Submission Date: 2020-11-23
Review Date: 2020-12-02
Pubblication Date: 2020-12-09
Printed on: Volume 2, Publications, Online Issue
Following the earthquake of August 24, 2016 that hit Central Italy, the only hospital in the Amatriciana valley represented by F. Grifoni, was closed due to its unusability. Subsequently, the ASL of Rieti, in support with the Lazio Region and the National Civil Protection, in 2017 to make up for this deficiency, created a PASS (socio-health assistance point) with also a diagnostic image for the needs. of the First Aid h12, not including outpatient radiological examinations to the many inhabitants who have decided, with stubbornness and tenacity, not to abandon these magnificent villages. Precisely for the sense of self-denial and gratitude to these lands, which also welcomed some of us (Enrico, Emanuele, Alessandro) as TSRM professionals within the Amatrician hospital, we decided together with other colleagues to collaborate and create an innovative project of health revival. Using a SWOT matrix and a cost / effectiveness analysis, we have designed a home radiology service capable of delivering diagnostic tests to the entire community which has a mountain area of 174 km2, 69 hamlets and a high old age index among the population.
On 24 August 2016 at 3.36, an earthquake measuring 6.0 on the Ritcher scale struck Central Italy, destroying the small mountain village Amatrice in just 140 seconds. Almost three years after the catastrophic event, within the Don Minozzi area of Amatrice, a Social Health Assistance Point (PASS) with the objective of compensating for the inconveniences deriving from the unavailability of the F. Grifoni Hospital and guaranteeing health assistance to the Amatrician population and to the numerous operators present in the post-earthquake reconstruction area. In very slow steps, the PASS has been, over the years, further strengthened with a First Aid h. 12 and with the restoration of various specialist outpatient activities, a radiological station was inaugurated last November 2018. In reality it is only a small diagnostic imaging unit which, placed in a container, guarantees emergency-urgency diagnostic services and therefore cannot be used for ordinary radiological outpatient examinations aimed at the population, mostly elderly, thus forced to move to the nearby Marche and Abruzzo regions. Together with the current hardships and the stalemate in the territory of Amatrice, this work aims to analyze through a SWOT Analysis and the study of the BREAK EVEN POINT (BPE), the advantages / disadvantages and costs / revenues of the employment of a home radiology on this mountain area. Currently, home radiology activities make it possible to guarantee radiological assistance in such conditions that transport to the hospital would be excessively difficult. The subjects who would benefit most are those suffering from pulmonary, cardiac, oncological, neuro-logical, osteoarticular, orthopedic diseases, as well as people with movement difficulties or non-ambulatory, disabled and elderly people. The aim is to demonstrate the validity of home radiology in a context increasingly aimed at healthcare decentralization, especially in a post-earthquake mountain environment such as that of Amatrice.
Materials and methods
Depending on the data currently available, it will be processed:
- a SWOT analysis
- a cost / effectiveness analysis
- a detailed description of the latest generation radiological technological equipment taken into consideration in implementing our project
The SWOT matrix will highlight the strengths, weaknesses, opportunities and constraints regarding the experimental project of Home Radiology in the Municipality of Amatrice. The resulting assessments derive mainly from an analysis of data, information and indicators that present a complete picture of the situation. The chosen indicators will be assigned to one of the four SWOT classes within the matrix. Specifically, we decided to analyze various factors, including the territory, demographic statistics, “new towns”, traffic conditions and pre-earthquake radiological performance performed in an outpatient setting within the U.O.C. Diagnostic imaging of the F. Grifoni Hospital. To support the following study, we have developed a cost / effectiveness analysis with the calculation of the Break Even Point (BEP breakeven point). In the last part, a detailed description of the technology of the equipment in use will be provided with the respective methods of execution.
