Time-driven activity-based costing in health care: A systematic review of the literature

Evidence-Based Experiences of Using Time-Driven Activity-Based Costing in Telemedicine-Based Health Care Delivery Protocols

Background: In the era of value-based health care, maximizing health outcomes and minimizing costs require different value optimization strategies. To maximize value and ensure control of expenditure, time-driven activity-based costing (TDABC) is widely used in health care organizations. In our study, we examined the impact of telehealth technologies on value creation by using the TDABC approach. Methods: We mapped four pairs of (traditional and telemedicine supported) health care delivery processes in terms of time, resource use, and information flow. Data were collected from four sources: approved protocol descriptions, in-depth interviews with senior clinicians, a financial controlling database of unit costs, and additional comments from controlling experts. Results: We found that technological improvements do not necessarily increase the value of protocols. Of the protocols studied, two telemedicine protocols proved to be more cost-effective (80.37% and 45.29% compared with the originals). However, significant cost overruns were detected in two other telemedicine protocols (902.90% and 161.01%, respectively). An increased value could be detected only when the use of telemedicine technology resulted in greater savings in net human capacity compared with the additional expenditure related to telemedicine technology. Conclusions: We concluded that the use of telemedicine technology leads to modifications in protocols at numerous points, which have a significant impact on cost levels. It is not sufficient to examine only the costs of modified steps, as proposed in the TDABC methodology. Our study also suggests that a refined TDABC method is a potential tool for assessing the complex effects of technological change.

Motion analysis in adult spinal deformity: A time-driven activity-based costing perspective

BACKGROUND

A novel motion analysis (MA) protocol for patients with adult spinal deformity (ASD) was developed within University Hospitals Leuven, aiming for better functional outcomes by improved treatment planning and decision making.

RESEARCH QUESTION

Can insights into the costs of a research-focused MA (RMA) protocol support the transition to a concise clinical MA (CMA) protocol and facilitate its potential adoption as standard clinical care?

METHODS

Time-driven activity-based costing (TD-ABC) was used to quantify the costs directly related to performing the MA protocol. Time durations were derived from observations and interviews and validated using time intervals retrospectively derived from previous motion analyses metadata. Costs were computed based on resource time usage and the per-minute cost of practical capacity. An expert panel then refined the RMA into a CMA protocol by excluding some trials, utilizing cost insights and insights in the potential clinical relevance of trials, including their discriminative abilities, their ability to highlight compensatory mechanisms and their standardization potential. The clinical costs of the CMA were then again calculated using the same methodology.

RESULTS

The average time to perform the RMA was 179.0 minutes and dropped to 130.9 minutes after the expert panel excluded 12 types of motion trials. The total cost of this new CMA was € 220.83. The largest cost component of the CMA was staff costs (68.1 %), followed by the cost of equipment (30.2 %).

SIGNIFICANCE

This study demonstrates how cost insights complement insights on clinical relevance when defining a motion analysis protocol for integration in standard clinical care. Future value- improvements to the protocol should also integrate insights on its impact on treatment outcome.

Value-based evaluation of gestational diabetes mellitus care pathway redesign by using cost and outcome data

BACKGROUND

Gestational diabetes mellitus (GDM) is a common complication of pregnancy. Implementation of Value-Based Healthcare (VBHC) to GDM care is worthwhile as traditional GDM care is fragmented and fails to meet the needs of women with GDM. Value of care can be improved through optimization and redesign of the care pathway and implementation of an outcome-based payment model. This study was conducted to perform a value-based evaluation of GDM care pathway redesign by using cost- and outcome data.

METHODS

This study was designed as a single center, prospective, observational cohort study. In January 2022, GDM care was redesigned by substituting GDM care activities from an Internal Medicine Department (IMD) to an Integrated Maternity Care Organization (IMCO) in the Netherlands. Women diagnosed with GDM in 2021 were assigned to a pre-intervention cohort (N = 264) and those diagnosed in 2022 to a post-intervention cohort (N = 407). The impact of the intervention on value of care for women with GDM was evaluated by comparing clinical outcomes, patient-reported experience measures (GDM Responsiveness questionnaire), and costs (Time-Driven Activity-Based Costing) between the cohorts.

RESULTS

Referrals to the IMD for GDM decreased by 84.8% (pre-intervention: 100%, post-intervention: 15.2%, p <.001), patient-reported experiences significantly improved (Mean responsiveness pre-intervention: 3.46, post-intervention: 3.63, p: 0.00). Initiation of insulin treatment decreased by 46.8% (pre-intervention: 25.0%, post-intervention: 13.3%, p <.001). Maternal- and neonatal clinical outcomes were not different after redesign. Weighted average costs per GDM treatment were 9.7% lower post-intervention (pre-intervention: €168,37, post-intervention: €151,97).

CONCLUSIONS

The redesign of GDM care positively impacted value through decreased referrals and improved patient-reported experiences while clinical outcomes remained constant. By de-fragmenting GDM care, cost savings were realized. This study contributes to the improvement of care delivery, particularly in pregnancy and childbirth, by promoting the adoption of comprehensive, value-based evaluations of redesign initiatives and supports the further uptake of VBHC in maternity care.

Cost of physiotherapy non-attendance at a metropolitan hospital in Australia: A time-driven activity-based costing study

OBJECTIVES

(1) Identify the processes, staff time and labour costs associated with non-attendance at two physiotherapy outpatient clinics using time-driven activity-based costing; (2) estimate labour cost-burden of non-attendance response scenarios.

DESIGN

A six-step time-driven activity-based costing method was used, including scenario analyses.

SETTING

Two tertiary hospital outpatient clinics.

PARTICIPANTS

Clinic non-attendance rates were determined from digital administrative records for participating clinics. Interviews and iterative discussions were conducted with 15 administrative and clinical staff to establish process maps and key parameters.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was health service labour cost associated with clinic non-attendance. Four key work processes were identified and costed (2023, A$).

RESULTS

Clinic non-attendance rates for the 2018-2021 period were 8% (Clinic 1) and 10% (Clinic 2). Complex triaging cases constituted greater costs than simple triaging cases. Projected annual costs of non-attendance were as high as A$114 827 for a single clinic. The most expensive referral and response scenario was internal referral with non-attendance that was converted to a telephone appointment (mean cost of A$113/appointment).

CONCLUSION

Non-attendance rates at participating clinics were at the lower end of values reported in prior literature; however, substantial healthcare resource waste was still evident. Findings highlighted the extent to which non-attendance at scheduled clinic appointments may not only impact patients' welfare through lost treatment opportunity, but also carry substantial opportunity cost from wasted hospital resources that could have been allocated to other referred patients. Establishing the effectiveness and cost-effectiveness of interventions to reduce non-attendance remains a priority.

Time-Driven Activity-Based Cost Analysis to Decrease Financial Burden of Manipulation Under Anesthesia after Total Knee Arthroplasty

BACKGROUND

Despite total knee arthroplasty (TKA) being considered one of the most successful orthopaedic procedures, stiffness may lead to dissatisfaction. Manipulation under anesthesia (MUA) is a first-line treatment option for stiffness after TKA. Since patients who have stiffness following TKA often have higher costs, there is a need to understand the cost to the hospital of an MUA. We sought to use Time-Driven Activity-Based Costing (TDABC) to accurately determine MUA hospital costs.

METHODS

Previously collected financial data of 510 knees in 479 patients who underwent MUA after TKA at a single institution between January 07, 2015, and May 23, 2023, were retrospectively reviewed. Demographics, history of TKA, length of stay, and discharge disposition were included to assess for patient-specific risk factors related to increased cost of MUA. The TDABC costs, including all personnel and supply costs, were calculated and compared to the hospital reimbursement for each patient.

RESULTS

The average total cost of an MUA was 1,749.72 dollars ($). Personnel costs accounted for 71.4% of total costs. Commercial insurance plans were associated with a higher cost of MUA (P = 0.048), but age (P = 0.081), sex (P = 0.18), body mass index (P = 0.11), or American Society of Anesthesiologists score (P = 0.88) were not. Mean hospital reimbursement was $1,909.18, and mean hospital revenue was $159.46.

CONCLUSION

The MUAs have substantial hospital costs, with most expenses coming from preoperative testing and procedural personnel costs. The majority of MUAs occurred within the 90-day TKA global payment period, which is important to consider for hospital reimbursement policies.

Analysis and assessment of biomedical scientists' needs for clinical laboratory: activity-based management as an evaluation methodology

Introduction

Healthcare systems have to protect citizens' health by developing models combining concepts of efficiency, effectiveness and quality of care. The post-Covid-19 pandemic context has highlighted the relevance of efficiently managing and allocating human resources. In this scenario, the analysis and calculation of personnel needs take on strategic importance. The project aims to suggest a methodology to define the needs of Biomedical Scientists. The goal is to create a standard model adaptable to different contexts.

Methods

This project, developed in cooperation with the Italian Society of Clinical Biochemistry and Clinical Molecular Biology, has created a new format following the "Activity Based Management" approach. It is characterized by continuous improvements, based on analysis of processes, broken down into sub-processes and activities. After the phase of format development, a phase of application to different contexts, such as biochemistry and the hematology sectors, followed.

Results

The suggested methodology allows to estimate the number of Full Time Equivalents necessary for the management of the laboratory processes. Furthermore, an objective and analytical data is obtained, because it is based on timely numerical surveys that included productivity and execution times of the different activities.

Discussion

Using the format had a relevant impact on the analysis of the processes, their efficiency, and their possible improvement. This method allowed to evaluate and improve the analytical and "extra-production" activities, often underestimated but having a decisive role in the process. The proposed format can be considered a valid tool for laboratory managers to analyze and evaluating the needs of Biomedical Scientists in the laboratory. Activity Based Management allowed us to obtain precise and objective data and, at the same time, to focus on the main objective of any clinical laboratory: to create value for the patient by supporting diagnosis and treatment of paths through safe and reliable laboratory tests, which depends on a correct allocation of human resources.

Cost Analysis of Intravascular Ultrasound Guidance for Transjugular Intrahepatic Portosystemic Shunt Creation

PURPOSE

To compare costs of intravascular ultrasound (IVUS)-guided transjugular intrahepatic portosystemic shunt (TIPS) creation versus non-IVUS-guided TIPS creation, accounting for differences in procedure time and resource utilization.

