Background

The epidemiological changes of the last 30 years have caused a reduction in acute care for populations and an exponential growth in the number of outpatient and diagnostic services. Moreover, technological innovations in the diagnostic sector have made services more efficient, but at the same time more expensive, thus increasing costs.

Citizens and physicians increasingly request diagnostic services, often without considering their possible negative effects, such as radiation caused by CT examinations. It appears that the offer of diagnostic services does not cover the demand from patients, thus causing waiting lists to be increasingly longer and patients to be highly unsatisfied.

Policy makers must therefore face a complex situation resulting from longer waiting times, the increasing demand of diagnostic services from patients and increasing costs.

Which mechanisms may be adopted in order to face such situations and assist managers of public health systems to identify the causes of the problem and possible solutions?

On the one hand, the regional health system, with a universal coverage mission, should provide an adequate number of diagnostic imaging (DI) services to grant equity of access to all citizens and should deliver such services in a timely manner and according to patients’ needs. On the other hand, it should reduce the patients’ radiation exposure and the inappropriate duplication of examinations as much as possible.

The WHO argues that the use rates of DI services should be adapted to the local needs and should be determined by (1) the type and size of the hospital; (2) the number and type of patients: disease burden, inpatients and outpatients and (3) the therapeutic capabilities. Guyatt et al1 underlined the importance of accounting for the reassuring effect of an investigation on the wellness of a worried patient, while Hendel2 suggested that intangible factors, local practice and clinical judgement must be carefully considered in the DI procedure appropriateness assessment.

Certainly, the huge growth of DI procedures observed in the last few years raises concern about a possible overuse of these services.2–5 According to the European referral guidelines for imaging, the causes of DI service overuse are multiple: repeated investigations, investigations performed although unlikely to affect patient management and premature or incorrect investigations.

Miller3 and Lysdahl and Børretzen6 observed that the number of supplied DI services is very different among geographical areas and that, often, geographical areas that supply a larger number of DI services do not present better health outcomes for the inhabitants. Song et al7 reported that there was no evidence of a survival benefit among people who moved to regions with a higher-intensity level of procedures compared to those who moved to lower-intensity regions.

These results suggest that the analysis of the DI services variability across geographical regions could be an important step towards the understanding of the primary determinants of DI procedure growth rates and towards a definition of appropriate use standards. A significant variation in areas considered homogeneous in terms of age, gender or mortality may indicate that the use of radiological services is not optimal and underuse or overuse occurs.

This paper presents the results of a research project aiming at exploring the factors that explain the variability in waiting times and the use of CT and MRI examination rates in Tuscany. The final purpose of the project is to support the regional administration planning process regarding resource allocation and to set standards and gals for local health authorities (LHAs).

Tuscan context and the research questions

The Italian National Health System is based on the principle of universal coverage and it is financed by general taxation. Following the decentralisation process that started in the 1990s, regions are responsible for organising and providing healthcare services, while the national level has to ensure universal coverage for the whole population. In total, 82% of healthcare expenditure is public (Source: OECD data 2009). The remaining 18% of private expenses for healthcare mainly concerns dental care and some other few specialist visits, copayment and drugs. Healthcare services can be provided by both private and public institutions, their mix varies within Italian regions. In Tuscany over 90% of services are provided by public institutions.

In particular, CT and MRI examinations are mainly covered by public expenditure and the few private providers of diagnostic imaging services work under contract with the public health authorities. The last Italian survey on citizens’ behaviour and consumptions, carried out on 2005 by the Italian National Institute of Statistics, demonstrated that more than 80% of diagnostic services are covered by public expenditure and copayment. The percentage of DI covered by out of pocket varies across Italian regions. In Tuscany the percentage is about 16% (vs the Italian average of 20%), thus only a minor number of DI services is not registered into the regional administrative data.8

The Tuscan region reallocates resources among LHAs using the regional capitation formula. Hence, LHAs are responsible for the resource allocation process of all the healthcare services. To achieve this task, LHAs are in charge of organising the supply structure and consequently they define the number of specialists and the equipment to be dedicated to diagnostic imaging.

The overall economic value of services such as CT and MRI in Tuscany is around 65 million Euros (about 1% of the regional budget). The volume of these services for the 3.7 million of residents is one of the highest in Italy (Italian Ministry of Health www.salute.gov.it). Despite high volumes, the actual offerings in Tuscany seem to not be enough.

