Radiology Diagnostics , Oncological Radiation therapy ... services prescribing as core cost drivers of these departments • It could provide insight into roots of clinical decision

Assist. Professor Mihajlo Jakovljevic MD, PhD Rankovic A, Rancic N, Jovanovic M,Ivanovic M,

Gajovic O, Vukicevic M, Lazic Z

The Medical Faculty, University of Kragujevac, Serbia

Radiology Diagnostics , Oncological

Radiation therapy , Nuclear Medicine and

Interventional Radiology Services

Utilization Patterns and Economic

Consequences Analysis in a Large Tertiary

Care University Hospital –

four Year Trends 2007 - 2010

Short introduction to the Serbian

health care system • Serbia is upper middle income eastern European transitional economy

$11,255 (2011 estimate, Purchase Power Parity basis) (IMF)

• Total health expenditure measured in percents of gross national income 8-9% (WHO), which is significantly lower than OECD average (OECD Health Statistical Exctracts, 2010)

• Serbian national health care sector has been influenced by socialist macroeconomic milleu inherited by near past

• Public health care of state owned sector and part of private owned are financed by one main core Fund – National health Insurance Institute

• Accessibility and equity of health care are provided through compulsory and general health insurance of the employees (mostly in public sector) to all the residents regardless of their income

• Last decade package of voluntary health insurance was introduced, which means a big changes in treatment of outpatients, and cheaper services for the inpatients, contrary to the private health sector

• Health-economic assessment based decision making as a tool for resource allocation still has to pave its way among local policy makers

Introduction to the University

Tertiary Care Hospital observed • Large tertiary facilities represent huge consumers of the

health care budget available

• We decided for the Clinical Center in Kragujevac because it developed from the oldest permanent hospital in Serbia founded 1836 and is centrally located in the country

• For that reason we have chosen this university clinic with 1293 beds, 2200 employees, 205,576 inpatients-hospital admisions during observed period of time 2007-2010 and more than 1 600 000 outpatient examinations

• Some 2 000 000 inhabitants gravitate towards this facility while 600 000 people from the region are directly treated in it in case of need, without previous admission to the secondary lower-rank facilities

Why should we raise the issue of radiology

services consumption patterns and costs ?

• Diversity of radiological examinations and treatment options provided is increasing worldwide due to technology advances in medicine

• Impact these services impose to the contemporary hospital budgets is becoming more important than in past decades

• Health economic estimates of radiation-mediated medical procedures are seldom in literature

• This trial would be among the few ones to compare all these interventions in a large scale trial

• We need to determine and describe prescribing patterns of radiology services prescribing as core cost drivers of these departments

• It could provide insight into roots of clinical decision making process contributing to unacceptable allocation of health care resources

Material • General administrative and invoice database of clinical

center created by regular updating of goods/services consumed during outpatient and/or inpatient care provided by ward clerks from 2007-2010

• Clinical data provided by attending physicians (450 employed, mostly specialists of particular branches) from 2007-2010

• Patient hospital admission files were sorted related to final diagnosis at discharge (ICD-10 codes), other clinical and demographic features of patients (205,576 files present)

• Researchers splitted Health Insurance Fund code, so called “the blue book” , chapter with radiology-related goods and services offered, into 45 classes – allowing for an in depth analysis of utilization patterns

Methods

• An in depth, retrospective, bottom-up, trend analysis of services consumption patterns and expenses relative to diagnosis at discharge conducted from perspective of Third party payer

• The 4-year-long time span of observation 2007-2010 of the expenditure trends of the total radiologic services from the spheres of the classical radiographics, high tech imaging diagnostics, interventional radiology, radiation therapy and procedures of nuclear medicine

• By the cooperation of the clinics and departments in charge the extraction of the main database was obtained

• Analysis and interpretation of data were provided by help of radiologist, pharmacoeconomist, software engineer, mechanical engineer, statistician and few clinicians

Division of general medical care

services observed • Hospital admission

• Consultations (both

GP and specialist’s)