The Municipality of Amatrice, expands on a very vast and jagged territory of 174 km2, is composed of 69 hamlets and despite its proximity to other regions, it has a critical road system especially during the winter period due to frequent snowfalls. Following the post-earthquake closure of the F. Grifoni hospital, the reference hospital of the provincial capital (Rieti) remains the San Camillo de Lellis which is about 65 km away, with travel times of about an hour. Data in hand as of 31/12/2016 Amatrice is made up of 2,532 citizens of which 1330 females and 1202 men, an average age of 50.1 years. The elderly component is very significant overall, the over 65s represent 32% of the population while only 9.6% of citizens are between 0 and 14 years old. To cope with the inaccessibility and numerous collapses of the buildings inside the crater, the Civil Protection in symbiosis with the Government, the Lazio Region and the Municipality have set up SAE emergency housing solutions in the various hamlets and in the center of the country (Fig. 1) , creating real “new towns”.
To date, 42 new urbanized areas have been built in the entire municipality of Amatrice, where 532 SAEs have been built with three types of internal sizes (40-60-80 m2). Even the roads have suffered considerable damage, it must be remembered that the road network in the area of interest guarantees the mobility of crossing, distribution and access to an area with a very widespread and fragmented presence of urban centers. This network is functional to the operation of the Civil Protection, the emergency vehicles and must also ensure the possibility of moving the rubble from the red areas present in the area to the temporary and definitive storage centers. Following the earthquake, health services are provided by the Rieti ASL through the Amatrice PASS. Data provided by the ASL of Rieti, the mobility balance was precisely about 15,000 admissions in passive mobility and about 2,300 admissions in active intra and extra regional mobility. Unfortunately for passive mobility outside the region there are no updated sources, this could possibly have documented the number of inhabitants residing inside the crater forced to go to nearby Marche or Abruzzo (Km closer than the capital of the Rieti province) to undergo health services, specifically outpatient radiological, as the PASS of Amatrice, despite having a first aid radiological service logistically and organizationally, is not able to perform outpatient examinations. The following tables extrapolate the radiological services performed on an outpatient basis at the Diagnostic Imaging Unit of the F. Grifoni Hospital in Amatrice (Tab. 1) starting from 1-1-2015 to 23 August 2016 and the number of radiological services performed at the PASS of Amatrice (Tab. 2) under First Aid performed from 24-07-2018 to 10-12-2018.
|Rx vertebral column||641|
|Rx shoulder and upper limbs||498|
|Rx pelvis and hip||793|
|Rx lower limbs||896|
Below is the description of the SWOT analysis with its matrix.
Mortality index (S1): due to the 2016 earthquake, the mortality rate is 54%. Old age index (S2): the level of aging is 332.9 per 100 inhabitants, the average age is 51 years with reference to the year 2016. Average composition of the family unit (S3): in the Municipality of Amatrice there are 1253 families, the average size of family units is 2.00. Population density (S4): in 2016 it was 14.51. Replacement index (S5): this value is 151%, with a progressive margin of increase, which means that the population of working age is very old. Realization of new urban areas (S6): it has allowed the population to be intensified in new areas, this would allow the home radiology service to plan examinations based on location without having to travel kilometers in search of the patient’s home to perform the services . Viability (S7): to date some roads that run through the crater areas show some instability and are in the process of consolidation.
Points of weakness
Birth rate (W1): 5.8%, slightly down on previous years. Dependency or social load index (W2): in 2018 there were 70.1 dependent individuals, every 100 working. Foreign Citizens (W3): as of 1 January 2018 there are 156 and represent 6.2% of the resident population. Lack of a network of collaboration between professionals (W4): to date there is no direct collaboration in the area between health professionals (geriatricians, general practitioners, pharmacies) able to interface with each other with the aim of promoting and advertising a new reality as home radiology could be. Mobile network (W5): Being an area nestled in the mountains, Amatrice is not aware of the total coverage of the mobile network for data transmission.
