Radiol med DOI 10.1007/s11547-015-0566-5
CARDIAC RADIOLOGY
Cardiac‑CT and Cardiac‑MR examinations cost analysis, based on data of four Italian Centers Maurizio Centonze1 · Giuseppe Lorenzin2 · Andrea Francesconi3 · Filippo Cademartiri4,5 · Giulia Casagranda1 · Michele Fusaro6 · Guido Ligabue7 · Giovanna Zanetti2 · Demetrio Spanti2 · Francesco De Cobelli8
Received: 1 June 2015 / Accepted: 7 July 2015 © Italian Society of Medical Radiology 2015
Abstract Purpose To establish the appropriate number of CardiacCT and Cardio-MR examinations, to determine an economically justified and sustainable investment in these two technologies, for an exclusive cardiologic use. Materials and methods From July 2013 to July 2014, through a survey in four different Italian Departments of Radiology, data on the costs of Cardiac-CT and Cardiac-MR examinations were collected. For the evaluation of the costs of examinations, it was used an analytical accounting system, considering only the direct costs (consumables, health personnel work time, equipment amortization/maintenance) and other costs (utilities, services, etc.). Indirect costs (general costs) were not assessed. It was made a simulation, assuming an exclusive use of the CT and MR equipments for CardiacCT and Cardiac-MR examinations, calculating the annual * Maurizio Centonze
[email protected] 1
Department of Diagnostic Imaging, APSS di Trento, Trento, Italy
2
Servizio Controllo di Gestione (Management Control Service), APSS di Trento, Trento, Italy
3
Department of Management and Economy, University of Trento, Trento, Italy
4
Cardio‑Vascular Imaging Unit, Giovanni XXIII Hospital, Monastier di Treviso (TV), Treviso, Italy
5
Erasmus Medical Center University, Rotterdam, The Netherlands
6
Department of Radiology, Ospedale Ca’ Foncello, Treviso, Italy
7
Department of Radiology, University of Modena and Reggio Emilia, Modena, Italy
8
Department of Radiology, IRCCS San Raffaele, Milan, Italy
number necessary to arrive at the Break Even Point (BEP: the point at which cost or expenses and revenue are equal). Results On the basis of the CT costs, in order to reach the BEP, performing only Cardiac-CT examinations, an average of 2641–2752 examinations/year is needed. The annual time commitment of the Medical Professional to ensure the number of examinations to reach the BEP is 2625–2750 h/ year, equivalent to two Medical Doctors in a Cardiology Department. The recent Cardiac-CT Italian Registry, in the period January–June 2011, reports a number of examinations of 3455 patients in 47 different Centers, distributed throughout the whole national territory. With regard to MR, in order to reach the BEP, performing only Cardiac-MR examinations, an average of 2435–3123 examinations/year is needed. The annual time commitment of the Medical Professional to ensure the number of examinations to reach the BEP is 2437–3125 h/year, equivalent to two Medical Doctors in a Cardiology Department. The recent CardiacMR Italian Registry reports a number of examinations of 3776 patients in 40 Centers, distributed throughout the whole national territory. Conclusion This research has shown that, only on the basis of costs, currently in Italy is anti-economic an exclusive use of CT or MR equipment for cardiac exams, unless it’s not decided, regardless of the recent guidelines and clinical indications, to submit all patients with cardiac diseases (diseases of the coronary arteries and cardiomyopathies) to Cardiac-CT and Cardiac-MR examinations. This might likely to increase both the inappropriate examinations and either health spending and in the case of CT with important repercussions, in terms of radio-exposure, subject to forensic procedures. Keywords Cost analysis · Cardiac-CT · Cardiac MRI · HTA
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Introduction The 1990s marked a turn-point in the development of economy in the Italian Health Organizations: this discipline had a constant evolution under the qualitative and quantitative viewpoint. The reform of the National Health Service (NHS), which developed through a complex and articulated sequence of measures, was characterized by the will of the law-makers at first of introducing and, later on, of promoting a managerial culture, based on the new model of corporate management on a strong responsibilization of the medical Staff [1, 2]. Moreover, the conversion of Italian health structures into trade companies has made cogent the need of developing a higher attention on the topic of costs with the objective of optimizing the process of delivering services and performance, in order to meet the requirement of health and psycho-physical well-being of the population, not only in terms of efficacy (quality of performance) but also of efficiency (optimization of the employed resources). In this range, Diagnostic Imaging, considered as one of the most expensive branches of modern medicine, was an excellent test of cost containment, also in relationship to the relative easiness of