• Surgical Interventions

• Psychotherapeutic

techniques

• Physiatric treatment

• Pharmaceutical care

• Nursing care

• Laboratory analysis

• Patohystology ,

Cytology tests

• Dialysis provision

• Law medicine ,

Forensic services

• Other services eg

social care , transport

• Administrative

expenses

Division of goods consumed

(including medicines)

• Consumables, ordinary

• Contrasts

• Films

• Blood and its

derivatives

• Medicines

(ATC code right)

Alimentary tract and metabolism

Blood and blood forming organs

Cardiovascular system

Dermatologicals

Genito urinary system and sex hormones

Systemic hormonal preparations, excl. sex

hormones and insulins

Anti-infectives for systemic use

Antineoplastic and immunomodulating agents

Musculo-skeletal system

Nervous system

Antiparasitic products, insecticides and

repellents

Respiratory system

Sensory organs

Various

Radiology

related

Examinations

and

Treatment

Procedures

Radiology

Diagnostic

Services

Interventional

Radiology

Services

Nuclear

medicine

procedures

Radiation

Therapy

Classical

radiographics

High tech

imaging

diagnostics

*Cardial

*Vascular

*Orthopaedic

*Urological

*Neurosurgical

*Rest (invasive

procedures)

Diagnostics Treatment

Brachy

therapy

(intracavitary

applications

of emission

sources)

Teletherapy

Division of core services observed

We shall observe and analyse three

subfacilities – clinical departments

Radiology Diagnostics

Service (it is organized in the way it has

no own beds but provides examinations and treatment interventions for all clinics) –

classical and high-tech imagining methods

Oncology and

Radiation Therapy Center

(has its own beds, providing all treatment services to the cancer

patients including cytostatic, surgical and radiation approaches)

Nuclear Medicine

Center (distinct department,

has its own beds, providing mostly

diagnostic services)

2007 2008 2009 2010

NUMBER OF PATIENTS ADMITTED (regardless of

radiological examination presence/absance)

45677 50459 53433 56007

Nuclear Medicine 4456 2041 2566 2990

Radiology Diagnostic Service *(including interventional) 15224 14918 15903 14050

Radiation therapy 437 477 527 539

NUMBER OF HOSPITAL ADMISSIONS Nuclear Medicine 5193 2114 2715 3267



TOTAL FREQUENCY OF SERVICES PROVIDED (including repeated procedures) Nuclear Medicine 18145 10670 18684 32002



DIVERSITY OF SERVICES OFFERED (number of different services available) Nuclear Medicine 73 159 128 169



TOTAL FINANCIAL VALUE OF SERVICES CONSUMED (¥ - JPY)

Nuclear Medicine 67,755,842.62 56,815,305.85 58,551,234.82 51,979,630.11

Radiology Diagnostic Service

*(including interventional)

280,644,065.30 560,927,449.20 575,686,394.10 477,528,679.50

Radiation therapy 101,792,442.80 140,137,552.20 95,040,869.47 71,231,595.94

COMMON RESULTS

Sample structure

16%

81%

3%

Nuclear Medicine

Radiology DiagnosticService *(includinginterventional)

Radiotherapy

Percent of patients treated among fractions Comparison of single hospital

admissions (%)

15%

83%

2%

Nuclear Medicine


Radiotherapy

529

1958

1166 Nuclear Medicine


Radiotherapy

Diversity of services offered

(number of different services available)

1%18%

81%

Nuclear Medicine


Radiotherapy

Total frequency of services (including repeated procedures)

Financial value of total services

utilized per clinical branch

9%

75%

16% Nuclear Medicine


Radiation Therapy

Total amount spent (%)

0,00

100.000.000,00

200.000.000,00

300.000.000,00

400.000.000,00

500.000.000,00

600.000.000,00

2007 2008 2009 2010

Nuclear Medicine

Radiation Therapy

Radiology Diagnostic Service*(including interventional)

Total financial value

of spending (YEN)