Migration balance (O1): there were 89 transfers of residence, while there were 95 new registrations in the Municipality Registry. Structure index of the active population (O2): the data updated to 2018 is 149.2%. Nursing Homes (O3): a nursing home is located a short distance from the Municipality of Amatrice, inside there are many elderly people who could use the home radiology service, thus avoiding transport to the Rieti hospital for diagnostic tests. Donations (O4): the home radiology project as it happened in the realization of the PASS of Amatrice could be realized thanks to the donations of private citizens-companies. Pre / post earthquake radiological performances (O5): based on the data in our possession, the pre-post sima radiological performances demonstrate the prevalence of chest – abdomen – skeletal x-ray, tests in which home radiology is able to give an effective and quality. Cost reduction (O6): as numerous publications in Northern Europe have analyzed, home radiology (telemedicine) represents an economic cut in the expense of the S.S.N. while ensuring quality exams. Possible reduction of passive mobility (O7): it is obvious that the Amatrice PASS, not being able to provide outpatient radiological services, forces the resident population to be mobile in the nearby Marche – Abbruzzo regions. Training courses (O8): possibility of carrying out specific courses to the TSRM personnel involved in order to expand the practical technical background of the method implemented. Benefits at the health, social, relational and human level (O9): reduction of inconvenience towards the patient by avoiding transport and tiring waiting, moreover it must be remembered that people, especially the elderly ones, are certainly better off in the tranquility of their home in the company of loved ones .
Natural balance (T1): the value is equal to -38 (data updated to 2017). Discomforts linked to the territory (T2): unfortunately the rebirth of this village is taking place very slowly, this is causing a lack of trust of citizens in the institutions with consequent closure of commercial activities and reductions in services
According to our study, the technologies to be used in the experimental home radiology service in the Municipality of Amatrice are few and of limited size. This report assesses the portable technology and the equipment dedicated to it, specifically:
- FOLDING STAND WITH WHEELS: The stand is an RX tube trolley (Fig. 2), completely removable and foldable, designed to be used for home examinations, both at the patient’s home. The trolley is built entirely of steel and aluminum, and folds up on itself to take up minimum space and to be easily transported
- SPL – HF – 8.0 PORTABLE RX HOSE: The proposed RX tube (Fig. 3) is a compact and extremely powerful system, 8 kW with standard 230V power supply. The main features are: maximum power 8 kW, two-point working technique with selection of kV and mAs, RX tube with double fire, use of the system with standard 230/240 V socket, automatic detection of the line power and the possibility of reducing manually the power to adapt to the electrical network present, high thermal capacity of the system, lightness (15kg) and manageability (dimensions 29x19x47 cm) with practical aluminum case, voltage range 40-125 kV, maximum current 100 mA, range of mAs 0.1 – 250 mAs, focal spot 0.6 – 1.5mm /0.6 – 2.8 mm, collimator with illumination and laser, customizable anatomical programs.
- BLUETOOTH DOSIMETER: The proposed dosimeter is battery powered. It can be easily inserted and removed from the monobloc and can also be used on other appliances. The connection to the acquisition station takes place automatically via bluetooth protocol.
- PIXIUM 3543 EZ DETECTOR: The detector (Fig. 4) proposed is one of the most sophisticated and advanced digital detectors, the high data of the DQE allow for perfect examinations with a low level of radiation. Characterized by an extreme lightness (2.8 kg), it is suitable for use in all radiological situations, combined with the Primo W console, the system is able to acquire radiographic images from any X-ray source, without the use of electro mechanical. The characteristic data of the detector are: Cesium Iodide technology on Amorphous Silicon substrate, standard size 35×43 CR – ISO4090 cassette, Pixel size 148 μm, acquisition matrix 2400 x 2880, weight 2.8 kg including battery battery autonomy up to 8 hours of work, maximum bearable weight: 150 kg, acquisition speed.
- FIRST ACQUISITION STATION W: Primo W (Fig. 5) is an autonomous acquisition station powered by batteries, it allows to obtain a complete and performing acquisition and post processing console. The hardware features a professional Panasonic laptop from the Tought series. The computer has the characteristic of being able to be used both as a laptop (with keyboard and monitor) and as only touch mode (only with touch monitor).