MATERIALS AND METHODS

This single-institution retrospective study estimated procedure time and resource utilization from 157 consecutive elective TIPS creation procedures, of which 91 were IVUS-guided and 66 were non-IVUS-guided. Differences in procedure costs were derived using time-driven activity-based costing. The difference in post-TIPS creation length of hospital stay was included in overall episode of care cost estimates.

RESULTS

IVUS-guided TIPS creation was 45.5 minutes faster (P < .001) and required 35.2 mL less contrast medium (P < .001), leading to savings of $325.34 on staffing, $58.21 on medications, and $76.59 on equipment usage. However, requiring $2,100 single-use disposable catheters, IVUS guidance was $1,484.96 more costly per procedure. Following TIPS creation, the mean length of hospital stay was 1.3 days after IVUS-guided procedures versus 2.1 days after non-IVUS-guided procedures (P = .001). With an estimated cost of $2,677 per hospital day, there was an overall savings of $656.64 with IVUS-guided TIPS creation.

CONCLUSIONS

Improved procedural metrics during TIPS creation alone are unlikely to offset the costs of IVUS guidance. However, based on improvements in immediate post-TIPS creation clinical outcomes, which may translate into shorter hospitalization, IVUS guidance is likely to reduce overall costs for the episode of care related to TIPS creation.

Systematic Review of Integration Strategies Across the US Healthcare System: Assessment of Price, Cost, and Quality of Care

BACKGROUND

In the last 30 years, consolidation of healthcare systems in the US has accelerated through mergers and acquisitions. We completed a systematic literature review on integration to determine if its reputation for enhancing the value of healthcare by reducing price as well as cost and spending and improving overall quality of care is justified.

STUDY DESIGN

A systematic review of the literature was completed for articles published in the US from 1990 to 2024. Primary inclusion criteria were horizontal integration (HI, joining 2 or more hospitals) and vertical integration (VI, merging of physicians and hospitals) and reporting on at least 1 measure of value (price, cost and spending, or quality).

RESULTS

Neither HI nor VI has resulted in consistent and significant improvements in price, cost or spending, or quality associated with healthcare delivery. We screened 1,297 articles and identified 37 that met inclusion criteria. Results from any form of integration were mixed. Thirteen of 14 studies (93%) about price reported price increases. Thirteen of 16 studies (81%) about cost and spending showed cost increases or no change. Twenty of 26 studies (77%) about quality showed reductions or no change from integration (HI, VI, or both).

CONCLUSIONS

Our review suggests that evidence is lacking to support the theory that integration is an effective strategy for improving the value of healthcare delivery. This finding represents an opportunity for healthcare leaders, including surgeons, to better define value in their efforts to improve quality while balancing the financial stability of the healthcare industry with a focus on benefiting the patient.

Time and Cost Savings of Virtual Established Plastic Surgery Care Using Time-Driven Activity-Based Costing: Lessons from an Academic Clinic

BACKGROUND

Various surgical subspecialties, including plastic surgery, have begun to embrace virtual clinic visits, especially since the COVID-19 pandemic. However, the impact of video visits on time optimization and cost incurred in outpatient plastic surgery clinics has not been studied.

METHODS

Using the time-driven activity-based costing method, the authors examined the time and cost of in-person and virtual visits at an academic plastic surgery clinic. The authors formulated process maps for 4 visit types: physician-led in-person, physician assistant-led in-person, physician-led virtual, and physician assistant-led virtual. The time associated with each visit type was generated by direct observation. The cost associated with each visit type was calculated from representative salary information and estimation of resource costs.

RESULTS

On average, virtual visits took less time (25.3 minutes for physician-led visits and 24.4 minutes for physician assistant-led visits) compared with in-person visits (48.2 minutes for physician-led and 41.1 minutes for physician assistant-led visits) ( P < 0.001). Virtual visits were also less expensive, at $52.80 for physician-led visits and $20.70 for physician assistant-led visits, compared with in-person visits ($261.13 for physician-led and $236.00 for physician assistant-led visits). Nonprovider activities made up the majority of traditional in-person visits (75.7% of the visit for physician-led and 77.6% for physician assistant-led visits), which contributed to higher overall cost of in-person visits for both groups of providers.

CONCLUSIONS

Virtual clinic visits can produce time and cost savings without reducing the amount of face-to-face time between providers and patients. Virtual visits can be a useful adjunct to traditional in-person visits.

Economic Argument for Innovative Design From Valuing Patient-Centered Stroke Rehabilitation

Purpose: This study examines the economic benefits of innovative design in a hospital ward with the capital and operational costs and societal and government benefits. Background: An economic view of health care delivery options considers both the costs and benefits of an intervention for the economy, funders, and patients. Previous studies have focused on the financial costs of capital as an asset class for hospital development. Methods: Four hypothetical stroke rehabilitation units were designed within a larger Living Labs program (the NOVELL project). A standard stroke rehabilitation hospital ward design was compared to three alternative designs. The alternative designs expanded areas for therapy, social engagement, communal activities, and staff wellbeing, included activated corridors and enabled access to outdoor and recreational areas based on clinical evidence and expert advice. Results: The alternative designs are predicted to achieve A$3.3 million in savings annually for rehabilitation ward operational costs (a saving of 26%). Economy-wide benefits from the alternative designs are estimated to be A$12 million plus savings to government of between A$3.93 million and A$5.4 million per ward per annum. Conclusions: Adoption of innovation in design, clinical practice and evidence identification has the capacity to improve clinical effectiveness and patient outcomes. Economy wide benefits and cost improvements for health funders from the adoption of innovative design have been identified through micro- and macro-economic evaluation.

Procedure Type and Preoperative Patient-Reported Outcome Metrics Predict Variation in the Value of Hip Arthroscopy for Femoroacetabular Impingement

Purpose

To characterize variation in the value of hip arthroscopy for femoroacetabular impingement and explore associations between value and patient-specific demographic characteristics, comorbidities, preoperative patient-reported outcome measures (PROMs), and intraoperative variables.

Methods

We included all patients aged 18 years or older who underwent primary arthroscopic acetabular labral repair or debridement between 2015 and 2020 with minimum 2-year follow-up. The exclusion criteria were hip dysplasia, advanced hip osteoarthritis (TÖnnis grade >1), or unreconcilable documenting errors. Value was calculated by dividing 2-year postoperative International Hip Outcome Tool 33 scores by time-driven activity-based costs. To protect the confidentiality of internal hospital cost data, the study average for value was normalized to 100. Multivariable linear mixed-effects models were used to identify factors underlying variation in value.

Results

This study included 161 patients. There were 76 women (47.2%) and 85 men, with a mean age of 36.0 years (standard deviation [SD], 10.9 years) and mean body mass index (BMI) of 25.8 (SD, 4.3). Most patients were white (92.5%), were not Hispanic (93.8%), and were commercially insured (92.5%). Preoperatively, 57.1% of hips were classified as Tönnis grade 1 (57.1%) whereas the remainder were grade 0. The normalized value of hip arthroscopy ranged from 25.4 to 216.4 (mean ± SD, 100 ± 38.4), with a 3.0-fold variation between patients in the 10th and 90th percentiles. Higher value was significantly associated with Tönnis grade 0 (12.2-point increase, P = .025), no prior contralateral hip arthroscopy (17.3-point increase, P = .039), higher preoperative PROMs (0.52-point increase per 1-unit increase, P < .001), and no bone marrow aspirate concentrate or microfracture (33.8-point increase, P < .001). Value was also significantly associated with osteoplasty type and labral treatment technique (P < .05 for both). In contrast, operative year, age, sex, BMI, race, ethnicity, Outerbridge grade, and American Society of Anesthesiologists score were not independently associated with value. A model incorporating these factors as fixed effects and the surgery center as a random effect explained 42.3% of the observed variation in value. Sensitivity analyses revealed that value drivers may vary slightly across PROMs.

Conclusions

This study revealed wide variation in the value of hip arthroscopy that was most strongly explained by osteoplasty type, labral management technique, and preoperative PROMs. In contrast, patient demographic characteristics such as age, sex, and BMI contributed minimal independent variability.

Level of Evidence

Level IV, economic and decision analysis.

The Application of Time-Driven Activity-Based Costing in Oncology: A Systematic Review

OBJECTIVES

Time-driven activity-based costing (TD-ABC) holds promise to control costs and enhance value in oncology, but the current landscape of its applications remains uncharted. This study aimed to: (1) document the applications of TD-ABC in oncology and unveil its strengths and limitations, (2) assess the extent to which studies adhere to Kaplan and Porter's method, and (3) appraise study quality.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. To be eligible for inclusion, studies had to provide an empirical application of TD-ABC within oncology. Structured data extraction included key characteristics such as cancer type, perspective, and analysis setting. Quality was assessed using the TD-ABC Healthcare Consortium Consensus Statement checklist.

RESULTS

A total of 59 studies met the inclusion criteria, two-thirds of which were published within the last 5 years. Most studies were conducted in high-income countries and analyzed common cancer types. The provider's perspective (85%) dominated, and studies typically relied on single-institution data (76%). No study assessed costs over a complete cycle of care and most focused on the costs of radiotherapy (56%) or surgery (20%). Articles generally did not adhere to the seven-step method, and average study quality was low (52%), particularly because of inadequate content in methods and results.

CONCLUSIONS

Oncology has emerged as a productive field for TD-ABC analyses, showcasing the effectiveness of TD-ABC in capturing the costs of healthcare processes in which medical devices are integral to care delivery. Nevertheless, concerns arise because of the low overall study quality and the lack of a consistent methodology.

Time-Driven Activity-Based Costing (TDABC) in Otolaryngology: A Scoping Review

OBJECTIVE

Accurately measuring the cost of a clinical process is critical to identifying ways to increase the value of a healthcare process. The objective of this study was to review time-driven activity-based costing (TDABC) in otolaryngology and to illustrate areas where value may be increased.

DATA SOURCES

PubMed, Web of Science, Embase, CINAHL Complete, and Business Source Complete from database inception to August 2024.