measuring and monitoring its performance, intended as the number of diagnostic-interventional examinations and as professional efficiency of Radiologists or Technologist. In the last 15 years, the very fast technological advancement of Diagnostic Imaging, especially in the field of Computed Tomography (CT: multidetector equipments with high gantry speed rotation) and Magnetic Resonance (MR: equipments with homogeneous magnetic field, powerful field gradients, high slew-rate, multi-channel coils), enabled the development of a series of application in clinical sectors, until few years ago precluded to noninvasive Diagnostic Imaging: in particular, in the field of cardiology both CT and MR were established as versatile, safe and reliable methods for the evaluation of patients with suspected coronary arteries atherosclerotic disease (CT) and known or suspected cardiomyopathy (MR) [3–5]. Especially this latter diagnostic method was found to be an extremely accurate and absolutely noninvasive diagnostic method for most of the cardiac pathologies [5]. Therefore, the number of requests for MR examinations of the heart (Cardiac-MR) is constantly increasing and many Health Organizations are planning the acquisition of modern equipments, even to the extent of suggesting some devoted exclusively to cardiac imaging under the Cardiologists responsibility, because Cardiac-MR is an indispensable diagnostic tool and also because not always and everywhere the Radiologists are enough trained to cope with this complex diagnostic field, since their diagnostic activity is very often overloaded by technically simpler tasks (baseline musculoskeletal and neurological Imaging),
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but in which the requirement of the population and the political–social trust are greater. The paucity of economic resources has caused the frequent recourse by the Decision Makers to the methodology of Health Technology Assessment (HTA), where the financial-organizational dimension (aspects related to the various types of costs, to the scale and purpose economies, to the variation of the organizing assets prompted by the use of technology) is acquiring an increasing importance in the processing of HTA reports underlying the decisions [6, 7]. The purpose of this multicenter survey is to establish the congruous number of Cardiac-CT and Cardiac-MR examinations, in order to determine as financially justified and sustainable an investment in these two technologies for an exclusively cardiologic utilization.
Materials and methods The Centers From July 2013 to July 2014, the cost data of Cardiac-CT and Cardiac-MR examinations were collected (respectively, Computed Tomography of Heart without and with contrast media, code 87412 of the Italian fee Nomenclator and Magnetic Resonance of Heart, code 88924), related to 2012 (consolidated data), from four different Italian Health Organizations. The four Centers which took part in the survey, in the form of filling a questionnaire prepared by the Management Control Service of Center 1, are located in the Northern-Eastern and Central Italy (Table 1). The two public hospitals (Centers 1 and 2) and the university hospital (Center 4) are of a similar size in both structural and logistic terms, as well as of the global activity performed, whereas the private health company (Center 3)—though of a smaller size—performs a number of Cardiac-CT and Cardiac-MR examinations which is overlapping on the one performed in the other 3 Centers, since such diagnostic activity is one of its distinctive vocations (Table 1). Cost calculation To calculate the costs of Cardiac-CT and Cardiac-MR examinations, a system of analytical accountability was used, considering only the direct costs necessary to perform the two tasks, namely the specific consumer goods, the working time of the Staff, the depreciation/maintenance of equipments and a part of the other costs (consumers, contracted services, etc.). On the contrary, the indirect costs were not evaluated (e.g., the costs of general functions such as administration and accountability, secretariat, general management, costs of auxiliary services, warehouses management, cleaning, etc.), due to the objective difficulties in
Radiol med Table 1 Type and features of the four survey Centers Data related to 31.12.2012
Radiology Center 1 (first of the line)
Radiology Center 2
Radiology Center 3
Radiology Center 4
Geographic site Type
Northern-Eastern Italy Public Health Company
Northern-Eastern Italy Public Health Company
Physicians (Radiologists) Nurses Technologists Coordinator
21.45 4.67 3
20 7 2
Northern-Eastern Italy Credited Private Health Company 5.03 2.5 1
Center Italy University Hospital Company 17 7.26 4.2
Technologists Basic Nurses Administrative Staff CT equipment MR equipment 2012 number of total examinations
40.64 15.93 9.62 2 (16 and 64 slices) 1 (1.5T) 140,867
44.34 8,84 11.5 1 (16 slices) 1 (1.5T) 164,384
9.69 1 9.22 1 (128 slices) 1 (1.5T) 46,596