- 4G WIFI ROUTER FOR TRANSMISSION OF IMAGES TO PACS: For communication with the PACS during the execution of home exams, a latest generation 4G modem with WiFi connection to the acquisition station was provided. For the transmission of images it is necessary to protect the connections on which these sensitive data travel, the solution is the configuration of a VPN. It will be necessary to have a firewall that has the ability to be configured for a “dedicated” VPN and work in concert with a PACS; the VPN must use the IPSec (IP Security) protocol with AES (Advanced Encryption Standard) 256-bit encryption algorithm as protection methodologies to which the authentication procedure to the PACS server via UserID and Password must be added.
- PRINTER: The Canon Pixma iP 7250 photo printer with Wi-Fi connectivity was chosen for printing the report and labels to be affixed to CD-DVDs.
- CAR: For the means of transport, the commercial vehicle Fiat Panda 4×4 Van Natural Power 0.9 TwinAir Pop outfitting with four-wheel drive was chosen for the heavy snowfalls that whiten the mountain area of Amatrice in the winter due to the road conditions not always paved due to post earthquake work. The choice of methane because it represents the cleanest fuel currently available.
- PHONE: For the phone, the Samsung Galaxy A20e smartphone with system was chosen, it has a 4G LTE module that allows data transfer and excellent internet browsing, passing through Wi-Fi connectivity and GPS.
The operational steps for the correct execution of the radiological examination will be listed below, starting from the methods of accessing the service to the delivery of the examination and archiving. The home radiological service will be carried out in a rotating organization by the figure of the Medical Radiology Technician (TSRM). During the home radiodiagnostic activity, the TSRM must wear work shoes EN ISO 20347 and a jacket / jacket against the elements in compliance with the EN 343 standard. opted that this service initially in the experimental phase, should be activated three times a month with a schedule ranging from 8.30 am to 04.30 pm, with a number of accesses equal to 10 each session.
Operational phase descriptions:
- How to access the service: Requests can be made by the treating doctors present in the Amatric area and by the specialist doctor through the creation of computerized agendas at the CUP. The hospital’s protected discharge center can report to the radiology secretariat any fragile patients followed by them who require home radiology, to be previously included in the work list.
- Administrative registration of reservations: The secretariat of the Diagnostic Imaging UOC of the San Camillo de Lellis Hospital receives the requests from the CUP electronically, submits them to the dedicated radiologist for justification for the examination and, if positive, prepares the work list by entering the patients in the Elefante company program (RIS).
- Exam execution: The TSRM before leaving from the administrative headquarters located in Rieti, viale del Terminillo n. 42, goes to the vehicle fleet office for the delivery of the means of transport. With the company car, he acquires the home radiological equipment and the list of tests to be performed. Traveling for about 70 km along the Salaria road to L’Aquila, it heads to the municipality of Amatrice with a travel time of 60 minutes. Arrived on site, unload all the portable equipment contained in two suitcases fixed on the stand. Once in the SAE home, the TSRM arranges for the examination authorization forms to be signed and for the processing of personal data, then the examination is carried out. Once the exam has been acquired, the TSRM notifies the radiologist by telephone and sends the image to the company server via a dedicated VPN line protected by personal passwords for sensitive data.