REVIEW METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews guidelines, peer-reviewed full-length articles analyzing an otolaryngology care process with TDABC were included. Data collected included study characteristics, objectives, method of process mapping and costing, key study findings, subspecialty focus, and limitations.

RESULTS

Nine were included in the final review. Subspecialties consisted of pediatric otolaryngology (N = 4), head and neck surgery (N = 3), and rhinology (N = 2). The primary study aims were to reduce waste (N = 4), quantify cost (N = 4), evaluate the impact of a new intervention (N = 3), and identify quality improvement opportunities (N = 3). Most articles used input from involved personnel and/or direct observation to create process maps and reviewed institutional and/or public records to obtain cost information. TDABC was primarily used to study outpatient clinics or surgeries. Common limitations included limited generalizability, susceptibility to biases, and incomplete information.

CONCLUSION

This scoping review demonstrated that TDABC can be a powerful and versatile tool for costing and identifying opportunities to increase the value of a care process in otolaryngology. Future costing studies can use TDABC to analyze care pathways in understudied otolaryngology subspecialties.

Evaluation of reporting in time-driven activity-based costing studies on cardiovascular diseases: a scoping review

Aim: This scoping review evaluates the application of the time-driven activity-based costing (TDABC) methodology in cardiovascular disease (CVD) studies. Materials & methods: The evaluation was conducted using the 32-item TDABC Healthcare Consortium Consensus Statement Checklist. A systematic search was performed in Medline, Embase and Scopus in September 2023, including only full-text, peer-reviewed studies reporting the application of TDABC in CVD research. Results: Twenty studies were included in the review. The positive response rate for individual studies ranged from 31 to 81%. The most frequently addressed checklist item was the clear definition of study objectives, while presenting costs per patient included in the analysis was the least reported item. Although 70% of the studies achieved a positive response rate above 50%, adherence to the TDABC checklist remains inconsistent. Conclusion: There is significant room for improvement in the reporting of TDABC methodology in CVD studies. Providing a more comprehensive and standardized description of the methodology would enhance the utility, reproducibility and accuracy of the information generated, supporting the development of evidence-based health policies and improving accountability in healthcare cost assessments.

Supporting managerial decisions: a comparison of new robotic platforms through time-driven activity-based costing within a value-based healthcare framework

BACKGROUND

The advent of novel robotic platforms requires that managers base their decisions on the value these platforms generate. This study showcases how micro-costing methodologies can assist managers in the decision-making process regarding the implementation of new robotic platforms within the value-based healthcare (VBHC) framework.

METHODS

We applied time-driven activity-based costing (TDABC) to evaluate cost disparities between the da Vinci and Hugo robotic systems for robot-assisted radical prostatectomy (RARP). Data were collected from consecutively enrolled patients with organ-confined prostate cancer. Basic cost information was gathered from Azienda Universitaria Integrata di Verona's finance and pharmacy departments. We conducted cost and sensitivity analyses to evaluate the most cost-sensitive parameters.

RESULTS

The da Vinci system incurred higher total costs for RARP than the Hugo system (€4,97.21 vs. € 3,511.73, p-value < 0.001) However, excluding surgical kit costs, the da Vinci platform proved less expensive (€1,481.18 vs. €1,926.18, p-value < 0.001). Sensitivity analyses identified surgical kit costs as the most influential parameter, followed by surgical duration and platform costs.

CONCLUSIONS

This study highlights the importance of micro-costing practices in supporting managerial decisions within a VBHC framework. When clinical outcomes are equivalent, the value of robotic platforms is related to cost savings. By using TDABC and sensitivity analyses, managers can pinpoint critical activities and parameters to optimize the effective adoption of new platforms.

Performance evaluation of the introduction of full sample traceability system within the specimen collection process

OBJECTIVES

To evaluate the efficacy, safety and efficiency performances related to the introduction of innovative traceability platforms and integrated blood collection systems, for the improvement of a total testing process, thus also assessing the economic and organizational sustainability of these innovative technologies.

METHODS

A mixed-method approach was utilized. A key-performance indicators dashboard was created based on a narrative literature review and expert consensus and was assessed through a real-life data collection from the University Hospital of Padova, Italy, comparing three scenarios over time (2013, 2016, 2019) with varying levels of technological integration. The economic and organizational sustainability was determined considering all the activities performed from the tube check-in to the validation of the results, with the integration of the management of the prevalent errors occurred during the process.

RESULTS

The introduction of integrated venous blood collection and full sample traceability systems resulted in significant improvements in laboratory performance. Errors in samples collected in inappropriate tubes decreased by 42 %, mislabelled samples by 47 %, and samples with irregularities by 100 %. Economic analysis revealed a cost saving of 12.7 % per tube, equating to a total saving of 447,263.80 € over a 12-month period. Organizational efficiency improved with a reduction of 13,061.95 h in time spent on sample management, allowing for increased laboratory capacity and throughput.

CONCLUSIONS

Results revealed the strategic relevance of introducing integrated venous blood collection and full sample traceability systems, within the Laboratory setting, with a real-life demonstration of TLA economic and organizational sustainability, generating an overall improvement of the process efficiency.

A Bootstrap Method to Estimate Cost of Behavioral Intervention Implementation: A Proof of Concept

OBJECTIVE

To develop a bootstrapping method to augment time-driven activity-based costing (TDABC) analysis intended to allow more realistic cost estimates.

DATA SOURCES

Secondary data from a multisite clinical trial conducted from 2016 to 2018 on an ostomy self-management telehealth intervention for cancer survivors.

STUDY DESIGN

The intervention cost was newly estimated by incorporating expected patient participation rates calculated via bootstrapping. This cost was compared against the cost estimate obtained via traditional TDABC.

DATA COLLECTION

Study personnel self-reported the time spent on each activity associated with the intervention. We also utilized patient participation data collected from the trial.

PRINCIPAL FINDINGS

The total cost of the telehealth intervention estimated via the bootstrapping method was $210,052.62 (95% CI: 208,652.13, 211,402.51), with an average cost per participant of $1981.63 (95% CI: 1968.42, 1994.36). Traditional TDABC analysis yielded $186,363 or $1758 per participant. Further adjusting assumptions about the cost of the postintervention monitoring phase, our approach yielded an alternative estimate of $176,362.56 (95% CI: 174,962.07, 177,712.45) and an average cost per participant of $1663.80 (95% CI: 1650.59, 1676.53) suggesting both methods yielded similar bottom-line results.

CONCLUSIONS

Incorporating bootstrapping into traditional TDABC methodology is feasible and is likely to capture variance in clinical trial data.

Time-driven cost analysis of pediatric liver biopsy completed in pediatric sedation clinic and operating room

BACKGROUND

Pediatric ultrasound (US)-guided percutaneous liver biopsy is a commonly performed procedure in children, and may be performed in a variety of clinical settings. However, there is little research on the relative costs associated with different sedation methods and locations.

OBJECTIVE

This study uses time-driven activity-based costing (TDABC) to identify relevant costs associated with different biopsy sedation techniques and locations to help inform providers and patients as well as guide value-conscious care. This study analyzes the direct costs associated with pediatric liver biopsy performed in an OR versus a dedicated pediatric sedation clinic.

MATERIALS AND METHODS

A single-center retrospective review including data from consecutive procedures all completed by one board-certified interventional radiology physician between June 2021 and April 2024 was performed. Exclusion criteria included procedures with lack of timestamps (N = 3), and multiple procedures being completed causing a deviation from the standard pathway process (N = 19). Direct costs were calculated using cost capacity rates (CCR) and TDABC methodology. Propensity score matching between procedures performed in a sedation clinic versus an operating room (OR) was performed adjusting for age, gender, American Society of Anesthesiologists (ASA) status, and inpatient status, and subsequent matches were analyzed via paired t-test in SPSS.

RESULTS

A total of 111 procedures performed in the OR (N = 71) or sedation clinic (N = 40) were found and considered for analysis (N = 55 male, N = 56 female; mean age = 9.13, SD = 6.69 years). A technical success rate of 100% and a complication frequency of 5% (N = 3, mean = 13.67, SD = 2.05, all grade 1) were observed. Complication frequency was not statistically significant between the sedation clinic (N = 1) and OR (N = 2) groups (P = 0.28). After propensity matching, N = 58 matched procedures (OR, N = 29; sedation clinic, N = 29) were included. Pre-procedure times in the sedation clinic were shorter in duration (62.11 ± 42.25) than in the OR (111.96 ± 62.11, P < 0.001). Total procedure times were also shorter in duration in the sedation clinic (14.07 ± 4.99) than in the OR (21.76 ± 18.22, P = 0.03). In addition, procedures completed in the OR utilized additional anesthesia staff for an average of 72 min, contributing to overall cost. The average total included costs for matched liver biopsy procedures were $1,089.51 ± 384.34 in the sedation clinic and $2,801.36 ± 1,201.52 in the OR (P < 0.001).

CONCLUSIONS

Liver biopsies completed in the sedation clinic were associated with significantly lower direct costs and were not associated with higher complication rates. These findings provide evidence for promoting pediatric sedation clinics as a safe and cost-effective location to perform liver biopsies in appropriate patients.

Design organization and clinical processes around patient characteristics: Evidence from a multiple case study of Hemophilia

Background: There is growing evidence of the relevance of designing organization of care around patient characteristics; this is especially true in the case of complex chronic diseases.Purpose: The goal of the paper - that focuses on the analysis of the clinical condition hemophilia in three different centers - is to address two different research questions:1. How can we define, within the same clinical condition, different patient profiles homogeneous in terms of intensity of service required (e.g. number of visits or diagnostics)? 2. What are the conditions to re-organize care around these patient profiles in a multidisciplinary and coordinated manner?Research design: The authors have used a multiple case study approach combining both qualitative and quantitative methodologies; in particularly the semi-structured interviews and the direct observation were aimed to map the process in order to come up with an estimate of the cost of the full cycle of care.Study sample: The research methodology has been applied consistently in three different centers. The selection of the structures has been based on two main different criteria: (i) high standards regarding both organizational and clinical aspects and (ii) willingness from management, nurses and physicians to provide data.Results: The study clearly shows that different patient profiles - within the same clinical condition - trigger a different set of diagnostic and therapeutic activities. It is, thus, important considering patient characteristics in the development and implementation of clinical pathways and this will imply relevant differences in terms of organizational and economic impact.Conclusions: These process-based analyses are very much critical especially if we want to move to a bundled and integrated payment system but, as shown by this study itself, require a lot of time and efforts since our healthcare information systems are still fragmented and vertically designed.

