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Nanjayya VB, Higgins AM, Morphett L, Thiara S, Jones A, Pellegrino VA, Sheldrake J, Bernard S, Kaye D, Nichol A, Cooper DJ. Actual Cost of Extracorporeal Cardiopulmonary Resuscitation: A Time-Driven Activity-Based Costing Study. Crit Care Explor 2024; 6:e1121. [PMID: 38958545 PMCID: PMC11224838 DOI: 10.1097/cce.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVES To determine the actual cost and drivers of the cost of an extracorporeal cardiopulmonary resuscitation (E-CPR) care cycle. PERSPECTIVE A time-driven activity-based costing study conducted from a healthcare provider perspective. SETTING A quaternary care ICU providing around-the-clock E-CPR service for out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) in Australia. METHODS The E-CPR care cycle was defined as the time from initiating E-CPR to hospital discharge or death of the patient. Detailed process maps with discrete steps and probabilistic decision nodes accounting for the complex trajectories of E-CPR patients were developed. Data about clinical and nonclinical resources and timing of activities was collected multiple times for each process . Total direct costs were calculated using the time estimates and unit costs per resource for all clinical and nonclinical resources. The total direct costs were combined with indirect costs to obtain the total cost of E-CPR. RESULTS From 10 E-CPR care cycles observed during the study period, a minimum of 3 observations were obtained per process. The E-CPR care cycle's mean (95% CI) cost was $75,014 ($66,209-83,222). Initiation of extracorporeal membrane oxygenation (ECMO) and ECMO management constituted 18% of costs. The ICU management (35%) and surgical costs (20%) were the primary cost determinants. IHCA had a higher mean (95% CI) cost than OHCA ($87,940 [75,372-100,570] vs. 62,595 [53,994-71,890], p < 0.01), mainly because of the increased survival and ICU length of stay of patients with IHCA. The mean cost for each E-CPR survivor was $129,503 ($112,422-147,224). CONCLUSIONS Significant costs are associated with E-CPR for refractory cardiac arrest. The cost of E-CPR for IHCA was higher compared with the cost of E-CPR for OHCA. The major determinants of the E-CPR costs were ICU and surgical costs. These data can inform the cost-effectiveness analysis of E-CPR in the future.
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Affiliation(s)
- Vinodh B. Nanjayya
- Intensive Care Department, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Alisa M. Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Laura Morphett
- Performance Analysis and Reporting Department, Alfred Health, Melbourne, VIC, Australia
| | - Sonny Thiara
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - Annalie Jones
- Intensive Care Department, Alfred Hospital, Melbourne, VIC, Australia
| | - Vincent A. Pellegrino
- Intensive Care Department, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jayne Sheldrake
- Intensive Care Department, Alfred Hospital, Melbourne, VIC, Australia
| | - Stephen Bernard
- Intensive Care Department, Alfred Hospital, Melbourne, VIC, Australia
| | - David Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, VIC, Australia
| | - Alistair Nichol
- Intensive Care Department, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - D. James Cooper
- Intensive Care Department, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Iachecen F, Dallagassa MR, Portela Santos EA, Carvalho DR, Ioshii SO. Is it possible to automate the discovery of process maps for the time-driven activity-based costing method? A systematic review. BMC Health Serv Res 2023; 23:1408. [PMID: 38093275 PMCID: PMC10720189 DOI: 10.1186/s12913-023-10411-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023] Open
Abstract
OBJECTIVES The main objective of this manuscript was to identify the methods used to create process maps for care pathways that utilized the time-driven activity-based costing method. METHODS This is a systematic mapping review. Searches were performed in the Embase, PubMed, CINAHL, Scopus, and Web of Science electronic literature databases from 2004 to September 25, 2022. The included studies reported practical cases from healthcare institutions in all medical fields as long as the time-driven activity-based costing method was employed. We used the time-driven activity-based costing method and analyzed the created process maps and a qualitative approach to identify the main fields. RESULTS A total of 412 studies were retrieved, and 70 articles were included. Most of the articles are related to the fields of orthopedics and childbirth-related to hospital surgical procedures. We also identified various studies in the field of oncology and telemedicine services. The main methods for creating the process maps were direct observational practices, complemented by the involvement of multidisciplinary teams through surveys and interviews. Only 33% of the studies used hospital documents or healthcare data records to integrate with the process maps, and in 67% of the studies, the created maps were not validated by specialists. CONCLUSIONS The application of process mining techniques effectively automates models generated through clinical pathways. They are applied to the time-driven activity-based costing method, making the process more agile and contributing to the visualization of high degrees of variations encountered in processes, thereby making it possible to enhance and achieve continual improvements in processes.