Radiology Diagnostics

Service

Top 10 classical radiographic diagnostics

services consumed per unit / per value

Chest graph in the maximum expiratory AP

RO graphy of knee joint, lower

leg, ankle or foot in two directions

RO graphy of elbow joint or wrist- 2 times

RO graphy of carpalnih hand

or shooting or twometacarpal bones

Ro graphy of paranasal sinuses

RO graphy of the abdomen in

the PA positionand profile

RO graphy pelvis - APposition

RO L and LC spine in two directions

RO of cervical spine

RO position of the hip joint AP

Chest graph in the maximum expiratory AP

The esophagus, stomach and duodenum -

double volume control. methods targeted

shooting

Irrigography double contrast medium

RO graphy of knee joint, lower leg, ankle or

foot in two directions

Lung RO graphy in the D or L decubitus

Skull RO graphy in children

RO graphy pelvis - APposition

RO L and LC spine in two directions

RO graphy PA skull in profile position

RO graphy of the abdomen in

the PA position and profile

Top 10 high tech imaging radiological

examinations services consumed

per unit / per value

CT of head and neck without contrast media

Target CT images with reconstruction of some

organs

CT abdominal organs with contrast medium

CT abdominal organs without contrast media

Angio CT

Of thoracic CT without contrast media

Thoracic CT with contrast medium of

CT of head and neck with contrast medium

CT other tissues and bones

CT lumbar spine without contrast

Standard ultrasound examination of abdomen

(examination of the liver, gallbladder,

pancreas,spleen and kidneys)

Target CT images with reconstruction of some

organs

Thoracic CT with contrast medium

CT abdominal organs without contrast media

Of thoracic CT without contrast media

CT of abdominal organs with contrast medium

CT lumbar spine without contrast

Angio CT

CT other tissues and bones

CT head and neck without contrast media

Overall Radiology Diagnostics

Expenditures Trend

Overall Radiology Diagnostics…

0.00

50,000,000.00

100,000,000.00

150,000,000.00

200,000,000.00

250,000,000.00

300,000,000.00

350,000,000.00

400,000,000.00

450,000,000.00

500,000,000.00

20072008

20092010

Overall Radiology Diagnostics Costs Trend

Radiology Diagnostics Service

trends

53416

183540

928777

1591285

2007 2008 2009 2010

TOTAL FREQUENCY OF SERVICES DELIVERED


216

488

596

658

2007 2008 2009 2010

Diversity of services offered (number of different services

available)

Diversity of services offered (number of different servicesavailable)

Top 10 most expensive diagnosis in

radiology diagnostics (ICD-10)

– Z95 Presence of implants and grafts to

the heart and blood vessels

– I20 Angina pectoris chest tightness

– C73 Malignant thyroid tumors

– G81 Unilateral paralysis

– I10 hypertension, of unknown origin

– I21 Acute myocardial infarction

– J82 Eosinofilocitosis of lung -

Langerhans cell granulomatosis

– I67 Other diseases of brain blood

vessels

– Z45 Setting up and maintaining the

built-aids

– I60 Haemorrhagia subarachnoidalis

Key finding at Radiology

Diagnostics Service

AVERAGE COSTS PER ADMISSION

0.00

5000.00

10000.00

15000.00

20000.00

25000.00

30000.00

35000.00

20072008

20092010


AVERAGE COSTS PER PATIENT TREATED

Nuclear Medicine Center

Top 10 Nuclear Medicine procedures

consumed per unit / per value

• Scintigraphy of the whole body J-131

• Titer tireoglobulin antibody

• Tireoglobulin (RIA)

• determination of insulin RIA

• Cortisol determination(RIA)-method of incubation and separation

• Serum Prolactin (RIA) LTH

• Mikrosomic antibody (anti TMS) (IRMA)

• Free T3 (FT3) – RIA


• TSH – tireothropic homone RIA

• Titer tireoglobulin antibody

• Determination of cortisol (RIA) –method of incubation and separation

• Scintigraphy of the whole body J-131

• Insulin determination RIA

• Tireoglobulin (RIA)

• Serum prolactin (RIA) LTH


• Microsomic antibodies (anti TMS) (IRMA)


• TSH - tireotrophic hormone RIA

Nuclear Medicine Center overall consumption

trend - we could easily observe recession

caused drop down in 2008

0

10000000

20000000

30000000

40000000

50000000

60000000

2007

2008

2009

2010

OTHER (nonspecific interventions)

TREATMENT OPTIONS

DIAGNOSTIC SERVICES

TOOLS and CONSUMABLES *(radioisotopesand contrasts mostly)