Cost-effectiveness of AI for pediatric diabetic eye exams from a health system perspective

Autonomous artificial intelligence (AI) for pediatric diabetic retinal disease (DRD) screening has demonstrated safety, effectiveness, and the potential to enhance health equity and clinician productivity. We examined the cost-effectiveness of an autonomous AI strategy versus a traditional eye care provider (ECP) strategy during the initial year of implementation from a health system perspective. The incremental cost-effectiveness ratio (ICER) was the main outcome measure. Compared to the ECP strategy, the base-case analysis shows that the AI strategy results in an additional cost of $242 per patient screened to a cost saving of $140 per patient screened, depending on health system size and patient volume. Notably, the AI screening strategy breaks even and demonstrates cost savings when a pediatric endocrine site screens 241 or more patients annually. Autonomous AI-based screening consistently results in more patients screened with greater cost savings in most health system scenarios.

Scoping Review: Anesthesiologist Involvement in Alternative Payment Models, Value Measurement, and Nonclinical Capabilities for Success in the United States of America

The US healthcare sector is undergoing significant payment reforms, leading to the emergence of Alternative Payment Models (APMs) aimed at improving clinical outcomes and patient experiences while reducing costs. This scoping review provides an overview of the involvement of anesthesiologists in APMs as found in published literature. It specifically aims to categorize and understand the breadth and depth of their participation, revolving around 3 main axes or "Aims": (1) shaping APMs through design and implementation, (2) gauging the value and quality of care provided by anesthesiologists within these models, and (3) enhancing nonclinical abilities of anesthesiologists for promoting more value in care. To map out the existing literature, a comprehensive search of relevant electronic databases was conducted, yielding a total of 2173 articles, of which 24 met the inclusion criteria, comprising 21 prospective or retrospective cohort studies, 2 surveys, and 1 case-control cohort study. Eleven publications (45%) discussed value-based, bundled, or episode-based payments, whereas the rest discussed non-payment-based models, such as Enhanced Recovery After Surgery (7 articles, 29%), Perioperative Surgical Home (4 articles, 17%), or other models (3 articles, 13%).The review identified key themes related to each aim. The most prominent themes for aim 1 included protocol standardization (16 articles, 67%), design and implementation leadership (8 articles, 33%), multidisciplinary collaboration (7 articles, 29%), and role expansion (5 articles, 21%). For aim 2, the common themes were Process-Based & Patient-Centric Metrics (1 article, 4%), Shared Accountability (3 articles, 13%), and Time-Driven Activity-Based Costing (TDABC) (3 articles, 13%). Furthermore, we identified a wide range of quality metrics, spanning 8 domains that were used in these studies to evaluate anesthesiologists' performance. For aim 3, the main extracted themes included Education on Healthcare Transformation and Policies (3 articles, 13%), Exploring Collaborative Leadership Skills (5 articles, 21%), and Embracing Advanced Analytics and Data Transparency (4 articles, 17%).Findings revealed the pivotal role of anesthesiologists in the design, implementation, and refinement of these emerging delivery and payment models. Our results highlight that while payment models are shifting toward value, patient-centered metrics have yet to be widely accepted for use in measuring quality and affecting payment for anesthesiologists. Gaps remain in understanding how anesthesiologists assess their direct impact and strategies for enhancing the sustainability of anesthesia practices. This review underscores the need for future research contributing to the successful adaptation of clinical practices in this new era of healthcare delivery.

Patient-level cost analysis of subfertility pathways in the Dutch healthcare system

BACKGROUND

Health economic evaluations require cost data as a key input, and reimbursement policies and systems should incentivize valuable care. Subfertility is a growing global phenomenon, and Dutch per-treatment DRGs alone do not support value-based decision-making because they don't reflect patient-level variation or the impact of technologies on costs across entire patient pathways.

METHODS

We present a real-world micro-costing analysis of subfertility patient pathways (n = 4.190) using time-driven activity-based costing (TDABC) and process mining in the Dutch healthcare system, and built a scalable and granular costing model.

RESULTS

We find that pathways (13.203 treatments, 4.190 patients, 10 years) from referral to pregnancy and birth vary greatly in costs (mean €6.329, maximum €36.976) and duration (mean 25,5 months, maximum 8,59 years), with structural variation within treatments (and DRGs) of up to 65%. Patient-level variation is highest in laboratory phases, and causally related to patients' cycle volume, type, and treatment methods. Large IVF or IVF-ICSI cycles are most common, and most valuable to patients and the healthcare system, but exceed their DRGs significantly (33%). We provide recommendations that reduce costs across patient pathways by €1.3 m in the Netherlands, to support value-based personalized care strategies. These findings are relevant to clinics following European protocols.

CONCLUSIONS

Fertility treatments like IVF feature significant cost variation due to the personalization of treatments, and rapidly evolving laboratory technologies. Incorporating cost granularity at the patient and treatment level (cycle volume, type, method) is critical for decision-making, economic analyses, and policy as both subfertility rates and treatment demand are rising.

Itemized point cost method in human resource cost accounting in medical service projects

BACKGROUND

The cost accounting of medical service projects forms the basis for disease cost accounting and DRG (Diagnosis-Related Groups) cost accounting. Among the various costs involved, human resources represent a significant portion and are highly complex, making their accurate accounting a critical and challenging aspect of cost accounting for medical service projects.

METHODS

This paper introduces the itemized point cost (IPC) method, a novel cost accounting approach based on the RBRVS (Resource-Based Relative Value Scale) theory. It outlines the core concepts of "points" and "process steps" within the IPC framework and details its application in human cost accounting. An example of impacted tooth extraction in the stomatology department of Hospital A is used to illustrate the IPC method's implementation process.

FINDINGS

A comparative analysis with activity-based costing and time-estimation costing methods shows that the IPC method is concise, practical, and operable. It is also aligned with the principles of cost-effectiveness.

CONCLUSIONS

The paper proposes strategies to promote the IPC method, including leveraging information technology, enhancing top-level design, and standardizing processes, to improve its adoption and effectiveness in medical cost accounting.

Costs of stereotactic ablative radiotherapy compared to conventional radiotherapy in the treatment of non-small cell lung cancer - a micro-costing study using Time-Driven Activity Based Costing (TDABC)

BACKGROUND

Lung cancer is one of the leading causes of morbidity and mortality in Brazil. Radiotherapy is an important therapeutic option, but the techniques used remain subjects of discussion. In this study, we compared the costs of conventional radiotherapy (CRT) and stereotactic ablative radiotherapy (SABR) in the treatment of early-stage non-small cell lung cancer (NSCLC).

METHODS

This cost analysis study adopted a micro-costing approach, following the TDABC (Time-Driven Activity-Based Costing) methodology. The study was conducted at a specialized public cancer hospital in São Paulo, Brazil. The analysis involved seven macro-processes related to radiotherapy treatment, identifying resources, costs, and time estimates for each step.

RESULTS

The cost analysis revealed that SABR treatment for NSCLC is significantly cheaper than CRT. The direct costs of SABR treatment ranged from $2,777.25 to $3,797.49, while CRT ranged from $5,562.65 to $6,052.94. The cost related to CRT treatment constituted more than 80% of the total costs, whereas in SABR, it ranges from 59 to 68%. Planning represented 9% to 10% of the cost in CRT, increasing to 22% to 30% in SABR.

CONCLUSIONS

The results highlight that SABR treatment is a cheaper option for early-stage NSCLC patients when compared to CRT. Furthermore, the increased time required for CRT treatment limits the number of patients who can be treated. These results may influence healthcare policies and the financing of the healthcare system, directly benefiting patients and promoting the efficient allocation of resources.

Assessing the long-term care (LTC) service needs of older adults based on time-driven activity-based costing (TDABC)-a cross-sectional survey in central China

BACKGROUND

The global population's aging has led to an increasing demand for long-term care (LTC), especially in developing countries like China. Comprehensive assessment of LTC service demands by including the time and cost analysis is crucial to inform the planning and financing of LTC resources, yet such research is lacking in China. Our research team has developed a quantitative index system of the medical and nursing services needs of older adults (QISMNSNE) based on the framework of Time-Driven Activity-Based Costing (TDABC), providing a valuable tool for measuring LTC service needs. This study aimed to assess the LTC service needs of older adults in China and the factors associated with such needs.

METHODS

A cross-sectional study was conducted in Changsha City, Hunan Province, China, from June 2021 to December 2022. A stratified multistage cluster sampling method was used to recruit 1,270 older adults from five nursing homes and three communities/streets in three regions of Changsha City. The LTC service needs were assessed by calculating the service time required from caregivers, nurses, and doctors and the total service time (min/d) using the QISMNSNE. Participants' disability, activities of daily living (ADLs), mental status and social involvement (MSSI), and sensory and communication (SC) were assessed using standard scales. Generalized linear regression models were used to analyze factors associated with LTC service needs.

RESULTS

The participants had an average age of 76.41 ± 8.38 years, with 43.7% being female. The median service time required from caregivers, nurses, and doctors was 53.34 min/d, 3.66 min/d, and 0.33 min/d, respectively, and the total service time was 83.31 min/d. The generalized linear regression model identified the following factors that were associated with higher total service time: aged 75-84 years, living in nursing homes, income over 5000 per month, ADLs, MSSI (9 ~ 40), SC, and having 3 ~ 4 kinds of geriatric comorbidity (P < 0.05).

CONCLUSIONS

Older adults have a high need for LTC services, especially those provided by caregivers, indicating an urgent need to expand and improve LTC systems. The LTC service time needed is associated with multilevel factors encompassing socio-demographic, functional, and psychological aspects. This study offers preliminary insights into the needs, demands, and costs of LTC services for older adults and provides essential guidance for future planning and financing of LTC resources.

