Value-Based Healthcare and Radiology: How can Value be Measured?

Abstract

The concept of value-based healthcare (VBH) emerges as a response to traditional models of healthcare system management. More specifically, in radiology, the transition from volume to value has been discussed by its main associations, having as the main concern regarding the role of the specialty in a more integrated healthcare context.

Through a qualitative study, this work aims to analyse and evaluate how this new concept can be implemented in radiology by identifying obstacles and mapping the technical and procedural improvements necessary for its correct implementation in the national context of healthcare provision. Through interviews with different elements of the healthcare sector (from doctors to industry partners and researchers), it was possible to draw a set of metrics for measuring the value of radiology, alongside the implementation of a VBH strategy.

As the main conclusion, the implementation of a strategic agenda for the creation of value in radiology at the national level should be based on the reduction of variability and the identification of best practices in terms of adequacy, quality, safety and efficiency, aiming to satisfy the needs of requesting doctors and patients.

Keywords

Value-based healthcare radiology value metrics healthcare ecosystem

Introduction

The sustainability of the healthcare sector is questioned by some challenges such as the aging of the population and technological advancement, with more number of active patients (Yaduvanshi & Sharma, 2017). This leads to the need of rethinking the way in which healthcare services are conceptualised, funded and provided.

In this context, the concept of value-based healthcare (VBH) emerges as a response to traditional models of healthcare system management. It advocates that its operation and financing should be based on patient-reported health measurements to increase efficiency and reduce costs.

More specifically, in radiology, the transition from volume to value has been discussed by its main associations, having as the main concern regarding the role of the specialty in a more integrated healthcare context (European Society, 2017; Moser et al., 2006; Mukherji, 2014; Norbash et al., 2014).

This work aims to analyse and evaluate how this new concept can be implemented in radiology by identifying obstacles and mapping the improvements (technical and procedural) necessary for its correct implementation in the context of healthcare provision.

Value in Health

The economy has transitioned from an industrialist economy of the material to an economy based on the immaterial, thereby requiring a measurement of the process of production and consumption of value for consumers (Bang et al., 2010).

Value, from the perspective of a business strategy, can be defined through three variables: the benefits (B) that a service or product provides to a consumer; the production costs (C) of that good or service; and the price (P), charged for the service or product (Heller, 2014).

However, when trying to apply these concepts to the healthcare sector, a problem emerges that health benefits are difficult to measure. Despite the complexity, Porter and Teisberg (2006) suggested that, in the case of the healthcare sector, the value should be measured based on the outcomes achieved considering the costs that the organisation incurred in providing healthcare. It should also focus on the patient and have the clear goal of optimising health outcomes.

In order to respond to this need, the ICHOM (International Consortium for Health Outcomes Measurement) was created, with the main promoters as the Harvard Business School, the Karolinska Institute and The Boston Consulting Group (Porter & Teisberg, 2006). This organisation’s mission is to demonstrate the potential of VBH by defining standards for measuring results that are measured and valued by patients (PROMs—Patient-Reported Outcome Measures, PREMs—Patient-Reported Experience Measures; International Consortium for Health Outcome Measurements, 2018).

Generically, there has been an increase in the interest of Organization for Economic Cooperation and Development (OECD) countries in the use of PROMs, along with other quality and outcome metrics. The OECD, considering the PaRIS (Patient Reported Indicator Surveys) initiative, has also proposed the adoption of PREMs in outpatient care, which should later be expanded to clinical areas that have received little attention to date, such as mental health, palliative care and primary care (Organisation for Economic Co-operation and Development, 2017).

Value of Healthcare in Portugal

The Portuguese healthcare system adopts a mixed funding model, with Bismarckian components (existence of private hospitals and health insurance) and Beverigian components (the State finances, owns and manages the health facilities of the National Health Service), the latter being predominant (Simões, 2009).