Nuclear Medicine Services - trends

Diversity of services offered (number

of different services available)

0

50

100

150

200

0 1 2 3 4 5

Diversity of servicesoffered (number ofdifferent servicesavailable)

TOTAL FREQUENCY OF SERVICES

DELIVERED

0

10000

20000

30000

40000

0 1 2 3 4 5

TOTAL FREQUENCY OFSERVICES DELIVERED

Key finding

at nuclear medicine center


AVERAGE COSTS PER PATIENT…0.00

2000.00

4000.00

6000.00

8000.00

10000.00

12000.00

14000.00

16000.00

18000.00

20072008

20092010



Oncology and Radiation

Therapy Center

Top 10 radiation therapy services consumed

per unit / per value

• Gentigrey (in units)

• Accelerator – isocentric technique

• Supervoltage accelerator radiotherapy with the modified field

• Supervoltage accelerator radiotherapy with wedge – shaped filter

• Determination of the air field graphs

• Determination of markers spelling

• Team treatment for aerial treatment of the patient

• Radiotherapy - accelerator leaning

• Afterloading application with the applications with source intensity catheter

• Intracavital gynecological applications

• Gentigrey (in radiation absorbtion units)

• Determination of air fields spelling

• Intracavital gynecological applications

• Team treatment for aerial treatment of the patient

• Determination of markers spelling

• Accelerator- a isocentric technique

• Supervoltage accelerator radiotherapy with wedge –shaped filter

• Supervoltage accelerator radiotherapy with the modified field

• Radiographic verification using Selectron

• Team treatment-selectron

Radiation therapy - overall

consumption trend

20072008

20092010

0,00

10000000,00

20000000,00

30000000,00

40000000,00

50000000,00

60000000,00

70000000,00

RADIOTHERAPY (both tele- and brachy-)

CONSUMABLES

DRUGS

Radiation therapy trends in

services provision

2700000

2800000

2900000

3000000

3100000

3200000

3300000

3400000

3500000

3600000

1 2 3 4


TOTALFREQUENCYOF…

0.00

50.00

100.00

150.00

200.00

250.00

300.00

350.00

400.00

1 2 3 4

Diversity of services offered (number of different services

available)

Diversity ofservices offered(number ofdifferentservicesavailable)

Key finding at Oncology and

Radiation Therapy Center

AVERAGE COSTS PER ADMISSION0.00

2000.00

4000.00

6000.00

8000.00

10000.00

1 2 3 4

AVERAGE COSTS per HOSPITAL ADMISSION

AVERAGECOSTS PERADMISSION

AVERAGE…0.00

20000.00

40000.00

60000.00

80000.00

100000.00

120000.00

140000.00

1 2 3 4


AVERAGECOSTS PERPATIENTTREATED

Financial value of drugs consumed –

Shift in funding policy consequences

0.00

500000.00

1000000.00

1500000.00

2000000.00

2500000.00

3000000.00

2006 2007 2008 2009 2010 2011

Antineoplastic drugs

Antineoplasticdrugs

0

500000

1000000

1500000

2000000

2500000

2006 2007 2008 2009 2010 2011

Other Drugs

OtherDrugs

Discussion

• On average, each radiologically examined

patient got :

– one frontal chest graph,

– each 7th got the ultrasound examination of

the abdomen,

– each 19th a CT check of the endocranium,

– whereas each 25th patient got the NMR of the

head.

Thyroid gland examinations dominate

nuclear medicine services

• In Serbia the thyroid gland diseases are increasing

• This is most evident when we look at nuclear medicine

services to the first top 10 services,and the volume and

consumption, 6-7 are connected with the examination of

thyroid gland

• It is believed that the main reason for this poor economic

status of the population (upper middle gross national

income per capita), therefore, poor diet, modern life style

• In the last decade a five-fold increase is marked in

thyroid gland diseases and other endocrine glands

Radiation therapy

• The leap of the malignant diseases which require the

radiotherapy is rising as well

• Thus, although the percentage share of these services

expenditure in relation to the entire annual consumption

decreased, consumed value of these services increased

by one third

• The most of the services provided at The Oncology

Clinic were from the radiotherapy domain

• On the other side, core Republican health insurance

Fund imposed strict limitations on prescribed cytostatic

drugs reimbursement (indication – first choice medicines

should be more affordable ones although often not

clinically most efficient ones…)