Time-Driven, Activity-Based Cost Analysis of Pars Plana Vitrectomy in Rhegmatogenous Retinal Detachment at a Large Academic Center

Purpose: To perform a time-driven, activity-based cost analysis of retinal detachment (RD) surgery and compare it with reimbursement rates. Methods: This economic analysis at a single academic institution used time-driven, activity-based costing methodology to determine the cost of rhegmatogenous RD repair with primary pars plana vitrectomy. A process flow map was created to highlight each surgical case's operative episodes, including clinical follow-ups. Time logs were obtained from the electronic health record for each operative phase and clinical follow-up. The overhead and anesthesia costs were collected from the institution's cost accounting system. The direct material and personnel costs were obtained from internal financial data. Results: Seventy-six cases that met the inclusion criteria were included in the cost analysis study. The time-driven, activity-based cost of RD was $6247.17, and the reimbursement was $5442.91. Therefore, each procedure had a net negative loss of $804.26. To break even, the average operation time would need to be reduced from the determined average of 90.49 minutes to 64.90 minutes. Conclusions: This study found that Medicare underestimates the true cost of RD surgery. Changes in referral patterns may be motivated by reimbursement rates lower than the cost of the procedure, which could ultimately affect patient access to care.

Understanding Provider Cost of MRI for Appendicitis in Children: A Time-Driven Activity-Based Costing Analysis

OBJECTIVE

To use time driven activity-based costing to characterize the provider cost of rapid MRI for appendicitis compared to other MRI examinations billed with the same Current Procedural Terminology codes commonly used for MRI appendicitis examinations.

METHODS

Rapid MRI appendicitis examination was compared with MRI pelvis without intravenous contrast, MRI abdomen/pelvis without intravenous contrast, and MRI abdomen/pelvis with intravenous contrast. Process maps for each examination were created through direct shadowing of patient procedures (n = 20) and feedback from relevant health care professionals. Additional data were collected from the electronic medical record for 327 MRI examinations. Practical capacity cost rates were calculated for personnel, equipment, and facilities. The cost of each step was calculated by multiplying the capacity cost rate with the mean duration of each step. Stepwise costs were summed to generate a total cost for each MRI examination.

RESULTS

The mean duration and costs for MRI examination type were as follows: MRI appendicitis: 11 (range: 6-25) min, $20.03 (7.80-44.24); MRI pelvis without intravenous contrast: 55 (29-205) min, $105.99 (64.18-285.13); MRI abdomen/pelvis without intravenous contrast: 65 (26-173) min, $144.83 (61.16-196.50); MRI abdomen/pelvis with intravenous contrast: 128 (39-303) min, $236.99 (102.62-556.54).

CONCLUSION

The estimated cost of providing a rapid appendicitis MRI examination is significantly less than other MRI examinations billed using Current Procedural Terminology codes typically used for appendicitis MRI. Mechanisms to appropriately bill rapid MRI examinations with limited sequences are needed to improve cost efficiency for the patient and to enable wider use of limited MRI examinations in the pediatric population.

Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing

STUDY OBJECTIVE

Boarding admitted patients in emergency departments (EDs) is a national crisis that is worsening despite potential financial disadvantages. The objective of this study was to assess costs associated with boarding.

METHODS

We conducted a prospective, observational investigation of patients admitted through an ED for management of acute stroke at a large, urban, academic, comprehensive stroke center hospital. We employed time-driven activity-based costing methodology to estimate cost for patient care activities during admission and aggregated results to estimate the total cost of boarding versus inpatient care. Primary outcomes were total daily costs per patient for medical-surgical (med/surg) boarding, med/surg inpatient care, ICU boarding, and ICU inpatient care.

RESULTS

The total daily cost per patient with acute stroke was US$1856, for med/surg boarding versus US$993 for med/surg inpatient care and US$2267, for ICU boarding versus US$2165, for ICU inpatient care. These differences were even greater when accounting for costs associated with traveler nurses. ED nurses spent 293 min/d (mean) caring for each med/surg boarder; inpatient nurses spent 313 min/d for each med/surg inpatient. ED nurses spent 419 min/d caring for each ICU boarder; inpatient nurses spent 787 min/d for each ICU inpatient. Neurology attendings and residents spent 25 and 52 min/d caring for each med/surg boarder versus 62 minutes and 90 minutes for each med/surg inpatient, respectively.

CONCLUSION

Using advanced cost-accounting methods, our investigation provides novel evidence that boarding of admitted patients is financially costly, adding greater urgency for elimination of this practice.

Value in acute care surgery, part 3: Defining value in acute surgical care-It depends on the perspective

ABSTRACT

The prior articles in this series have focused on measuring cost and quality in acute care surgery. This third article in the series explains the current ways of defining value in acute care surgery, based on different stakeholders in the health care system-the patient, the health care organization, the payer and society. The heterogenous valuations of the different stakeholders require that the framework for determining high-value care in acute care surgery incorporates all viewpoints.

LEVEL OF EVIDENCE

Expert Opinion; Level V.

Assessing cost and cost savings of teleconsultation in long-term care facilities: a time-driven activity-based costing analysis within a value-based healthcare framework

BACKGROUND

Quebec's healthcare system faces significant challenges due to labour shortage, particularly in long-term care facilities (CHSLDs). The aging population and increasing demand for services compound this issue. Teleconsultation presents a promising solution to mitigate labour shortage, especially in small CHSLDs outside urban centers. This study aims to evaluate the cost and cost savings associated with teleconsultation in CHSLDs, utilizing the Time-Driven Activity-Based Costing (TDABC) model within the framework of Value-Based Healthcare (VBHC).

METHODS

This study focuses on CHSLDs with fewer than 50 beds in remote regions of Quebec, where teleconsultation for nighttime nursing care was implemented. Time and cost data were collected from three CHSLDs over varying periods. The TDABC model, aligned with VBHC principles, was applied through five steps, including process mapping, estimating activity times, calculating resource costs, and determining total costs.

RESULTS

Teleconsultation increased the cost per minute for nursing care compared to traditional care, attributed to additional tasks during remote consultations and potential technical challenges. However, cost savings were realized due to reduced need for onsite nursing staff during non-eventful nights. Overall, substantial savings were observed over the project duration, aligning with VBHC's focus on delivering high-value healthcare.

CONCLUSIONS

This study contributes both theoretically and practically by demonstrating the application of TDABC within the VBHC framework in CHSLDs. The findings support the cost savings from the use of teleconsultation in small CHSLDs. Further research should explore the long-term sustainability and scalability of teleconsultation across different CHSLD sizes and settings within the VBHC context to ensure high-value healthcare delivery.

Direct Variable Cost Comparison of Endoscopic Versus Open Carpal Tunnel Release: A Time-Driven Activity-Based Costing Analysis

INTRODUCTION

To improve the delivery of value-based health care, a deeper understanding of the cost drivers in hand surgery is warranted. Time-driven activity-based costing (TDABC) offers a more accurate estimation of resource utilization compared with top-down accounting methods. This study used TDABC to compare the facility costs of open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR).

METHODS

We identified 845 consecutive, unilateral carpal tunnel release (516 open, 329 endoscopic) surgeries performed at an orthopaedic specialty hospital between 2015 and 2021. Itemized facility costs were calculated using a TDABC algorithm. Patient demographics, comorbidities, surgical characteristics, and itemized costs were compared between OCTR and ECTR. Multivariate regression was used to determine the independent effect of endoscopic surgery on true facility costs.

RESULTS

Total facility costs were $352 higher in ECTR compared with OCTR ($882 versus $530). ECTR cases had higher personnel costs ($499 versus $420), likely because of longer surgical time (15 versus 11 minutes) and total operating room time (35 versus 27 minutes). ECTR cases also had higher supply costs ($383 versus $110). Controlling for demographics and comorbidities, ECTR was associated with an increase in personnel costs of $35.74 (95% CI, $26.32 to $45.15), supply costs of $230.28 (95% CI, $205.17 to $255.39), and total facility costs of $265.99 (95% CI, $237.01 to $294.97) per case.

DISCUSSION

Using TDABC, ECTR was 66% more costly to the facility compared with OCTR. To reduce the costs related to endoscopic surgery, efforts to decrease surgical time and negotiate lower ECTR-specific supply costs are warranted.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level II.

Variation in the Cost of Hip Arthroscopy for Labral Pathological Conditions: A Time-Driven Activity-Based Costing Analysis

BACKGROUND

Despite growing interest in delivering high-value orthopaedic care, the costs associated with hip arthroscopy remain poorly understood. By employing time-driven activity-based costing (TDABC), we aimed to characterize the cost composition of hip arthroscopy for labral pathological conditions and to identify factors that drive variation in cost.

METHODS

Using TDABC, we measured the costs of 890 outpatient hip arthroscopy procedures for labral pathological conditions across 5 surgeons at 4 surgery centers from 2015 to 2022. All patients were ≥18 years old and were treated by surgeons who each performed ≥20 surgeries during the study period. Costs were normalized to protect the confidentiality of internal hospital cost data. Descriptive analyses and multivariable linear regression were performed to identify factors underlying cost variation.

RESULTS

The study sample consisted of 515 women (57.9%) and 375 men (42.1%), with a mean age (and standard deviation) of 37.1 ± 12.7 years. Most of the procedures were performed in patients who were White (90.6%) or not Hispanic (93.4%). The normalized total cost of hip arthroscopy per procedure ranged from 43.4 to 203.7 (mean, 100 ± 24.2). Of the 3 phases of the care cycle, the intraoperative phase was identified as the largest generator of cost (>90%). On average, supply costs accounted for 48.8% of total costs, whereas labor costs accounted for 51.2%. A 2.5-fold variation between the 10th and 90th percentiles for total cost was attributed to supplies, which was greater than the 1.8-fold variation attributed to labor. Variation in total costs was most effectively explained by the labral management method (partial R 2 = 0.332), operating surgeon (partial R 2 = 0.326), osteoplasty type (partial R 2 = 0.087), and surgery center (partial R 2 = 0.086). Male gender (p < 0.001) and younger age (p = 0.032) were also associated with significantly increased costs. Finally, data trends revealed a shift toward labral preservation techniques over debridement during the study period (with the rate of such techniques increasing from 77.8% to 93.2%; P trend = 0.0039) and a strong correlation between later operative year and increased supply costs, labor costs, and operative time (p < 0.001 for each).