This system has been subject to several reforms since its creation. The most recent was the economic and financial adjustment plan promoted by members of the Portuguese government, European Commission, European Central Bank, European Stability Mechanism and International Monetary Fund (IMF) between 2011 and 2014 (Banco de Portugal, 2020). As a result of this plan, health spending has reversed its growth, with fiscal consolidation measures reducing spending, from values that decreased from 9.8% of gross domestic product (GDP) in 2010 to 9% of GDP in 2015 (the EU average for that year was 9.9% as a function of GDP) (Pordata, 2018). In 2017, public funding for the healthcare system was 67% and private funding was 33% (APAH, ROCHE, & IQVIA, 2018).

Moreover, in terms of the resilience of the healthcare system, it is expected that the aging of the population and the difficulties in retaining staff will worsen the problems of financial sustainability and human resources (OECD/European Observatory on Health Systems and Policies, 2017).

Despite the reduction of funding in healthcare, Portugal has been investing on innovative initiatives to improve the provision of healthcare services, as shown in Table 1.

Table 1.

Innovative and Value-based Healthcare Projects Developed in Portugal.

Year	Project	Goal	Reference
2005	P4P program at the level of primary health care	Improvement of accessibility, efficiency, quality and continuity of care and satisfaction of professionals and citizens	Lourenço (2016a)
2007	Pilot Comprehensive Price Payments Program for HIV Treatment	The success of this project led to the financing model applied to HIV being expanded to other chronic conditions	Lourenço (2016b)
2015	ERS created SINAS (National Health Assessment System)	System for evaluating the different dimensions of quality of healthcare providers	ERS (2019)
2018	3F Economic and Financial Adjustment Plan Financing, Formula for the Future	Analysis of the current model of financing for hospitals and identification of solutions that allow the creation of value for patients and development of pilot projects with hospitals	APAH (2018)
2018	FAROL pilot project	Developed in the context of lung cancer pathology. Measurement of healthcare outcomes (clinical and relative to the patient’s experience) over the entire patient’s journey (through an ICHOM data set) and determination of the real cost of treatment (using the TDABC methodology)	APAH (2018)
2018	POLARIS	Test a population-based financing model, which will be compared with the current budgets of primary and secondary healthcare units	APAH, ROCHE & IQVIA (2018)

Source: Authors´ analysis.

Value in Radiology

Radiology has gone through a period of growth in recent decades. Technological advances like computed tomography (CT) and magnetic resonance imaging (MRI) have contributed to the improvement of healthcare provision by enabling new forms of diagnosis. The emergence of PACS (Picture Archiving and Communication System) was a revolution and contributed to the increase in efficiency and workload. But, it led to an increase in the workload and isolation of radiologists in relation to other specialties (Stackelberg et al., 2018).

Despite the advances in radiology, the 2008 economic crisis had a negative impact on its evolution. It led to a reduction in the renewal of imaging equipment, and there was a tendency to postpone and/or downgrade maintenance programmes. There was a significant reduction in reimbursements for certain procedures, forcing the reorganisation of facilities and human resources. The reduction of resources for the maintenance of equipment and installations had a negative impact on the normal activity of professionals and on radiological quality and safety (European Society of Radiology (ESR), 2014; 2015). The industry and equipment manufacturers were also affected due to the reduction in investment by manufacturers in R&D projects and in carrying out partnerships and training programs for technicians (ESR, 2015).

Radiology Value Chain

The radiology value chain forms a model of a transactional nature. Its sustainability depends on conducting a high volume of examinations and reports, which aims to create and organise imaging information quickly and accurately, thereby influencing clinical decision-making.

The digitisation and disaggregation of the traditional value chain thus presents challenges and opportunities (Enzmann, 2012).

It becomes necessary to take advantage of the possibilities of digitisation, re-aggregating the value chain and adopting new ways of creating value, which contribute to cost reduction, to the reduction of the duration of episodes of healthcare provision and to the improvement of results of healthcare for patients (Gillies et al., 2016).