- Reporting of images: The radiologist connects with his password to the company server, reads the exam in DICOM format, reports the same with a certified digital signature, and sends the confirmation to the TSRM
- Delivery of the examination and archiving: The TSRM during the reporting time copies the DICOM file to CD through a burner and puts away the equipment. As soon as the return confirmation from the doctor is received, the TSRM acquires the report from the server and prints it in real time, delivering everything to the patient. We can therefore calculate the average execution time of the service (examination, printing and reporting) and estimate it around 30/40 minutes. All documentation and images are saved on a back-up server and stored in the company archive for the time established by law; all information is treated according to the current privacy law
Reflection on the feasibility of implementing a home radiology service must necessarily consider the economic variables involved in its initial development phase. The main and most expensive investment is clearly made up of portable equipment. The overall purchase is estimated here in total costs of approximately € 59,000.00, amortized at 20% according to the accounting dictates applied to the Health Authorities of the Lazio Region and is in any case clearly lower than that of a new traditional radiological equipment. The means of transport, in the study identified in a Fiat Panda 4×4 Natural Power 0.9 Twin Air Pop outfitting, is about € 14,500, but a company car already present in the Asl Rieti company car park could be or used, or, as already occurred in other realities and experiments, it could be donated by private individuals, at no cost to the Company, excluding normal maintenance and associated accessory costs, quantifiable in € 100.00 per month. In the home radiology service as well as in this designed study, the other costs to consider are: the Samsung Galaxy A20e business phone (market value of about € 170.00) and the Canon Pixma iP 7250 photo printer with Wi-Fi connectivity (market value around € 70.00). In addition to tangible material assets, the analysis considers the TSRM personnel involved, the expected cost of the service performed by the radiology technician in carrying out the diagnostic investigation which amounts to approximately € 19.25 / h. and from the study of the data acquired, an average time of 40 minutes was formulated for each patient who carries out an X-ray examination at home. It must be premised that the reporting on costs and possible revenues deriving from final services cannot, however, be totally considered appropriate, because in reality, the service hypothesized here would compensate for the outpatient service present in the provincial capital which is about 60 km away, moreover there are many “hidden revenues ”Which indirectly affect the economic and financial profile of the radiological activity carried out by the Rieti Local Health Authority and which by their very nature are inseparable. Consider, for example, the reduction in costs for improper access, or the reduction of waiting lists for outpatient activities and all the fixed costs existing within the individual processes and for the individual services associated with these problems, under the aspect of efficiency, effectiveness and appropriateness of the service offered. Furthermore, if you look at the perspective of the non self-sufficient assisted person, a patient who must undergo an X-ray examination, in the absence of a home service must certainly be transported to a hospital structure, generally through a private ambulance or through a family member, a friend. The transport of a patient by ambulance alone has a cost of about € 150-200 round trip, while the family member is forced, if a worker, to take advantage of a day off and fuel consumption. In the event that the patient has an immediate visit, it could lead to a higher cost to health due to the possible worsening of the patient’s health conditions, or even passive mobility to nearby provinces that are more convenient to reach. Finally, no less difficult is the constant balancing between health protection and business economy criteria. Reflecting only in terms of “revenues” obviously one could not think of being able to cover the costs based on the simple application of the regional Nomenclator for the services offered by the NHS, which unfortunately is not yet updated in the Lazio Region for home radiological activities. In the following graphs, it is evident that the total costs and the possible hypothesized revenues cannot reach an equilibrium point if not negative. In other respects, however, the reasoning cannot be set in these terms precisely because the service in question should be offered by the public structure and in fact, nothing would change if these revenues were compared with the introduction of a new traditional radiology equipment.
However, if you look at the profile of the number of services performed, you can find the Break even Point at which the services provided can cover the costs incurred for their realization, this value is equal to about 310 exams, which means about 5-6 exams per week (for 52 weeks per year). Which, for a reality like Amatrice, could today be considered a good compromise, to be integrated with that of traditional radiology offered in the Rieti capital.
In order not to forget the drama of those hours, we decided, through this paper, to make a small professional contribution to the health revival of this mountain area, analyzing the possible post-earthquake solutions in creating a concrete experimental project of home radiology, able to to guarantee above all the elderly and in difficulty inhabitants a radiological offer oriented towards telemedicine. The validity of this project was also demonstrated during the 1st TSRM-PSTR National Congress held in Rimini from 11 to 13 October 2019, already on that date the importance of telemedicine was stressed and even more, today, in this period Covid 19 emergency where home radiology, the TSRM and medical radiologist could play a key role in the diagnosis and monitoring of the most fragile patients. We are sure that in the Amatrician context where home assistance fails to completely satisfy the needs of the population, the absence of a radiological clinic, the high aging rate, such a vast territory (69 hamlets) and a critical road system, the home radiology service could represent the health re-starting point for all those citizens who have decided not to abandon these lands. Now it is up to the regional, provincial and municipal institutions to believe in change, not based on statistical numbers, but on the consideration, attention and sensitivity that every single individual, especially if sick and in difficulty, should have.
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