CONCLUSIONS

By applying TDABC to outpatient hip arthroscopy, we identified wide patient-to-patient cost variation that was most effectively explained by the method of labral management, the operating surgeon, the osteoplasty type, and the surgery center. Given current procedural coding trends, declining reimbursements, and rising health-care costs, these insights may enable stakeholders to design bundled payment structures that better align reimbursements with costs.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level IV . See Instructions for Authors for a complete description of levels of evidence.

Cost of hemophilia A in Brazil: a microcosting study

BACKGROUND

Patients with Hemophilia are continually monitored at treatment centers to avoid and control bleeding episodes. This study estimated the direct and indirect costs per patient with hemophilia A in Brazil and evaluated the cost variability across different age groups.

METHODS

A prospective observational research was conducted with retrospective data collection of patients assisted at three referral blood centers in Brazil. Time-driven Activity-based Costing method was used to analyze direct costs, while indirect costs were estimated based on interviews with family and caregivers. Cost per patient was analyzed according to age categories, stratified into 3 groups (0-11;12-18 or older than 19 years old). The non-parametric Mann-Whitney test was used to confirm the differences in costs across groups.

RESULTS

Data from 140 hemophilia A patients were analyzed; 53 were 0-11 years, 29 were 12-18 years, and the remaining were older than 19 years. The median cost per patient per year was R$450,831 (IQR R$219,842; R$785,149; $174,566), being possible to confirm age as a cost driver: older patients had higher costs than younger's (p = 0.001; median cost: 0-11 yrs R$299,320; 12-18 yrs R$521,936; ≥19 yrs R$718,969).

CONCLUSION

This study is innovative in providing cost information for hemophilia A using a microcosting technique. The variation in costs across patient age groups can sustain more accurate health policies driven to increase access to cutting-edge technologies and reduce the burden of the disease.

Deep Inspiration Breath Hold in Left-Sided Breast Radiotherapy: A Balance Between Side Effects and Costs

Background

Deep inspiration breath hold (DIBH) is an effective technique for reducing heart exposure during radiotherapy for left-sided breast cancer. Despite its benefits, cost considerations and its impact on workflow remain significant barriers to widespread adoption.

Objectives

This study aimed to assess the cost-effectiveness of DIBH and compare its operational, financial, and clinical outcomes with free breathing (FB) in breast cancer treatment.

Methods

Treatment plans for 100 patients with left-sided breast cancer were generated using both DIBH and FB techniques. Dosimetric data, including the average mean heart dose, were calculated for each technique and used to estimate the cardiotoxicity of radiotherapy. A state-transition microsimulation model based on SCORE2 (Systematic Coronary Risk Evaluation) algorithms projected the effects of DIBH on cardiovascular outcomes and quality-adjusted life-years (QALYs). Costs were calculated from a provider perspective using time-driven activity-based costing, applying a willingness-to-pay threshold of €40,000 for cost-effectiveness assessment. A discrete event simulation model assessed the impacts of DIBH vs FB on throughput and waiting times in the radiotherapy workflow.

Results

In the base case scenario, DIBH was associated with an absolute risk reduction of 1.72% (95% CI: 1.67%-1.76%) in total cardiovascular events and 0.69% (95% CI: 0.67%-0.72%) in fatal cardiovascular events over 20 years. Additionally, DIBH was estimated to provide an incremental 0.04 QALYs (95% CI: 0.05-0.05) per left-sided breast cancer patient over the same time period. However, DIBH increased treatment times, reducing maximum achievable throughput by 12.48% (95% CI: 12.36%-12.75%) and increasing costs by €617 per left-sided breast cancer patient (95% CI: €615-€619). The incremental cost-effectiveness ratio was €14,023 per QALY.

Conclusions

Despite time investments, DIBH is cost-effective in the Belgian population. The growing adoption of DIBH may benefit long-term cardiovascular health in breast cancer survivors.

Cost Comparison of Prostatic Artery Embolization Between In-Hospital and Outpatient-Based Lab Settings

Purpose This study aimed to determine the costs associated with prostatic artery embolization (PAE) performed in hospital and outpatient-based lab (OBL) settings. Methods Procedures were performed in similarly equipped procedure suites located within a tertiary hospital or OBL. Time-driven activity-based costing (TDABC) was utilized to calculate procedural costs incurred by the institution. Process maps were created describing personnel, space, equipment, and materials. The time duration of each procedural step was recorded independently by a nurse caring for the patient at the time of the procedure, and mean values were included in our model. Using institutional and publicly available financial data, costs, and capacity cost rates were determined. Results Thirty-seven PAE procedures met inclusion criteria with a mean patient age of 70.4 (+/- 6.7) years and a mean prostate gland size of 129.7 (+/-56.4) cc. Twenty-six procedures were performed within the hospital setting, and 11 procedures were performed within the OBL. Reduction in International Prostate Symptom Score (IPSS) was not significantly different following hospital and OBL procedures (57.2% vs. 82.4%, P = 0.0796). Mean procedural time was not significantly different between the hospital and OBL settings (136.6 vs. 147.3 minutes, P = 0.1893). However, the duration between admission and discharge was significantly longer for procedures performed in a hospital (468.8 vs. 325.4 minutes, P <0.0001). Total costs for hospital-based procedures were marginally higher ($3,858.28 vs. $3,642.67). Conclusion Total PAE cost was similar between the hospital and OBL settings. However, longer periprocedural times for hospital-based procedures and differences in reimbursement may favor the performance of PAE in an OBL setting.

Exploring cost changes with time-driven activity-based costing after service delivery redesign in Dutch maternity care

The implementation of Value-Based Healthcare (VBHC) has spread across international healthcare systems, aiming to improve decision-making by combining information about patient outcomes and costs of care. Time-Driven Activity-Based Costing (TDABC) is introduced as a pragmatic yet accurate method to calculate costs of care pathways. It is often applied to demonstrate value-improving opportunities, such as interventions aimed at service delivery redesign. It is imperative for healthcare managers to know whether these interventions yield the expected outcome of improving patient value, for which TDABC is also suitable. However, its application becomes more complex and labour intensive if the intervention extends beyond activity-level changes in existing care pathways, to the implementation of entirely new care pathways. The complexity arises from the potential influence of such interventions on the costs of related care pathways. To fully comprehend the impact of such interventions on organizational costs, it is important to include these factors in the cost calculation. Given the substantial effort required for this analysis, this may explain the limited number of prior TDABC studies with similar objectives. This methodological development paper addresses this gap by offering a pragmatic enrichment of the TDABC methodology. This enrichment is twofold. First, it provides guidance on calculating a change in costs without the need for a total cost calculation. Second, to secure granularity, a more detailed level of cost-allocation is proposed. The aim is to encourage further application of TDABC to conduct financial evaluations of promising interventions in the domain of VBHC and service delivery redesign.

Cost of Care for Non-communicable Diseases: Which Types of Healthcare Providers are the Most Economical in India's Chhattisgarh State?

BACKGROUND

Non-communicable diseases (NCDs) affect a large number of people globally and their burden has been growing. Healthcare for NCDs often involves high out-of-pocket expenditure and rising costs of providing services. Financing and providing care for NCDs have become a major challenge for health systems. Despite the high burden of NCDs in India, there is little information available on the costs involved in NCD care.

METHODS

The study was aimed at finding out the average monthly cost of outpatient care per NCD patient. The average cost was defined as all resources spent directly by government and citizens to get a month of care for a NCD patient. The cost borne by the government on public facilities was taken into account and activity-based costing was used to apportion it to the function of providing outpatient NCD care. For robustness, time-driven activity-based costing and sensitivity analyses were also performed. The study was conducted in Chhattisgarh State and involved a household survey and a facility survey, conducted simultaneously at the end of 2022. The surveys had a sample representative of the state, covering 3500 individuals above age of 30 years and 108 health facilities.

RESULTS

The average monthly cost per NCD patient was Indian Rupees (INR) 688 for public providers, INR 1389 for formal for-profit providers and INR 408 for informal private providers and they managed 53.5, 34.3 and 12.0% of NCD patients respectively. The disease profile of patients handled by different types of providers was similar. The average cost per patient was lowest for the primary care facilities in the public sector.

CONCLUSIONS

The average direct cost of NCD care for government and citizens put together was substantially higher in case of formal for-profit providers compared with public facilities, even after taking into account the government subsidies to public sector. This has implications for allocative efficiency and the desired public-private provider mix in health systems.

Application of Time-Driven Activity-Based Costing for Head and Neck Microvascular Free Flap Reconstruction

OBJECTIVE

Traditional hospital accounting fails to provide an accurate cost of complex surgical care. Here we describe the application of time-driven activity-based costing (TDABC) to characterize costs of head and neck oncologic procedures involving free tissue transfer.

STUDY DESIGN

Retrospective cohort study.

SETTING

Single tertiary academic medical center.

METHODS

An analysis of head and neck oncologic procedures involving microvascular free flap reconstruction from 2018 to 2020 (n = 485) was performed using TDABC methodology to measure cost across operative case and postoperative admission, using quantity of time and cost per unit of each resource to characterize resource utilization. Univariate and generalized linear mixed models were used to examine associations between patient and hospital characteristics and cost of care delivery.

RESULTS

The total cost of care delivery was $41,905.77 ± 21,870.27 with operating room (OR) supplies accounting for only 10% of the total cost. Multivariable analyses identified significant cost drivers including operative time, postoperative length of stay, number of return trips to the OR, postoperative complication, number of free flaps performed, and patient transfer from another hospital or via emergency department admission (P < .05).

CONCLUSION

Operative time and postoperative length of stay, but not operative supplies, were primary drivers of cost of care for head and neck oncology cases involving free tissue transfer. TDABC offers granular cost characterization to inform cost optimization through unused capacity identification and postoperative admission efficiencies.