32.8 1.25 6 2 (16 and 128 slices) 1 (1.5T) 148,182
2012 number of total CT examinations
22,299
15,056
3447
17,893
2012 number of Cardiac-CT examinations
45
57
77
231
2012 number of total RM examinations
5763
5467
8455
5124
2012 number of Cardiac-MR examinations
252
182
152
312
their identification and ascription with homogeneous structures between the four Centers. In addition, currently, it does not exist a nationally validated algorithm that allows an objective and indisputable allocation of indirect costs on the multiplicity of different examinations offered by a diagnostic imaging service. Therefore, indirect costs were not included in the calculation of the Cardiac-CT and CardiacMR examinations costs; however, knowing that the margin of error is in fact minimal, because their value is very fragmented. Criteria of exploitation of the examinations cost components All the various CT or MR tasks, performed by the same equipment of Cardiac-CT and Cardiac-MR examinations and delivered in 2012 by the single Center, were multiplied by the corresponding tariff (from the National Price-List), in order to obtain a weighted amount of the tasks. Then, all the weighted amounts were summed up to estimate the global weight of all the examinations performed with that equipment. (A) Determination of the costs of depreciation and maintenance for single examination
1. The depreciation rates were summed up to the annual costs of maintenance of the equipment devoted to the performance of all the CT and MR examinations. The resulting amount was divided by the global weight (see the previous section), to obtain a rate of depreciation costs/maintenance for weighted unit. 2. The weight associated with Cardiac-CT and CardiacMR examinations was multiplied by the cost of depreciation/maintenance per weight unit, to obtain their corresponding cost of depreciation/maintenance, corresponding to the relevant weight. 3. Then, the cost of depreciation/maintenance of CardiacCT and Cardiac-MR examinations was divided by the amount of examinations performed, to obtain the cost of depreciation and maintenance per single examination. (B) Determination of the “other costs” for single examination The global amount of the “other costs” (various consumers, contracted services, general expenses, etc.) of Radiology Unit was divided by the global number of examinations performed (not only CT and MR). (C) Determination of the Staff cost for single examination
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Table 2 Cost of Cardiac-CT and Cardiac-MR examinations in the single Center and mean value
Radiol med Center 1
Center 2
Center 3
Center 4
Mean value
Tariff
Cardiac-CT (87412) Cost No. of examinations
€ 184.53 45
€ 172.18 57
€ 242.96 77
€ 181.16 231
€ 195.21
€ 205.00
Cardiac-MR (88924) Cost
€ 254.68
€ 279.56
€ 404.80
€ 203.70
€ 285.68
€ 261.60
No. of examinations
252
182
152
312
1. The mean cost of the Staff equivalent unit and of qualification was calculated by dividing the global annual costs of the single professional figure for the equivalent units on service of the same qualification. 2. The cost/minute for Staff equivalent unit and for qualification was calculated by dividing the mean cost for qualification (point 1) by the annual hourly debt (38 h/week × 52 weeks for Medical Doctors; 36 h/ week × 52 weeks for the other professional figures) and then for 60 min. 3. The minutes of engagement by professional qualification to perform the Cardiac-CT and Cardiac-MR examinations were then calculated by multiplying the time devoted by the single professional qualification by the number of professionals involved in the same qualification. 4. Finally, the cost of the Staff was calculated for each examination by multiplying the cost/minute of each individual qualification (point 2) by the global time employed by the corresponding qualification for that specific examination (point 3) and summing up the resulting costs by qualification. (D) Determination of the cost of consumer goods The cost of the consumer goods employed to perform the single examination was reported as mentioned in the detection questionnaire. The sum of the costs for single Cardiac-CT or CardiacMR examination results from the sum of the four cost components listed above: A + B + C + D. When the costs of Cardiac-CT and Cardiac-MR examinations for single center and their mean value have been calculated, a simulation of exclusive utilization of the relevant equipment for such types of examinations was made, calculating the annual number necessary to reach the Break Even Point (BEP denotes the amount of Cardiac-CT or Cardiac-MR examinations necessary to cover the costs, without profits or losses). Since, in this simulation, the examinations, which should be performed by CT and MR equipment, would be, respectively, only Cardiac-CT and Cardiac-MR, BEP is the result of the ratio between the sum of fixed costs and the tariff of Nomenclator, from which the variable costs for each examination have been subtracted.