In this way, European Society of Radiology (ESR) has been arguing that the value of radiology is multifaceted and is not limited to the number of tests performed. It also considers that it is essential to measure the impact of diagnosis on healthcare outcomes for patients (European Society, 2017).

Measurement of Value in Radiology

The concepts of value and quality are related, and value can be defined as the ratio between quality and cost (Duong et al., 2016) or the ratio between quality and cost multiplied by efficiency (Rawson, 2012).

Radiology should be able to fit into the value paradigm through the implementation of a strategic agenda, based on the principles of Imaging 3.0™ developed by the American College of Radiology, which will allow to map the activities performed along the value chain. Thus, it is necessary to develop performance indicators that are specific in relation to the activities to be monitored, thereby allowing action and response in time (Sharpe Jr. et al., 2015).

The main challenge in the evaluation, using performance indicators based on the results, is the fact that they can be influenced by external factors such as the severity of the disease, among others (Kelley & Hurst, 2006). Thus, it is necessary to know how to identify what should be monitored (Harvey et al., 2016). Too many performance indicators can result in distraction, and insufficient performance indicators can prevent multiple process failures from being identified (Harvey & Sotardi, 2018).

Table 2.

Quality Metrics Proposed by Several Authors.

Activities	Proposed Quality Metric
Fitness for examination requests	Adherence to clinical guidelines, based on evidence and institutionally approved, upon request Identification of duplicate studies Rejection of unnecessary or redundant studies Availability of the radiologist to provide support or consultation to the requesting physician
Patient schedule and preparation	Convenient scheduling for the patient Scheduling and carrying out complementary examinations on the same day Time elapsed from scheduling to taking the examination Instruction to the patient regarding the examination to be performed
Examination protocols	Presence and percentage of use of protocols that do not use ionising radiation Presence and percentage of use of low radiation dose protocols in computed tomography equipment Evidence of the existence of continuous training programmes in protection against ionising radiation
Image modalities and examination	Punctuality in examinations Radiation dose monitoring and recording and benchmarking Registration and analysis of adverse reactions and contrast leakage Evidence of the existence and use of protocols for the treatment of adverse reactions and contrast leakage Instruction to the patient by the radiology technician, before and after the examination
Run report	Access to relevant clinical data and previous patient examination Use of standardised terminology in reporting Accuracy, clarity and specificity of the report Frequency of recommendations Time elapsed between the end of the examination and the completion of the report
Report communication	Ease of access to the report by the requesting physician Easy access to the report by the patient Report understood by the patient Consultation by the radiologist to the patient
Impact of the report	Number of cases discussed between the radiologist and the requesting physician (following the completion and communication of the report) Percentage of cases in which the consultation between the radiologist and the requesting physician has an impact on the preparation or alteration of treatment plans
Outcomes	Did the diagnosis or image-guided intervention eliminate the need for more invasive or costly procedures? Did the diagnosis or image-guided intervention reduce the length of hospital stay and/or morbidity for the patient? Satisfaction of the requesting physician Patient satisfaction

Source: Adapted from Boland et al. (2015, 2017), European Society (2017) and Patel (2015).

Table 2 shows several quality metrics related to typical activities in the radiology value chain, which were proposed by different authors (Patel, 2015; Boland et al., 2015; 2017; European Society, 2017).

To manage the value created, the processes inherent to the workflow of a radiology service must be monitored and continuously improved through an information technology infrastructure. This must be patient-centred and allow data extraction and its conversion into information by using business intelligence tools (Boland et al., 2015).

Then, a structured report must allow to accurately describe the radiological findings, avoiding ambiguity in the reports and facilitating comparability (European Society, 2018; Gefen & Chang, 2017; Rubin, 2008; Wang et al., 2014). Finally, connectivity allows the dissemination and sharing of information between electronic healthcare records at the regional level (Kohli et al., 2015; Mendelson & Rubin, 2013) while ensuring data privacy, confidentiality and integrity (Kansagra et al., 2016; Kohli et al., 2015; Mendelson & Rubin, 2013).