In 2010, waiting times in Tuscany were more than 60 days on average; however, for some LHAs, waiting times reached up to 90 days; variability appeared to be very great: waiting times went from 14 to 260 days. Moreover, citizens claim that waiting times are quite long; this is the main reason why some of them choose the private supplier (see, for instance, the results of 2005 survey directed to population9).

Tuscan policy makers, therefore, consider waiting times to be one of the most important challenges to achieve, also because the National Government requested these diagnostic services to be delivered to patients within 30 days (Piano Nazionale di Governo delle Liste di Attesa—PNGLA 2010–2012).

As regards the use rates per inhabitant standardised by age and sex, great variability (for MRI and CT) was registered in 2009 and 2010: CT use rates went from 45 to 88 per 1000 inhabitants, while the MRI use rates went from 56 to 83 per 1000 inhabitants.

The results indicate that, although Tuscany is a homogeneous territory from a sociodemographic perspective and represents excellence within the Italian regions in terms of quality of healthcare and governance,10 there is great variability across the region in terms of both waiting times and DI use rates.

Geographical variation in the DI use rates may constitute overuse or underuse with a consequent risk of inappropriateness of the service.6 Bhargavan and Sunshine11 highlighted great variability in the provision of DI services across areas and suggested that the use of appropriateness criteria, such as those defined by the American College of Radiology (ACR), may minimise these differences. Moreover, they explored this variability to highlight the state-level variables that affect it most, and they observed that the greater the number of Medicare providers, the greater the DI investigation rate per 1000 inhabitants. However, it is worth highlighting that the variability across regions could be affected by other factors like the availability of diagnostic technologies, socioeconomic factors (ie, education and income) or the number of radiologists in the region.6 ,12 Moreover, Lysdahl and Børretzen6 observed that each area may present a propensity towards a particular procedure considered a reasonable approach for a specific indication, which may lead each area to present a substitution effect among procedures types. On the contrary, it is found that the high use of one modality does not correspond with low use of an alternative modality for specific organs (locations), supporting the assumption that overuse really exists in high-use areas, thus leading to potentially inappropriate resource allocation.

In 2010, the Tuscan region evaluated as inappropriate district areas that registered use rates of the diagnostic imaging services far from the regional median use rate. Those districts may face the risk of an excessive number of radiation exposures (in the case that they are above the median) or a lack of services (in the case that they are lower than the median).13 This assumption yields some disadvantages because it does not take into account differences in medical procedures, where any decision involves a certain degree of discretion, the disease burden of particular areas or patient preferences and outcomes.14 However, Lysdahl and Børretzen6 observed that the number of supplied DI services did not correspond to better health outcomes for inhabitants. Moreover, Song et al7 found that the mortality rate was not lower in areas presenting a high intensity of practices, as one could expect. Low-intensity and high-intensity areas present similar outcomes and, after 3 years, there is no evidence of a survival benefit among people who moved to higher-intensity regions compared to those who moved to lower intensity regions.

Considering these premises, the present research investigated the relationship between volumes and waiting times to find out if long waiting times are determined by high volumes of diagnostic services delivered to residents, as well as to assess the impact of factors such as the presence of private suppliers and providers. Some authors15 ,16 suggest that, when coping with variation in healthcare, managers have to show, discuss and monitor data to question professional discretion. Hence, we analysed the following issues:

RQ1: Does variability in the DI rate depend on the presence of private medical providers?

RQ2: Is there a substitution effect among diagnostic procedures or a problem of procedure mix?

RQ3: What is the relationship between the volumes delivered and the waiting times?

The most common strategy to reduce waiting times is to increase the supply throughout, on the one hand the enhancement of the production capacity (ie, boosting the opening hours of scans to perform more examinations per scan and increase the number of examinations per radiologist), and on the other hand the increase in personnel/equipment or the contracting out.17 Boosting the supply structure may increase the volumes (indeed, capacity is one of the factors that could explain the variability, as reported by scholars6 ,12 ,14 ,18).

RQ4: Does the number of radiologists and scans available for each LHA or the percentage of services contracted out affect volumes and waiting times?

RQ5: Which tool may support policy makers and managers to cope with demand and waiting times?

This paper presents some first evidence regarding the questions suggested and proposes a method to enhance the professional consciousness of specialists towards better resource allocation and performance management.