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Results The Management Control Service of Center 1, which has processed the data extrapolated from the questionnaires distributed to the four Centers, has at first calculated the cost of Cardiac-CT and Cardiac-MR examinations in the single Centers, extracting the mean value (Table 2). Before describing in detail the modes of achievement of BEP, it is necessary to point out the types of cost in question, focusing in particular on the cost of the Staff. The Health Organizations, typically hospitals, are characterized by a structure of the costs, which is strongly oriented towards the fixed ones and the most important topic is the cost of labor. This is a characteristic, which is common in the majority of companies producing services, even in areas differing from the health one. The cost of the Staff is handled in the Anglosaxon literature as a variable cost. Indeed, it is assumed that the number of worked hours is proportional to the amount of tasks requested. This scenario is nearly never present in Italy where the work relationships are more “stiff”, especially in the public health organizations, where the sizing of the Staff is structured in such a way as to assure the complete operativeness of the various structures, from the wards to the in-patient and the outpatient services, to the diagnostic services, to the administrative offices, etc. In the Italian Health Organizations, the cost of the Staff is about the 30–40 % of the global costs. Two different scenarios of calculation of BEP were suggested for both the diagnostic methods (CT and MR), where the single difference consists in the type of purchase offer of the equipment, the CONSIP one—“Concessionaria Servizi Informativi Pubblici”, i.e., the national purchase center of the Italian Public Administration—(Tables 3/ CT, MR) versus the Company one, which offers the equipment at an intermediate price versus the current market price (Tables 4/CT, MR). In both cases, the fixed costs include the Staff (cost of one Physician, one Technologist, one Nurse for each individual Cardiac-CT and CardiacMR examination), the annual rates of depreciation of CT and MR equipment (period 8 years, as established by the Decree of the Ministry of Finance of 31.12.1988) and the annual fees of maintenance. The variable costs are the consumer goods and “other costs”. The sum of the various cost
Radiol med Table 3 Number of examinations to reach the BEP (CONSIP purchase offer)
Table 4 Number of examinations to reach the BEP (Company purchase offer)
Center 1 Center 2 Center 3 Center 4 Average
Center 1 Center 2 Center 3 Center 4 Average
Cardiac-CT Fixed costs Namely: Staff Depreciations Maintenance Unit variable costs
373.855 230.850 63.005 80.000 61
331.343 188.337 63.005 80.000 70
464.555 321.549 63.005 80.000 72
322.507 179.502 63.005 80.000 51
373.065 230.060 63.005 80.000 64
37
56
61
40
49
24 205 2.595
14 205 2.460
11 205 3.505
11 205 2.097
15 205 2.641
402.060 230.850 71.211 100.000 102
359.548 188.337 71.211 100.000 118
492.760 321.549 71.211 100.000 119
350.713 179.502 71.211 100.000 48
401.270 230.060 71.211 100.000 97
79
104
108
37
82
Other costs Tariff (88924)
24 262
14 262
11 262
11 262
15 262
Number of examinations for BEP
2.526
2.510
3.448
1.640
2.435
Namely: consumer goods Other costs Tariff (87412) Number of examinations for BEP Cardiac-MR Fixed costs Namely: Staff Depreciations Maintenances Unit variable costs Namely: consumer goods
items enabled to calculate the number of Cardiac-CT and Cardiac-MR examinations per single Center and the mean value for the achievement of BEP.