Therefore, this study aims to answer the question: taking into account the concept of VBH provision, in the context of the Portuguese health system, what is the value created by imaging care, how is it perceived by the stakeholders and how it can be measured?

Methodology

A qualitative research methodology was used to search for the answer to the question asked.

For the literature review, a bibliographic collection was carried out related to the subject to be studied by using the databases ScienceDirect^®, ClinicalKey^®, Scopus^®, SpringerLink^® and PubMed, which allowed a better understanding of the concepts underlying this work and its importance.

Semi-structured interviews were also carried out by taking into account the heterogeneity of the participants in order to comply with the principle of diversification (Guerra, 2006). The interviews were based on relatively open questions to obtain information from the interviewees, whose profile is described in Table 3. The participants were selected according to the objectives of the study. Thus, questions common to all respondents and others of a more technical and specific nature were elaborated. All interviewees had prior access to the interview guide, and all interviews were conducted in person, except for one (carried out via email).

Table 3.

Selection of Participants.

Group	Profile
A—Clinics	Doctor (specialty—radiology I) Interview 1
	Doctor (specialty—radiology II) Interview 3
	Doctor (specialty—radiology III) Interview 5
	Doctor (specialty—nephrology) Interview 2
	Doctor (specialty—general surgery II) Interview 13
B—Clinicians with experience in management/coordination of healthcare facilities	Doctor (specialty—public health) Interview 6
	Doctor (specialty—general and family medicine) Interview 8
	Doctor (specialty—general surgery I) Interview 10
C—Economists	Economist I (Doctor of Health Economics) Interview 7
C—Economists	Economist II (healthcare management specialist) Interview 9
D—Researchers	Researcher and doctor in health sciences and technologies Interview 4
D—Researchers	Researcher and doctor in information systems integration in hospitals Interview 11
E—Industry partners	Consultant, business manager and sales account executive in a medical technology company Interview 12

Source: Authors´ analysis.

In a subsequent phase, the content of the interviews was analysed by content analysis (Moraes, 1999), and a categorical/thematic analysis was carried out.

The technique comprised the following steps: (1) preparation of information—the different samples of information were identified for further analysis; (2) transformation of the content in units—the units of analysis were defined depending on the nature of the problem, the research objectives and the type of material analysed; (3) categorisation or classification of units into categories—the data were grouped considering the common aspects between them. The data were grouped into subcategories and categories, framed with the previously defined themes; (4) description—for each group of interviewees, a table was created with the synthesis of results. In the tables, key ideas are found, intersected and expressed in units of analysis; and (5) interpretation—carried out through an exploration of the meanings, expressed in the various categories of the analysis, in contrast to the theoretical foundation explained in the review bibliography.

The content analysis of the interviews, which will be discussed in the next section, covers the following themes: perception of the concept of healthcare delivery based on value; perceived value in relation to radiology and measurement of value in radiology. The topics are aligned with the objectives of this study and deal with the major themes identified in the literature review.

Results and Discussion

VBH in the Healthcare System

The VBH concept crosses the financial and clinical aspects, while seeking to ensure the financial sustainability of healthcare systems, by reducing waste and maximising health outcomes for patients (Yavas et al., 2016). The realisation of this objective implies the reorganisation of the current form of care provision, currently performed in a poorly integrated manner. This last aspect was highlighted by the three interviewees from Group B and one interviewee from Group C. They consider that it is important to have greater integration of processes on the part of the various levels of care.

In Group B, one interviewee indicated that there has been an attempt by hospital administrators to improve the integration of care, which seems to suggest that there is awareness and willingness to move towards a VBH strategy (in part or as a whole). Also, in this group, an interviewee suggested that the existence of corporate and financial interests is a barrier to better coordination and organisation.

