Economic impact of SARS-COV2 infection in the Department of diagnostic imaging

The COVID-19 pandemic caused an unprecedented effect on national radiological investigations. Since the World Health Organization officially declared the COVID-19 as a global pandemic, health policies have been rapidly organized to limit the spread of the virus and decrease the risk of exposure. These restrictions, in combination with home-stay arrangements and the onset of economic recession. As a result of public policies, financial difficulties and patient fear, many radiology departments have suffered a significant reduction in diagnostic examinations with important implications for their economic stability. The aim of this work is to evaluate the economic impact of the COVID-19 pandemic in the Radiology Department of an infectious disease


Introduction
In Italy, the first case of SARS-CoV-2 infection (causing the systemic disease named COVID- 19) was officially reported on 20.02.2020. Since then the disease has evolved rapidly, causing a public health emergency not only in Italy but worldwide. The rapid growth in the number of patients with COVID-19, has revolutionized the hospital management, especially among the intensive care units, conditioning the daily multidisciplinary work of those health facilities most involved in the care of COVID-19. To limit the spread of the disease and create additional hospitalization and staffing capacities, many hospitals have closed wards and outpatients, postponing or cancelling hospitalizations, visits, examinations and services performed in election. Although the reduction in outpatient revenues and elective admissions may be partially offset by increased bed occupancy, new intensive care units and recovery of health care after the pandemic, this may not be sufficient. Some hospitals may have increased revenue from COVID-19 hospital admissions as well as higher personnel and additional resources costs, while other hospitals will suffer mostly loss of revenue because of state provisions to minimise non-essential services (1).
The COVID-19 pandemic caused an unprecedented effect on national radiological investigations. Since the World Health Organization officially declared the COVID-19 as a global pandemic, health policies have been rapidly organized to limit the spread of the virus and decrease the risk of exposure. These restrictions, in combination with homestay arrangements and the onset of economic recession, led to a sharp reduction in the demand for benefits (2) and loss diagnosis in primary and follow up diseases especially in oncologic patients To reduce the risk of exposure and transmission to healthcare professionals and patients and to minimize contamination of equipment during COVID-19 patient transportation, our Radiology Department followed specific guidelines for an appropriate use of imaging diagnostic equipment (3)(4) All non-urgent procedures, if possible, have been postponed in patients with confirmed or suspected COVID-19. In particular, the use of chest CT in patients with COVID-19 was suggested for symptomatic hospitalized patients with specific clinical indications.
As a result of public policies, financial difficulties and patient fear, many radiology departments have suffered a significant reduction in diagnostic examinations with important implications for their economic stability.
In order to prepare a short-and long-term response to the COVID-19 crisis, objective data are needed to understand the magnitude of the reduction in activity volumes and imaging modes. .

Materials and Methods
The The progressive technological evolution introduced increasingly complex and expensive radiological equipments. The consequence is that the total number of examinations carried out does not reflect the actual workload on radiologists anymore (5)(6)(7)(8).
For this reason, activity data were aggregated into homogeneous groups (no. of traditional radiology examinations, ultrasound, CT or MRI, interventional procedures) that were then evaluated according to four systems: 1. Numerical count of radiological examinations produced by the service.
2. Economic value based on the regional tariff system of the Lazio Region. To assess the complexity of examinations, the difficulty index expressed by the ratio of work-RVU/examinations and SNR points/examinations was also evaluated (10-11).
We then proceeded to differentiate the data obtained between inpatients and outpatients, and analyzed in particular the data related to intensive care and examinations performed at the bedside of patients in the ward.
Further analysis was sustained on the comparison of costs incurred by the radiology department during the periods under review to assess the overall economic impact of the outbreak (12-14).

Economic evaluation in Euros
In the comparison between 2019 and 2020, the overall turnover of our department

Urgent examinations in the department: traditional radiology and ultrasound
In 2019, 231 examinations were performed in the traditional radiology and ultrasound department, in 2020 381 (+65%); the largest increase was in ultrasound 37 examinations For external exams in 2019, a value of 2.59 was calculated, in 2020 a value of 3.08 (+18.80%).

Costs
The overall cost of production in 2020 increased by 28.

Discussion
The data reported for our structure obviously have limitations related to our particular type, without ED and dedicated exclusively to the diagnosis and treatment reductions of 56% for MR, 53% for conventional radiology, and 47% for CT [15][16]; in particular for outpatients, the most significant decreases peaked for mammography examinations (94%), followed in descending order by nuclear medicine (85%), MRI (74%), ultrasound (64%), interventional radiology (56%), CT (46%), and radiography (22%) (17)(18) One study tracked the trend in wRWUs documenting an average decline of 52% in the United States during the pandemic peak. By modality, CT and traditional radiography (including mammography) together accounted for well over half of the total practice wRVU decreases (19).
An Italian study evaluated data over an 8-week period during the Italian lockdown (March 9-May 3, 2020) cancer center, it showed a reduction in volume of 26.0% for CT, 34.7% for MRI, 34.8% for X-ray and 58.5% for US (20) Our experience confirms an overall decline in radiology examinations (-64%), especially external examinations (-80%) (the only exception being internal CT examinations which increased +70%) resulting in a decline in revenue (-47%), compounded by a marked increase in direct costs resulted in a heavy liability.
The pandemic has also changed our way of working with an increase in radiological examinations to be performed in the department (+65%) (ultrasound and traditional radiology) and a marked commitment to meet urgent requests (+44%) (especially CT +139%) of all departments and in particular intensive care units (+47%).
The analysis of the workload obviously shows an almost superimposable overall decrease both analyzing the w-rvu (-47%) and the SIRM-SNR points (-50%), it should be noted that instead in the analysis of internal patients there is an increase in workloads respectively +21% and +14% (as opposed to the number of examinations) supported by a decrease in low-complexity examinations as confirmed by the increase of both complexity indices respectively +25% and +18%.
This decrease in radiological activity has been related by some to multiple factors including the severity of the ongoing pandemic, social restrictions on population movement, patients' fears/concerns about leaving their homes and entering hospital facilities, delays in booking external radiological examinations during the acute phase of the pandemic, the impact of the economic recession on healthcare costs, and the type of radiological examination needed [21][22].
Certainly, this pandemic period has profoundly altered our work rhythms and diagnostic workflows. The economic loss of a Diagnostic Imaging department is evident and unavoidable especially considering the current economic parameters of remuneration of radiological activity. This is even more evident in a Radiology department, like ours, dedicated exclusively to patients with infectious diseases and currently engaged only with COVID-19 patients.
Probably, as it has already been aired in other areas, it will be necessary to include correction factors in the management and economic evaluation of the patient with COVID-19 that not only always determines a slowdown of the normal workflow for the known problems of environmental isolation and equipment and sanitation but also determines a significant increase in operating costs of the department (23-25)

Patents
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Author Contributions: Conceptualization, CM. and VS; methodology, AP, FA and FDS; software, NF and SI; validation PC., writing-original draft preparation, MC; writing-review and editing, PC and VS.; supervision, SI. All authors have read and agreed to the published version of the manuscript.