthy volunteers and 27 patients with suspected renal malignancy) underwent T1-, T2-weighted and T1-weighted contrast-enhanced magnetic resonance imaging (MRI). Diffusion-weighted images were obtained with a single-shot spin-echo echo-planar imaging (SE-EPI) sequence with a b value of 500 s/mm(2). All lesions were surgically resected, and mean tumour cellularity was calculated. Comparison between tumour cellularity and mean ADC value was performed using simple linear regression analysis. RESULTS: The mean ADC value in normal renal parenchyma was 2.35+/-0.31 x 10(-3) mm(2)/s, whereas mean ADC value in renal malignancies was 1.72+/-0.21 x 10(-3) mm(2)/s. In our population, there were no statistically significant differences between ADC values of different histological types. The analysis of mean ADC values showed an inverse linear correlation with cellularity in renal malignancies (r=-0.73, p<0.01). CONCLUSIONS: DW-MRI is able to differentiate between normal and neoplastic renal parenchyma on the basis of tissue cellularity.