The search for the economic sustainability of the NHS is a common concern for three interviewees from Group A and one interviewer from Group B. These referred to the existence of inefficiencies in the level of care, which lead to wastage of resources, including geographical and allocation asymmetries.

The opinions of the different stakeholders are in line with that described in the literature as a strategic agenda for the implementation of a VBH model. The importance of measuring results was highlighted by two interviewees from Group B, two interviewees from Group C and one interviewee from Group E.

In the implementation of VBH, the use of information technologies in the sector is suggested, with the creation of technological platforms that allow the stakeholders to have access to the best information available, allowing to reduce, or even eliminate, redundancies in the provision of care.

In the opinion of a Group D interviewee, it will be increasingly important to attend to aspects related to the traceability of information related to the provision of care, promotion of interoperability and integration of computer systems, and guarantee of the confidentiality and security of patient data.

An interviewee in group B considered that the concept of value is related to the aspects of the quality of healthcare intervention, which include efficiency, access and the context where citizens live. In this context, the focus on prevention acquires enormous relevance. Achieving this objective implies reinforcing the role of primary healthcare as the first line of response due to its importance in health promotion, disease prevention and health management of the population. The interviewee warned for the existence of bad practices and consumerism, in addition to the existence of few studies on public health in Portugal.

It is important to understand whether Portugal in fact is moving towards a vision of a strategic agenda and system reform that is real and with continuity in terms of healthcare policies. In the opinion of a Group C interviewee, the concept is already in the mouth of politicians and managers, but in practice, it does not apply in decisions. Sometimes, technical arguments can be disassembled based on ideological and sociological considerations, with decisions often being sustained in this way and less based on evidence.

VBH in Radiology

A consensual aspect among the interviewees of the five groups is that radiology plays an important role in the provision of healthcare.

The importance of the value of time and early diagnosis was reinforced by three interviewees from Group A, one interviewee from Group D and one interviewee from Group E. The perception of the value of radiology from a cost-effectiveness perspective was highlighted by one interviewee from Group C.

One interviewee from Group D highlighted the potential for secondary use of data to create value in radiology and the maturity that the specialty has acquired in the use of information technologies.

A Group E interviewee argued that traditional radiology partners should advance and innovate to the point of responding to current and future needs, following trends around value and contributing to the success of radiology in this new paradigm. He argued that equipment management tools increase efficiency and that dose management applications increase safety for patients. One of the main considerations made by the interviewees is related to the consequences of the success of radiology and technological advances that allowed the image to reach an extremely important role in medical decisions.

Measurement of Value in Radiology

After the analysis and considerations made by the interviewees in relation to the metrics initially suggested and expressed in Table 2, the proposed quality metrics are justified, referring to the activities carried out along the radiology value chain.

The relevance of metrics related to the adequacy of requests for imaging tests was consensual among respondents from the various groups.

Computer systems to support clinical decision, based on clinical guidance standards supported by the best available scientific evidence, may constitute a solution, with benefits in terms of the adequacy of requests for imaging tests and in terms of reducing unnecessary radiation exposure. The use of this type of systems may help to quantify the metrics ‘identification of duplicate studies’ and ‘rejection of unnecessary studies’. Ideally, these systems will have the potential to reduce the costs of overuse of medical imaging or provide an alternative to current restrictions on prescribing certain tests in certain care settings.

More effective cooperation with requesting physicians and greater awareness of the risks of excessive use of unnecessary or redundant imaging tests can bring value to patients and help ensure the economic sustainability of the healthcare system. As suggested by an interviewee from Group C, the metric ‘availability of the radiologist to provide support or consultation to the requesting physician’ was replaced by ‘availability of the radiologist to provide consultation to the requesting physician’.

The metrics referring to patient scheduling and preparation aim to measure the efficiency of various processes, which should enable patients to access healthcare provided by radiology services in a timely manner. In addition to the search for continuous improvement of efficiency in terms of scheduling activities, ‘patient instruction regarding the examination to be performed’ is essential, so that the diagnostic examination or intervention procedure has a greater chance of success. The effective integration between electronic healthcare records and imaging information systems is critical for the efficiency of these processes to be maximised (McEnery, 2014).