Classical Radiographics

Examinations • Levin et al study in Pennsylvania at about 6

million health insurance holders, stated

significantly higher expenses incurred in total, on

the radiologic check-ups, out of which 62% were

non-radiologic expenses

• It could be considered relatively modest

consumption of these services, but it still

represents an enormous expense in scenario of

upper middle income country health budget and

prevents necessary investments for other

purposes

Comparison of utilization frequency

with other author’s reports • The devastating fact is that regardless of the

discharge diagnosis each patient gets a lung

graph or every 19th gets a CT of the

endocranium on average -

• This is a dubious piece of information and when

it is compared with other studies Mytherey

Bhargavan and Jonathan H. Sunshine where out

of the total 4 176 diagnosed radiologic

procedures, 49,3% goes to all the radiologic

check ups, and 9,36 % to all the CTs

Health risks imposed by harmful

irradiation of patients • Among the top 10 most expensive methods is simple RO

chest graph ranked second,

• The reason for this being its irrational prescription, which

has to be stopped not only because of huge expenses

but also due to the unnecessary irradiation of patients

• It is a well known fact that the dosage during the CT

treatment is 300 times bigger than during the ordinary

cat scan-graph, and here lies the danger of the possible

tumor development which originate from the mutations

caused by such radiation

An example of selected Japanese

study results • In 1994 Japanese annual costs of MR imaging were $713,500

• The total number of procedures required per year to break even financially was calculated to be 3568, which was far greater than the actual number reported (1893)

• Therefore, the income from most units fell below the break-even point

• This was contrary to the US, were MR showed a net profit instead of net costs

• This financial deficit for MR imaging in Japan was due to the low level of the fee, as well as inefficient utilization

• The profitability of operating MR imaging units is sensitive to the number of patients examined. Japan’s physicians were trying to compensate for the low fee for MR imaging by expanding the volume of services

• The charge for MR imaging in Japan that time ($200) was one fifth of that in the United States (Hisahige A, AJR 1994;162:507-510)

Conclusion

• Due to the recession impact and consequtive local health policy measures, diversity of health care services has suffered short decline and recovered providing increase in total during time span observed

• Total expenditure related to services offered has increased likely due to aging population and rise of overall morbidity

• Consumption patterns noticed, should give an important momentum for policy makers to intervene and provide higher clinician’s guidelines adherence

• These findings confirm irrational prescribing of diagnostic procedures and necessities of introducing cost containment strategies

Interventions to promote guidelines

adherence and cut costs • Adoption of hospital level clinical protocols – algorythms considered

binding for attending physicians,

• Suggesting frequency of repeated examinations in particular conditions (e.g. fresh cerebrovascualr event, head CT at 0 point, 24 , 48, 96 hours only)

• Delivering to the clinicians short summaries of evidence on cost/effectiveness of particular diagnostic tests (RCT and meta analysis findings, NICE reports on certain medical technologies and procedures)

• Radiologists and radiotherapists should not be the only aimed specialist branches – to consider neurologists, neurosurgeons, cardiologists and oncology surgeons as well

• Provide comparison with better managed tertiary care facilities providing similar level of care with net profit incurred instead of costs

Acknowledgements

• Authors would like to thanks for financial support and assistance in this research project to:

– The Hosei University , Tokyo , Japan

– The University Clinical Center Kragujevac Serbia

– Ministry for Education and Science, The Republic of Serbia Grant N°175014

– Japanese people and government for the donated medical equipment to this particular hospital in total value of over $1,000,000

STUDENICA – Serbian Orthodox Christian Monastery - one of

the earliest permanent hospitals in medieval Europe (XII

century AD) - UNESCO World Cultural Herritage site

THANKS FOR YOUR ATTENTION !

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Radiology Diagnostics , Oncological Radiation therapy ... services prescribing as core cost drivers of these departments • It could provide insight into roots of clinical decision