Report on evaluation and rationalizing of distribution and

Report on evaluation and rationalizing of distribution and utilization of Radiotherapy units in Greece Aris Dermitzakis 1, Silviu Domente 2 & Nicolas Pallikarakis 3 1 Institute of Biomedical Technology INBIT 2 WHO Project Office, Greece, Division of Health Systems and Public Health, WHO Regional Office for Europe 3 Biomedical Technology Unit, University of Patras

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Collaboration with WHO The present work has been performed under the WHO collaboration initiative with the Ministry of Health (Mo. H) of Greece For “Strengthening Capacity for Universal Coverage”

Collaboration with WHO Translations of WHO publications in Greek

RATIONALIZING DISTRIBUTION AND UTILIZATION OF HIGH VALUE CAPITAL MEDICAL EQUIPMENT IN GREECE OUTLINE • INTRODUCTION/BACKGROUND • FINDINGS • DATA ANALYSIS AND DISCUSSION • CONCLUSIONS AND RECOMMENDATIONS

RATIONALIZING DISTRIBUTION AND UTILIZATION OF HIGH VALUE CAPITAL MEDICAL EQUIPMENT IN GREECE Mammography MRI: Magnetic Resonance Imaging CT: Computed Tomography PET: Positron Emission Tomography γ-Camera/SPECT: Single Photon Emission Computed Tomography RT: Radiotherapy Units (LINAC , Co-60, other)

RATIONALIZING DISTRIBUTION AND UTILIZATION OF HIGH VALUE CAPITAL MEDICAL EQUIPMENT IN GREECE • Assess the sufficiency and equity in the distribution of HVCE and its use in Greece • Identify eventual inequalities in terms of geographical coverage, specific needs and lack of HVCE • Estimate the costs for the use of HVCE • Reveal reasons of potential overuse • Put forward proposals for improvement

Greece is a European champion in MRI!

Greece is on the second place in Europe in CT units!

Overview of the Evolution of Installed HVCE 70. 00 60. 00 50. 00 MMUs CT Scanner MRI Scanner γ-Camera/SPECT PET/CT R/T Units 40. 00 30. 00 20. 00 10. 00 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

4000000 3500000 3000000 2500000 2000000 1500000 1000000 500000 0 10000 Mammograms CT MRI PET/CT 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Data on acts from 2008, 2012 from OECD and 2013 to 2016 from EOPPY 5000 0 GDP Per Capita in USD Number of Acts/Fractions in Different Modalities

RT: Radiotherapy Units Regional distribution R/T Units per 100. 000 Inhabitants 1 Country's Average 0. 9 Public Sector 0. 8 Private Sector 0. 7 0. 5 0. 4 0. 3 0. 2 0. 1 an on an ni Io ac t. M es W Isl ed re t. G es W ds ia e ec ly sa es ge Ae Th an e So ut h lo po nn Pe ge Ae es an s No rth on ed ac M st Ea iru ra Th d an ia l. M ra nt Ce Ep ce e et ed ac l. G ra nt Ce Cr on re ec tic a e ia 0 At RT 0. 6

Absolute number and number of units per 100. 000 inhabitants for RT units in each Health Region (Data for 2017 available from EEAE) Health Region Attica (Athens) Cyberknife LINAC Co-60 Tomotherapy γ Knife Central Macedonia (Thessaloniki) LINAC Co-60 Total RT Units Absolute Per 100 K Number Inhabitants 34 0, 89 1 0, 03 Private Sector Absolute Per 100 K Number Inhabitants 15 0, 39 1 0, 03 22 8 2 1 11 0, 57 0, 21 0, 05 0, 03 0, 58 11 0, 29 2 1 2 0, 05 0, 03 0, 11 9 2 2 0, 48 0, 11 0, 32 2 0, 11 LINAC 2 East Macedonia and Thrace (Alexandropolis) Public Sector Absolute Per 100 K Number Inhabitants 19 0, 50 0, 00 11 8 0, 29 0, 21 9 0, 48 0, 00 7 2 2 0, 37 0, 11 0, 32 0, 00 2 0, 32 2 0, 33 0, 00 2 0, 33 LINAC 1 0, 16 0, 00 1 0, 16 Co-60 1 0, 16 0, 00 1 0, 16 2 0, 59 0, 00 2 0, 59 LINAC 3 3 3 0, 41 0, 44 0, 14 0, 00 2 2 3 0, 27 0, 44 LINAC 3 0, 44 0, 00 3 0, 44 Total 57 0, 53 0, 17 39 0, 36 Crete (Heraklion) Epirus (Ioannina) Thessaly (Larisa) West Greece (Patras) 1 1 18

RT: Radiotherapy Units Use and Cost #Fractions/ YEAR Year 2013 2014 2015 2016 Public 232. 574 248. 409 245. 393 233. 892 Public 18. 564. 495 19. 373. 735 19. 416. 459 18. 616. 010 Private 64% 61% 58% 57% 132. 986 160. 617 174. 443 176. 549 50% 47% 44% 40% Total 36% 39% 42% 43% Total EOPYY Expenditure € Private 18. 630. 985 21. 625. 454 24. 896. 716 27. 935. 467 Number of Units 365. 560 409. 026 419. 836 410. 441 50% 53% 56% 60% 49 50 51 53 Total 37. 195. 480 40. 999. 189 44. 313. 175 46. 551. 477 Mean # Fractions/ Units/ Year 7460 8181 8232 7744 EOPYY Charges Per Fractions € Public Private 80 140 78 135 79 143 80 158