Discussion The cost analysis of the examinations shows that, concerning the Cardiac-CT, the values are rather similar in the three public Centers (from 172.18 euro of Center 2 to 184.53 euro of Center 1), whereas in the private one (Center 3) the cost is significantly higher (242.96 euro), mostly due to the higher cost for the Staff, which covers over the 59 % of the total amount, corresponding to 143.91 euro, nearly totally for Radiologist. Otherwise, the cost of the Staff covers a variable rate from 44 to 51 %, therefore rather high, also in 3 public Centers, with a mean value of 51 % in the four Centers (Tables 2/CT, 3/CT). Similar considerations apply to Cardiac-MR examinations: the cost of the examination
Cardiac-CT Fixed costs Namely: Staff Depreciations Maintenances Unit variable costs
389.516 230.850 78.666 80.000 61
347.004 188.337 78.666 80.000 70
480.216 321.549 78.666 80.000 72
338.168 179.502 78.666 80.000 51
388.726 230.060 78.666 80.000 64
37
56
61
40
49
24 205 2.704
14 205 2.576
11 205 3.624
11 205 2.198
15 205 2.752
515.385 230.850 184.535 100.000 102
472.872 188.337 184.535 100.000 118
606.084 321.549 184.535 100.000 119
464.037 179.502 184.535 100.000 48
514.595 230.060 184.535 100.000 97
79
104
108
37
82
Other costs Tariff
24 262
14 262
11 262
11 262
15 262
Number of examinations for BEP
3.237
3.301
4.242
2.170
3.123
Namely: consumer goods Other costs Tariff Number of examinations for BEP Cardiac-MR Fixed costs Namely: Staff Depreciations Maintenances Unit variable costs Namely: consumer goods
in the private Center is really higher (404.80 euro) versus the three public ones (from 203.70 euro of Center 4 to 279.56 euro of Center 2). Also in this instance, it is the Staff, which causes the high cost of Cardiac-MR examinations of Center 3 (56 % of the total amount). This percentage is rather high also for Center 4 (46 %) when compared with the similar percentage of Centers 1 and 2, respectively, 37 and 29 %. However, the relatively low total cost of Cardiac-MR examination of Center 4 results from a significant spare on paramagnetic contrast media, 16.81 euro/ examination against 56.92 euro of Center 1, 82.39 euro of Center 2 to reach 85.12 euro of Center 3. This datum is surprising because in these latter Centers, the molecule of paramagnetic contrast media is the same, which suggests the extreme inhomogeneity of the market offers. This finding also applies to the iodinated contrast agent employed for Cardiac-CT examinations: the same agent costs 19.80 euro/examination in Center 4, nearly the double in Center 2 (31.90 euro) and in Center 3 (37.20 euro), whereas
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Center 1, which uses a different agent, spends 13.00 euro/ examination. Based on the costs of the examinations to achieve the BEP, performing only Cardiac-CT examinations, from 2641 examinations/year (CONSIP purchase offer) to 2752 examinations/year (Company purchase offer), is necessary on average. Assuming as standard datum a number of working days of 250/year, the number of daily examinations ranges from 10.5 to 11. This number of examinations, considering the maximum operating capacity of a modern CT scan equipment at 64 and 128 slices, can be surely performed in one shift of 6 h/day (one examination every 30 min), as established in a recent official document of “Società Italiana di Radiologia Medica” (Italian Society of Medical Radiology) [8], whereas the reporting step (1 h/ examination) [8], which includes also the complex postprocessing of native images, which is an irreplaceable component of the report, requires globally 10.5 h/day (CONSIP purchase offer) or 11 h/day (Company purchase offer). On an annual basis (250 workdays), the hourly engagement of the Physician, to assure the number of examinations to achieve the BEP, could range from 2625 to 2750 h. Concerning the Cardiac-MR examinations, 2435 examinations/year (CONSIP purchase offer) to 3123 examinations/year (Company purchase offer) are necessary on average. This value, converted into terms of daily activity, corresponds to a number of daily examinations ranging between 9.74 and 12.5. Differing from CT, this number of examinations, even with very performing MR equipment, can be reached in at least 2 work shifts of 6 h/day (one examination every 60 min) [8]. Considering a medical engagement in the post-processing of images (1 h/examination) [8] and in the successive reporting step, respectively, 9.74 h/day (CONSIP purchase offer) or 12.5 h/(Company purchase offer) are necessary for Cardiac-MR examinations. On an annual basis (250 workdays), the hourly debt of the Physician would range from 2437 to 3125 h. Accordingly, an exclusive utilization of CT and MR for cardiologic examinations would involve the need of devoting at least 2 full-time Physicians. In the reality, the recent Italian Registries of CardiacCT [9] and Cardiac-MR [10], in the period from January to June 2011, report a number of examinations performed, respectively, of 3455 patients in 47 centers and of 3776 patients in 40 Centers on the whole Italian territory. All the examinations reported in the Italian Registries met the stringent criteria of appropriateness established by the most recent international guidelines [3–5]. In the light of the above described calculations of BEP, an exclusive utilization in cardiologic practice of CT and MR equipment, if could produce the positive effect of reducing the default inappropriateness, resulting from an easy access to the Cardiac-CT and Cardiac-MR examinations, on the contrary
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could risk of increasing the excess inappropriateness with high health expenditure, and in the instance of CT also with remarkable repercussions in terms of undue radio-exposure, prone to medical-forensic procedures.