The impact of prior authorization review on orthopaedic subspecialty care: a prospective multicenter analysis

BACKGROUND

Prior authorization review (PAR), in the United States, is a process that was initially intended to focus on hospital admissions and costly high-acuity care. Over time, payors have broadened the scope of PAR to include imaging studies, prescriptions, and routine treatment. The potential detrimental effect of PAR on health care has recently been brought into the limelight, but its impact on orthopedic subspecialty care remains unclear. This study investigated the denial rate, the duration of care delay, and the administrative burden of PAR on orthopedic subspecialty care.

METHODS

A prospective, multicenter study was performed analyzing the PAR process. Orthopedic shoulder and/or sports subspecialty practices from 6 states monitored payor-mandated PAR during the course of providing routine patient care. The insurance carrier (traditional Medicare, managed Medicare, Medicaid, commercial, worker's compensation, or government payor [ie, Tricare, Veterans Affairs]), location of service, rate of approval or denial, time to approval or denial, and administrative time required to complete process were all recorded and evaluated.

RESULTS

Of 1065 total PAR requests, we found a 1.5% (16/1065) overall denial rate for advanced imaging or surgery when recommended by an orthopedic subspecialist. Commercial and Medicaid insurance resulted in a small but statistically significantly higher rate of denial compared to traditional Medicare, managed Medicare, worker's compensation, or governmental insurance (P < .001). The average administrative time spent on a single PAR was 19.5 minutes, and patients waited an average of 2.2 days to receive initial approval. Managed Medicare, commercial insurance, worker's compensation, and Medicaid required approximately 3-4 times more administrative time to process a PAR than to traditional Medicare or other governmental insurance (P < .001). After controlling for the payor, we identified a significant difference in approval or denial based on geographic location (P < .001). An appeal resulted in a relatively low rate of subsequent denial (20%). However, approximately a third of all appeals remained in limbo for 30 days or more after the initial request.

CONCLUSIONS

This is the largest prospective analysis to date of the impact of PAR on orthopedic subspecialty care in the United States. Nearly all PAR requests are eventually approved when recommended by orthopedic subspecialists, despite requiring significant resource use and delaying care. Current PAR practices constitute an unnecessary process that increases administrative burden and negatively impacts access to orthopedic subspecialty care. As health care shifts to value-based care, PAR should be called into question, as it does not seem to add value but potentially negatively impacts cost and timeliness of care.

Cost of treating rheumatoid arthritis in the primary care public health system in Ireland: A time-driven activity-based cost analysis

Background

Chronic diseases are at epidemic proportions and continuing to increase in both incidence and prevalence globally. Therefore, there is a growing need to assess and improve on the value currently provided within chronic care pathways. Examining the costs associated with care pathways is a critical part of assessing this value in order to better understand and introduce potential cost-saving interventions.

Objectives

Examining one such chronic disease, Rheumatoid Arthritis (RA), this study aimed to assess the cost associated with RA in primary care within the Health Service Executive (HSE) in Ireland.

Methods

Following mapping of the care pathway, patient vignettes based on exemplar RA patient types were used to conduct semi-structed interviews with every member (N = 21) of the primary care RA pathway. Time-Driven Activity-Based Costing (TDABC) was then used to calculate the overall cost of each patient (vignette) type.

Results

RA is an expensive condition regardless of disease stage. However, newly diagnosed patients as well as those with advanced disease in need of surgical interventions demonstrated the highest costs in terms of primary care personnel use. Additionally, patients prescribed Biological Disease-Modifying Anti-Rheumatic Drugs (bDMARDs) cost significantly more than those on Conventional Synthetic Disease-Modifying Anti-Rheumatic Drugs (csDMARDs) regardless of disease stage or personnel resource use.

Conclusion

RA and a subset of RA patients that exert the highest healthcare costs are growing in prevalence. Therefore, this study contributes by assessing the costs associated with RA in HSE primary care that can facilitate better understanding the current value being provided and improve upon the current care pathway to cut future costs.

Improvements in technology and the expanding role of time-driven, activity-based costing to increase value in healthcare provider organizations: a literature review

Objective

This study evaluated the influence of technology on accurately measuring costs using time-driven activity-based costing (TDABC) in healthcare provider organizations by identifying the most recent scientific evidence of how it contributed to increasing the value of surgical care.

Methods

This is a literature-based analysis that mainly used two data sources: first, the most recent systematic reviews that specifically evaluated TDABC studies in the surgical field and, second, all articles that mentioned the use of CareMeasurement (CM) software to implement TDABC, which started to be published after the publication of the systematic review. The articles from the systematic review were grouped as manually performed TDABC, while those using CM were grouped as technology-based studies of TDABC implementations. The analyses focused on evaluating the impact of using technology to apply TDABC. A general description was followed by three levels of information extraction: the number of cases included, the number of articles published per year, and the contributions of TDABC to achieve cost savings and other improvements.

Results

Fourteen studies using real-world patient-level data to evaluate costs comprised the manual group of studies. Thirteen studies that reported the use of CM comprised the technology-based group of articles. In the manual studies, the average number of cases included per study was 160, while in the technology-based studies, the average number of cases included was 4,767. Technology-based studies, on average, have a more comprehensive impact than manual ones in providing accurate cost information from larger samples.

Conclusion

TDABC studies supported by technologies such as CM register more cases, identify cost-saving opportunities, and are frequently used to support reimbursement strategies based on value. The findings suggest that using TDABC with the support of technology can increase healthcare value.

Analysis of the costs of teleconsultation for the treatment of diabetes mellitus in the SUS

OBJECTIVE

To present the results of a cost analysis of remote consultations (teleconsultations) compared to in-person consultations for patients with type 2 diabetes, in the Brazilian public healthcare system (SUS) in the city of Joinville, Santa Catarina (SC). In addition to the costs from the local manager's perspective, the article also presents estimates from the patient's perspective, based on the transportation costs associated with each type of consultation.

METHOD

Data were collected from 246 consultations, both remote and in-person, between 2021 and 2023, in the context of a randomized clinical trial on the impact of teleconsultation carried out in the city of Joinville, SC. Teleconsultations were carried out at Primary Health Units (PHU) and in-person consultations at the Specialized Health Center. The consultation costs were calculate by the method time and activity-based costing (TDABC), and for the estimate of transportation costs data was collected directly from the research participants . The mean costs and time required to carry out each type of consultation in different scenarios and perspectives were analyzed and compared descriptively.

RESULTS

Considering only the local SUS manager's perspective, the costs for carrying out a teleconsultation were 4.5% higher than for an in-person consultation. However, when considering the transportation costs associated with each patient, the estimated value of the in-person consultation becomes 7.7% higher and, in the case of consultations in other municipalities, 15% higher than the teleconsultation.

CONCLUSION

The results demonstrate that the incorporation of teleconsultation within the SUS can bring economic advantages depending on the perspective and scenario considered, in addition to being a strategy with the potential to increase access to specialized care in the public network.

Optimizing Outpatient Radiation Oncology Consult Workflow by Using Time-Driven Activity-Based Costing: Efficiency and Financial Impacts

PURPOSE

Clinical efficiency is a key component of value-based health care. Our objective here was to identify workflow inefficiencies by using time-driven activity-based costing (TDABC) and evaluate the implementation of a new clinical workflow in high-volume outpatient radiation oncology clinics.

METHODS

Our quality improvement study was conducted with the Departments of GI, Genitourinary (GU), and Thoracic Radiation Oncology at a large academic cancer center and four community network sites. TDABC was used to create process maps and optimize workflow for outpatient consults. Patient encounter metrics were captured with a real-time status function in the electronic medical record. Time metrics were compared using Mann-Whitney U tests.

RESULTS

Individual patient encounter data for 1,328 consults before the intervention and 1,234 afterward across all sections were included. The median overall cycle time was reduced by 21% in GI (19 minutes), 18% in GU (16 minutes), and 12% at the community sites (9 minutes). The median financial savings per consult were $52 in US dollars (USD) for the GI, $33 USD for GU, $30 USD for thoracic, and $42 USD for the community sites. Patient satisfaction surveys (from 127 of 228 patients) showed that 99% of patients reported that their providers spent adequate time with them and 91% reported being seen by a care provider in a timely manner.

CONCLUSION

TDABC can effectively identify opportunities to improve clinical efficiency. Implementing workflow changes on the basis of our findings led to substantial reductions in overall encounter cycle times across several departments, as well as high patient satisfaction and significant financial savings.

Time-Driven Activity-Based Costing Analysis Identifies Use of Consumables and Operating Room Time as Factors Associated With Increased Cost of Outpatient Primary Hip Arthroscopic Labral Repair

PURPOSE

To use time-driven, activity-based costing (TDABC) methodology to investigate drivers of cost variation and to elucidate preoperative and intraoperative factors associated with increased cost of outpatient arthroscopic hip labral repair.

METHODS

A retrospective analysis of data from January 2020 to October 2021 was performed. Patients undergoing primary hip arthroscopy for labral repair in the outpatient setting were included. Indexed TDABC data from Avant-garde Health's analytics platform were used to represent cost-of-care breakdowns. Patients in the top decile of cost were defined as high cost, and cost category variance was determined as a percent increase between high and low cost. Analyses tested for associations between preoperative and perioperative factors with total cost. Surgical procedures performed concomitantly to labral repair were included in subanalyses.

RESULTS

Data from 151 patients were analyzed. Consumables made up 61% of total outpatient cost with surgical personnel costs (30%) being the second largest category. The average total cost was 19% higher for patients in the top decile of cost compared to the remainder of the cohort. Factors contributing to this difference were implants (36% higher), surgical personnel (20% higher), and operating room (OR) consumables (15% higher). Multivariate linear regression modeling indicated that OR time (Standardized β = 0.504; P < .001) and anchor quantity (standardized β = 0.443; P < .001) were significant predictors of increased cost. Femoroplasty (Unstandardized β = 15.274; P = .010), chondroplasty (Unstandardized β = 8.860; P = .009), excision of os acetabuli (unstandardized β = 13.619; P = .041), and trochanteric bursectomy (Unstandardized β = 21.176; P = .009) were also all independently associated with increasing operating time.

CONCLUSIONS

TDABC analysis showed that OR consumables and implants were the largest drivers of cost for the procedure. OR time was also shown to be a significant predictor of increased costs.