Analytical data, evolution and comparison concerning number of acts, installed units and costs reimbursed by EOPYY for Radiotherapy acts. (Data for 2013 to 2016 provided by EOPYY) Year # Reimbursed Acts / Year Public Private Total Numberof Units Year Total EOPYY Expenditure in € per year Public Private Total 2013 232. 574 64% 132. 986 36% 365. 560 49 2013 18. 564. 495 50% 18. 630. 985 50% 37. 195. 480 2014 248. 409 61% 160. 617 39% 409. 026 50 2014 19. 373. 735 47% 21. 625. 454 53% 40. 999. 189 2015 245. 393 58% 174. 443 42% 419. 836 51 2015 19. 416. 459 44% 24. 896. 716 56% 44. 313. 175 2016 233. 892 57% 176. 549 43% 410. 441 53 2016 18. 616. 010 40% 27. 935. 467 60% 46. 551. 477

RT: Radiotherapy Units Comparison with other EU countries RT Units per 1. 000 Inhabitants in Different EU Countries Number of Untis per 1. 000 Inhabitants 16 14 12 Austria Denmark Finland Greece Portugal 10 8 6 4 2 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Use and Cost RT: Radiotherapy Units Number of R/T Fractions per 1. 000 Inhabitants Evolution of the Number of Radiotherapy Fractions per 1000 Inhabitants in each Region. 80 70 60 50 2013 40 2014 30 2015 2016 20 10 0 Attica Central Macedonia Crete East Macedonia and Thrace Epirus Thessaly West Greece

Relative Distribution of RT Acts per 1. 000 inhabitans per Regional Sector 25% Percentange 20% 15% 10% 5% 0% Attica Central Macedonia Crete East Macedonia and Thrace Epirus Thessaly West Greece

GENERAL ISSUES Lack of Data: There is no data centrally available concerning medical equipment in general, due to the lack of a continuously updated inventory and the situation is similar for the information concerning the maintenance, age and actual use of the devices. Regional Distribution: RT are available only in big urban areas, with the public sector having very good presence in these two modalities Maintenance: Aggregated data on maintenance costs of R/T units in the public sector are not available. Most of the hospitals have maintenance contracts with the equipment providers that are however negotiated on a case-by-case basis and the actual costs are not known. It is necessary to apply modern computerised tools for medical equipment management Staffing: Adequate and balanced staffing of the departments providing diagnostic imaging and RT services is necessary. Additionally, the rapid technological developments, leading to the introduction of new or improved devices at an extremely high pace, impose lifelong learning and continuous training of all these professionals.

General Conclusions • According to the findings of the present study, the installed base in Greece of the medical equipment categories covered, is above the European average. However, in terms of distribution, apart from mammography, these technologies are mostly installed in large urban areas. The private sector is more present than the public and in some smaller cities in central Greece and some islands is the only provider of diagnostic imaging services with CT and MRI. • There is no data centrally available concerning medical equipment in general, due to the lack of a continuously updated inventory and the situation is similar for the information concerning the maintenance, age and actual use of the devices. • Appropriate staffing is also considered as a problem in many cases. Particularly in the Radiotherapy departments there is a discrepancy between the actual number of staff employed (especially non-medical) and the recommended by (already approved) EU guidelines. • Concerning the strategic planning for investments in new HVCE it is not well defined and decision-making is not evidence based and transparent in the public sector.

Recommendations • Greece should develop its Health Technology Assessment (HTA) capacity, as suggested by the WHO Mission report on Health Technology Assessment in Greece (World Health Organization, 2016 b), including Medical Devices (MDs). Rapid assessment and hospital based HTAs are very powerful tools into decision making for this type of technology. • Evidence based decisions for HVCE procurement, in the public sector, should be promoted at all levels. Involvement of scientific/professional societies and other stakeholders should be encouraged in an open dialog procedure • Availability of reliable data on the technology installed is absolutely necessary for correct decisions on technology procurement, management and replacement. A well-structured medical equipment inventory is essential in order to have an immediately available, clear and updated picture of the technology in use, in both the public and the private sector

Recommendations • The absence of Biomedical/Clinical engineering departments in most Greek hospitals is a great obstacle in the effective and safe management of medical technology, resulting in incomplete records and no maintenance quality and cost control. Maintenance of HVCE and the relevant costs should be followed, using modern computerized systems in all hospitals of the public sector. This is essential for the overall management of medical equipment in use. • Staffing of the relevant departments using HVCE should also be regulated taking into account best practices and guidelines, and according to the EU regulations and Directives. The application of these regulations should become a priority and the personnel in the respective departments to be based on the HVCE installed and not on the number of beds. • Continuing professional development (CPD) should also be organised in collaboration with professional societies, to assist personnel to keep in pace with recent technological developments.

Recommendations Finally, all actions and initiatives towards the implementation of such recommendations, should be well designed, based on correct baseline data concerning the existing needs, population, infrastructure, availability of human resources and additionally been accepted, through consensus building approaches with the users and stakeholders, to the larger possible extent. Clinical guidelines and best practices and safety issues, should be also taken into account during the analysis for prioritisation of needs.

THANK YOU The presenter declares no conflict of interest with the materials provided