Limits This survey has used the consolidated data of activity and costs of year 2012. Therefore, the increasing use of Cardiac-CT and Cardiac-MR should be considered also in the light of the steady improvements of technologies. Indeed, these improvements—reducing their restrictions—widen every year the spectrum of their clinical indications, which is mirrored by the frequent updating of the international guidelines. Moreover, if we want to actualize the costs, we should perform an amendment, based on the annual Italian inflation rate (2013: 1.2 %; November 2014: <1 %). A remarkable difficulty during the survey was the collection of data, since the various Management Services, encharged along with the Radiologist referees of the Centers, have submitted very inhomogeneous and not always comparable data. This has compelled the Service of the headline Center (Center 1) under some circumstances to perform operations of normalization, to compare the results of the four Centers. Finally, the four survey centers are distributed into adjacent Italian geographic micro-areas which are not totally representative of the whole national situation.
Conclusions The shortage of resources, which is characterizing the financial situation of the Western countries, compels constantly the Decision Makers—in both the political and managerial areas—to rationalize the choices for the social investments. Though the aspects of public health, in view of the sensitivity of the matter, are considered to be very important, it is impossible not to reduce the health offer, which—along with the pension system—is the most important expenditure in the state balances. Health technologies devoted to Diagnostic Imaging make no exception: indeed, they are always one of the most important sections of investments of Health Organizations. In the recent 20 years, the methodology of the HTA was an excellent tool to guide and support the decision-making processes. Though the driving forces are many—from efficacy to effectiveness, to juridical, ethical and social implications— as stated above—the economical aspect is the ineluctable factor for the acquisition of Diagnostic Imaging technology. This survey has demonstrated that, only on the basis of costs, at present in Italy an exclusive utilization of CT
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or MR equipment for cardiologic examinations is antieconomic, unless it is established, not considering the recent guidelines and clinical indications, to subject all the patients with cardiac pathologies (diseases of coronary arteries and cardiac diseases) to Cardiac-CT and CardiacMR examinations. Also considering such event, this choice could introduce unavoidably scale and purpose diseconomies, in relationship to technologies of diagnostic Imaging (Echocardiography and Coronary angiography), which are already devoted to patients with cardiac diseases. Nevertheless, it has to be considered that the availability of CT and MR equipments, exclusively dedicated to cardiac imaging, might risk creating an increase of examinations not properly appropriate, thanks to a more easy access to examinations, resulting in increased costs for the National Health Service. Acknowledgments We thank Dr. Katia Chisté and Angela Trentin (Service of Control of Management of APSS of Trento) for their valuable cooperation. Moreover, we thank Prof. Ernesto Di Cesare (University of L’Aquila) and Dr. Marco Francone (University La Sapienza of Rome) for the advices and supply of scientific material used in this work. Compliance with ethical standards Funding This study was not funded. Conflict of interest Author Maurizio Centonze declares that he has no conflict of interest. Co-Author Giuseppe Lorenzin declares that he has no conflict of interest. Co-Author Andrea Francesconi declares that he has no conflict of interest. Co-Author Filippo Cademartiri declares that he has no conflict of interest. Co-Author Giulia Casagranda declares that she has no conflict of interest. Co-Author Michele Fusaro declares that he has no conflict of interest. Co-Author Guido Ligabue declares that he has no conflict of interest. Co-Author Giovanna Zanetti declares that she has no conflict of interest. Co-Author Demetrio Spanti declares that he has no conflict of interest. Co-Author Francesco De Cobelli declares that he has no conflict of interest.
Ethical approval This article does not contain any studies with human participants or animals performed by any of the authors.
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