LEVEL OF EVIDENCE

Level IV, economic analysis.

Health economic evaluation of blended collaborative care for older multimorbid heart failure patients: study protocol

BACKGROUND

Integrated care, in particular the 'Blended Collaborative Care (BCC)' strategy, may have the potential to improve health-related quality of life (HRQoL) in multimorbid patients with heart failure (HF) and psychosocial burden at no or low additional cost. The ESCAPE trial is a randomised controlled trial for the evaluation of a BCC approach in five European countries. For the economic evaluation of alongside this trial, the four main objectives were: (i) to document the costs of delivering the intervention, (ii) to assess the running costs across study sites, (iii) to evaluate short-term cost-effectiveness and cost-utility compared to providers' usual care, and (iv) to examine the budgetary implications.

METHODS

The trial-based economic analyses will include cross-country cost-effectiveness and cost-utility assessments from a payer perspective. The cost-utility analysis will calculate quality-adjusted life years (QALYs) using the EQ-5D-5L and national value sets. Cost-effectiveness will include the cost per hospital admission avoided and the cost per depression-free days (DFD). Resource use will be measured from different sources, including electronic medical health records, standardised questionnaires, patient receipts and a care manager survey. Uncertainty will be addressed using bootstrapping.

DISCUSSION

The various methods and approaches used for data acquisition should provide insights into the potential benefits and cost-effectiveness of a BCC intervention. Providing the economic evaluation of ESCAPE will contribute to a country-based structural and organisational planning of BCC (e.g., the number of patients that may benefit, how many care managers are needed). Improved care is expected to enhance health-related quality of life at little or no extra cost.

TRIAL REGISTRATION

The study follows CHEERS2022 and is registered at the German Clinical Trials Register (DRKS00025120).

Time-Driven Activity-Based Cost Comparison of Osteoid Osteoma Ablation Techniques

OBJECTIVE

Compare the cost of performing an osteoid osteoma ablation using cone beam CT (CBCT) with overlay fluoroscopic guidance to ablation using conventional CT (CCT) guidance and microwave ablation (MWA) to radiofrequency ablation (RFA).

METHODS

An 11-year retrospective study was performed of all patients undergoing osteoid osteoma ablation. Ablation equipment included a Cool tip RFA probe (Covidien, Minneapolis, Minnesota) or a Neuwave PR MWA probe (Ethicon, Rariton, New Jersey). The room times as well as immediate recovery time were recorded for each case. Cost analysis was then performed using time-driven activity-based costing for rate-dependent variables including salaries, equipment depreciation, room time, and certain supplies. Time-independent costs included the disposable interventional radiology supplies and ablation systems. Costs were reported for each service providing care and using conventional cost accounting methods with variable and fixed expenditures.

RESULTS

A total of 91 patients underwent 96 ablation procedures in either CBCT (n = 66) or CCT (n = 30) using either MWA (n = 51) or RFA (n = 45). The anesthesia induction (22.7 ± 8.7 min versus 15.9 ± 7.2 min, P < .001), procedure (64.7 ± 27.5 min versus 47.3 ± 15.3 min; P = .001), and room times (137.7 ± 33.7 min versus 103.9 ± 22.6. min; P < .001) were significantly longer for CBCT procedures. The procedure time did not differ significantly between MWA and RFA (62.1 ± 27.4 min versus 56.1 ± 23.3 min; P = .27). Multiple regression analysis demonstrated lower age (P = .046), CBCT use (P = .001), RFA use (P = .02), and nonsupine patient position (P = .01) significantly increased the total procedural cost. After controlling for these variables, the total cost of CBCT ($5,981.32 ± $523.93 versus $5,378.93 ± $453.12; P = .001) remained higher than CCT and the total cost of RFA ($5,981.32 ± $523.93 versus $5,674.43 ± $549.14; P = .05) approached a higher cost than MWA.

CONCLUSION

The use of CBCT with overlay fluoroscopic guidance for osteoid osteoma ablation resulted in longer in-room times and greater cost when compared with CCT. These cost considerations should be weighed against potential radiation dose advantage of CBCT when choosing an image guidance modality. Younger age, RFA use, and nonsupine patient position additionally contributed to higher costs.

An economic evaluation of the expansion of electronic case reporting in an academic healthcare setting

Objectives

Determine the economic cost or benefit of expanding electronic case reporting (eCR) for 29 reportable conditions beyond the initial eCR implementation for COVID-19 at an academic health center.

Materials and methods

The return on investment (ROI) framework was used to quantify the economic impact of the expansion of eCR from the perspective of an academic health system over a 5-year time horizon. Sensitivity analyses were performed to assess key factors such as personnel cost, inflation, and number of expanded conditions.

Results

The total implementation costs for the implementation year were estimated to be $5031.46. The 5-year ROI for the expansion of eCR for the 29 conditions is expected to be 142% (net present value of savings: $7166). Based on the annual ROI, estimates suggest that the savings from the expansion of eCR will cover implementation costs in approximately 4.8 years. All sensitivity analyses yielded a strong ROI for the expansion of eCR.

Discussion and conclusion

Our findings suggest a strong ROI for the expansion of eCR at UHealth, with the most significant cost savings observed implementing eCR for all reportable conditions. An early effort to ensure data quality is recommended to expedite the transition from parallel reporting to production to improve the ROI for healthcare organizations. This study demonstrates a positive ROI for the expansion of eCR to additional reportable conditions beyond COVID-19 in an academic health setting, such as UHealth. While this evaluation focuses on the 5-year time horizon, the potential benefit could extend further.

A comprehensive value-based method for new nuclear medical service pricing: with case study of radium [223Ra] bone metastases treatment

IMPORTANCE

Innovative nuclear medicine services offer substantial clinical value to patients. However, these advancements often come with high costs. Traditional payment strategies do not incentivize medical institutes to provide new services nor determine the fair price for payers. A shift towards a value-based pricing strategy is imperative to address these challenges. Such a strategy would reconcile the cost of innovation with incentives, foster transparent allocation of healthcare resources, and expedite the accessibility of essential medical services.

OBJECTIVE

This study aims to develop and present a comprehensive, value-based pricing model for new nuclear medicine services, illustrated explicitly through a case study of the radium [223Ra] treatment for bone metastases. In constructing the pricing model, we have considered three primary value determinants: the cost of the new service, associated service risk, and the difficulty of the service provision. Our research can help healthcare leaders design an evidence-based Fee-For-Service (FFS) payment reference pricing with nuclear medicine services and price adjustments.

DESIGN, SETTING AND PARTICIPANTS

This multi-center study was conducted from March 2021 to February 2022 (including consultation meetings) and employed both qualitative and quantitative methodologies. We organized focus group consultations with physicians from nuclear medicine departments in Beijing, Chongqing, Guangzhou, and Shanghai to standardize the treatment process for radium [223Ra] bone metastases. We used a specially designed 'Radium Nuclide [223Ra] Bone Metastasis Data Collection Form' to gather nationwide resource consumption data to extract information from local databases. Four interviews with groups of experts were conducted to determine the add-up ratio, based on service risk and difficulty. The study organized consultation meeting with key stakeholders, including policymakers, service providers, clinical researchers, and health economists, to finalize the pricing equation and the pricing result of radium [223Ra] bone metastases service.

MAIN OUTCOMES AND MEASURES

We developed and detailed a pricing equation tailored for innovative services in the nuclear medicine department, illustrating its application through a step-by-step guide. A standardized service process was established to ensure consistency and accuracy. Adhering to best practice guidelines for health cost data analysis, we emphasized the importance of cross-validation of data, where validated data demonstrated less variation. However, it required a more advanced health information system to manage and analyze the data inputs effectively.

RESULTS

The standardized service of radium [223Ra] bone metastases includes: pre-injection assessment, treatment plan, administration, post-administration monitoring, waste disposal and monitoring. The average duration for each stage is 104 min, 39 min, 25 min, 72 min and 56 min. A standardized monetary value for medical consumables is 54.94 yuan ($7.6), and the standardised monetary value (medical consumables cost plus human input) is 763.68 yuan ($109.9). Applying an agreed value add-up ratio of 1.065, the standardized value is 810.19 yuan ($116.9). Feedback from a consultation meeting with policymakers and health economics researchers indicates a consensus that the pricing equation developed was reasonable and well-grounded.

CONCLUSION

This research is the first study in the field of nuclear medicine department pricing methodology. We introduce a comprehensive value-based nuclear medical service pricing method and use radium[223Ra] bone metastases treatment pricing in China as a case study. This study establishes a novel pricing framework and provides practical instructions on its implementation in a real-world healthcare setting.

Monthly multidisciplinary complex spine conference: a cost-analysis utilizing time-driven activity-based costing

PURPOSE

To understand costs and provide an initial framework associated with conference implementation as it pertains to complication prevention.

METHODS

Team members' time spent on conference preparation, presentation, and follow-up tasks was recorded and averaged to determine the time required to prepare and present one patient. Using 2022 hourly wage rates based on our urban hospital setting, wage values were calculated for each personnel type and applied to their time spent. The total cost of the conference was annualized and calculated from the time spent in the three phases of the conference multiplied by the wage rate. Published data on complication rates and associated costs before and after conference implementation were used to calculate total cost reduction.

RESULTS

With 3 active spine surgeons and 108 patients per year, the total time investment was 104.04 min per patient, costing $21,791 annually. Total RN equivalent value per patient was 5.25 for all three phases. Using a historical model, this multidisciplinary approach for adult spinal deformity reduced complications by 51% at 30 days, resulting in cost savings of $418,518 per year. Thus, the model demonstrates that implementation of this approach resulted in a potential total savings of $396,726/year.

CONCLUSION

Implementing a cost-saving tool for managing complex spinal disorders is a responsibility of the spine team, who should lead a multidisciplinary conference. The combination of TDABC and lean methodology can effectively demonstrate the variable costs associated with this multidisciplinary effort and models provide evidence of potential cost-savings when applied to a multidisciplinary adult spinal deformity conference. These findings should encourage clinicians and administrators to allocate resources to improve patient care by reducing complications and costs.