In terms of the activities related to the protocols for the examination, it is important to ensure that patients are not subjected to unnecessary ionising radiation. The assessment of the resources available in a radiology service can be assessed by analysing the ‘presence and percentage of use of protocols that do not use ionising radiation’. The metric ‘presence and percentage of use of low radiation dose protocols in computed tomography equipment’ was reformulated, in which the term ‘low dose’ was replaced by ‘optimised dose’.

For activities related to imaging modalities and examinations, several metrics are proposed that aim to ensure the safety of patients, with the exception of ‘punctuality in the examinations’, which aims to assess the contribution to their satisfaction and experience, as well as assessing the efficiency of processes at this level. The metrics ‘analysis and evaluation of adverse reactions and contrast leakage’ and ‘evidence of the existence and use of protocols for the treatment of adverse reactions and contrast leakage’ are essential. There should be evidence of the existence of training in this area, including simulations, in order to assess the effectiveness and efficiency of security processes (Loving et al., 2018).

When executing the report, it is important that the radiologist has access to the relevant clinical data and previous examinations of the patient. The structured report can help to facilitate the evaluation of the metrics ‘use of standardised terminology in the preparation of reports’ and ‘accuracy, clarity and specificity of the report’ (Donnelly et al., 2019; Goldberg-stein et al., 2017). The recommendations for additional tests, included in the report, should make a real contribution to the subsequent provision of care and not just a form of defensive medicine by the radiologist. The time elapsed between the end of the examination and the realisation of the report must be monitored and analysed, considering the different needs and contexts in which they are requested.

Members from Groups A, B, C and D spoke negatively regarding the metrics ‘report understood by the patient’ and ‘consultation by the radiologist to the patient’, which are related to the communication of the report and are considered to be of little relevance to the final result. Effective communication between doctors is a more significant contribution to patients. In this sense, the report must be well understood by the requesting physician, who, in this way, will be able to make informed decisions and share them with the patient for the management of their health. However, and considering the concerns in relation to the previously mentioned metrics, it was decided to remove the metric ‘easy access to the report by the patient’. In this way, the importance of communication between doctors is reinforced. The report must have an impact on treatment decisions, and for that, it must be accessible at the appropriate time to the needs of the requesting physician. In this sense, it is important to ensure and quantify the ‘ease of access to the report by the requesting physician’.

The metrics ‘number of cases discussed between the radiologist and the requesting physician (following the completion and communication of the report)’, referring to the impact of the report, were removed, as interviewees from Groups A, B and D consider that these metrics were unclear, unworkable and not applicable to the context of radiology. In this context, and taking into account the opinions expressed by an interviewee from Group D and an interviewee from Group B, the metric ‘percentage of cases in which the consultation between the radiologist and the requesting doctor has an impact on the elaboration or alteration’ was reformulated, and it was considered relevant to add the metric. These metrics referring to the impact of the report are considered as an intermediate outcome, possibly measurable through a feedback system aimed at requesting physicians (Shaikh et al., 2017).

Assessing whether the diagnosis or intervention eliminated the need for more invasive or costly procedures, whether it allowed reducing mortality or morbidity for the patient and the length of hospital stay and assessing the satisfaction of the requesting patients and doctors, is extremely important. Estimating the results of the diagnostic imaging process is, however, a challenge, given the difficulty of quantification and association with benefits for patients. One interviewee from Group A stated that the value is difficult to assess and that the task of putting the indirect cost to the hospital in numbers, of not using radiology, can be difficult to achieve. The nature of the metrics, which should not be punitive, and the focus on metrics with the greatest potential to impact results, was defended by one interviewee from Group A and one from Group C.

Despite the importance of focusing on metrics with more impact on results instead of the isolated quantification of countless metrics with residual impact, the development of quality metrics should reflect the real effort of continuous and integrated improvement of activities along the value chain. In this sense, it must be understood that all professionals involved in the value chain have an influence on the result, which will ultimately be the satisfaction of the requirements of the requesting doctors, which translate into obtaining benefits for patients and reducing costs to the healthcare system.

Conclusion

Theoretical and Practical Implications

Presently, there is the need to understand what is value for the patients (Emmett & Chandra, 2013). Referring to the objectives outlined and the research question formulated, it was possible to conclude that VBH is perceived as being important to face the sustainability problems that the national healthcare service as a system, as a whole, faces.

In a global way, the interviewees agree with the implementation of a strategic agenda for the creation of value and emphasise its importance, having identified several measures that have been applied at the national level, to improve the coordination, quality and cost-effectiveness of care. Therefore, it must be possible to draw conclusions from the experiments carried out, so that the success cases can be replicated at the national level.

There is a perception on the part of economists that all these measures and initiatives still need to be framed in a strategic political agenda for the creation of value in healthcare. It is important to reflect, for example, on the effectiveness of human resources policies in healthcare. These policies should aim to satisfy the needs of the population; guarantee the training, security and motivation of professionals; encourage full dedication; avoid conflicts of interest between public and private activity; facilitate mobility between the public and private sectors; and seek adequate coverage in the national territory.

As Porter and Teisberg (2006) mentioned, it is important to remember that the value must be defined according to the patient, and the value created for it must be the factor that determines the reward for the different players in the system. In the healthcare sector, competition must be redefined around this concept.

Regarding the perceived value in relation to radiology, its contribution to an early diagnosis and a reduction in morbidity was highlighted.

Despite the challenges that the specialty faces, it is essential to outline strategies that contribute to closer relations and encourage cooperation between radiology and other specialties, improve communication and information along the value chain and ensure the correct use of resources.

The implementation of a strategic agenda for the creation of value in radiology at the national level should be based on the reduction of variability and the identification of best practices in terms of adequacy, quality, safety and efficiency, aiming to satisfy the needs of requesting doctors and patients.

In this work, we tried to fit the proposed metrics with the national reality. For this purpose, these were adapted, considering the comments made by the interviewees and the literature review. This review allowed us to identify some trends and initiatives that, associated with a new legal situation, may have implications for future radiology business models. In this context, which is intended to be a positive development in relation to the current model, the proposed metrics may acquire greater relevance.

Methodological Implications and Suggestions for Future Research

At the methodological level, this study had some limitations. The enlargement of the profiles and groups of interviewees could help to expand the conclusions drawn from it, thereby valuing the results of the investigation. It would be interesting to obtain the perspective of an interviewee with the profile of a private hospital administrator and an interviewee belonging to an insurance company and to understand in which aspects the common and opposite views could be crossed in relation to the concept of value and in relation to the connections that these actors should establish among themselves, with a view to create value from the perspective of patients.

For the purposes of this study, interviews with patient representatives were not considered. An option based on the definition of agency relationship, considering that the creation of value, in the perspective of a specialty such as radiology (predominantly focused on diagnosis) resides, first, in meeting the needs of the requesting doctors, the ‘agent’, for the benefit of the patients.

The qualitative nature of the study, combined with the scope of the theme on which it focused, may also limit the results. The fact that the selection of participants is relatively small, even if diversified, does not allow the results to be generalised, although these may allow the development of future lines of research.

Regarding the proposed evaluation metrics, they need to be developed, namely with the definition of a rationale for each indicator, the data sources, and calculation formulas. It is considered important that this work is developed soon so that it has potential for application and, if successful, that it be implemented systematically.

Considering the necessary change in behaviours that foster organisational change in order to introduce value-based management into professional life, one should seek to look at the training of professionals as an important tool in enabling human resources, enabling them to an attitude proactive in implementing change mechanisms, with a view to provide care based on value creation.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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