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Affiliation(s)
- Franciele Iachecen
- Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná., 1155, Imaculada Conceição st., Curitiba, Paraná, 80215-90, Brazil.
| | - Marcelo Rosano Dallagassa
- Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná., 1155, Imaculada Conceição st., Curitiba, Paraná, 80215-90, Brazil
| | | | - Deborah Ribeiro Carvalho
- Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná., 1155, Imaculada Conceição st., Curitiba, Paraná, 80215-90, Brazil
| | - Sérgio Ossamu Ioshii
- Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná., 1155, Imaculada Conceição st., Curitiba, Paraná, 80215-90, Brazil
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Berthelot S, Longtin Y, Margni M, Guertin JR, LeBlanc A, Marx T, Mangou K, Bluteau A, Mantovani D, Mikhaylin S, Bergeron F, Dancause V, Desjardins A, Lahrichi N, Martin D, Sossa CJ, Lachapelle P, Genest I, Schaal S, Gignac A, Tremblay S, Hufty É, Bélanger L, Beatty E. Postpandemic Evaluation of the Eco-Efficiency of Personal Protective Equipment Against COVID-19 in Emergency Departments: Proposal for a Mixed Methods Study. JMIR Res Protoc 2023; 12:e50682. [PMID: 38060296 PMCID: PMC10739239 DOI: 10.2196/50682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has had a profound impact on emergency department (ED) care in Canada and around the world. To prevent transmission of COVID-19, personal protective equipment (PPE) was required for all ED care providers in contact with suspected cases. With mass vaccination and improvements in several infection prevention components, our hypothesis is that the risks of transmission of COVID-19 will be significantly reduced and that current PPE use will have economic and ecological consequences that exceed its anticipated benefits. Evidence is needed to evaluate PPE use so that recommendations can ensure the clinical, economic, and environmental efficiency (ie, eco-efficiency) of its use. OBJECTIVE To support the development of recommendations for the eco-efficient use of PPE, our research objectives are to (1) estimate the clinical effectiveness (reduced transmission, hospitalizations, mortality, and work absenteeism) of PPE against COVID-19 for health care workers; (2) estimate the financial cost of using PPE in the ED for the management of suspected or confirmed COVID-19 patients; and (3) estimate the ecological footprint of PPE use against COVID-19 in the ED. METHODS We will conduct a mixed method study to evaluate the eco-efficiency of PPE use in the 5 EDs of the CHU de Québec-Université Laval (Québec, Canada). To achieve our goals, the project will include four phases: systematic review of the literature to assess the clinical effectiveness of PPE (objective 1; phase 1); cost estimation of PPE use in the ED using a time-driven activity-based costing method (objective 2; phase 2); ecological footprint estimation of PPE use using a life cycle assessment approach (objective 3; phase 3); and cost-consequence analysis and focus groups (integration of objectives 1 to 3; phase 4). RESULTS The first 3 phases have started. The results of these phases will be available in 2023. Phase 4 will begin in 2023 and results will be available in 2024. CONCLUSIONS While the benefits of PPE use are likely to diminish as health care workers' immunity increases, it is important to assess its economic and ecological impacts to develop recommendations to guide its eco-efficient use. TRIAL REGISTRATION PROSPERO CRD42022302598; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=302598. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50682.
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Affiliation(s)
- Simon Berthelot
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche, CHU de Québec-Université Laval, Québec, QC, Canada
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université Laval, Québec, QC, Canada
| | | | - Manuele Margni
- Ecole Polytechnique, Université de Montréal, Montréal, QC, Canada
| | - Jason Robert Guertin
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche, CHU de Québec-Université Laval, Québec, QC, Canada
- Département de médecine sociale et préventive, Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Annie LeBlanc
- Département de médecine de famille et de médecine d'urgence, Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Tania Marx
- Services des urgences, Centre hospitalier universitaire de Besançon, Besançon, France
| | - Khadidiatou Mangou
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Ariane Bluteau
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Diego Mantovani
- Axe Médecine régénératrice, Centre de recherche, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Sergey Mikhaylin
- EcoFoodLab, Département des sciences de aliments, Institut sur la Nutrition et les Aliments Fonctionnels, Université Laval, Québec, QC, Canada
| | | | | | | | - Nadia Lahrichi
- Ecole Polytechnique, Université de Montréal, Montréal, QC, Canada
| | - Danielle Martin
- Fashion Design and Creative Direction, Toronto Metropolitan University, Toronto, ON, Canada
| | | | | | | | | | - Anne Gignac
- CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Éric Hufty
- CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Erica Beatty
- Département de médecine d'urgence, Hôpital Montfort, Ottawa, ON, Canada
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Richman BD, Kaplan RS, Kohli J, Purcell D, Shah M, Bonfrer I, Golden B, Hannam R, Mitchell W, Cehic D, Crispin G, Schulman KA. Billing And Insurance-Related Administrative Costs: A Cross-National Analysis. HEALTH AFFAIRS (PROJECT HOPE) 2022; 41:1098-1106. [PMID: 35914203 DOI: 10.1377/hlthaff.2022.00241] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Billing and insurance-related costs are a significant source of wasteful health care spending in Organization for Economic Cooperation and Development nations, but these administrative burdens vary across national systems. We executed a microlevel accounting of these costs in different national settings at six provider locations in five nations (Australia, Canada, Germany, the Netherlands, and Singapore) that supplements our prior study measuring the costs in the US. We found that billing and insurance-related costs for inpatient bills range from a low of $6 in Canada to a high of $215 in the US for an inpatient surgical bill (purchasing power parity adjusted). We created a taxonomy of billing and insurance-related activities (eligibility, coding, submission, and rework) that was applied to data from the six sites and allows cross-national comparisons. Higher costs in the US and Australia are attributed to high coding costs. Much of the savings achieved in some nations is attributable to assigning tasks to people in lower-skill job categories, although most of the savings are due to more efficient billing and insurance-related processes. Some nations also reduce these costs by offering financial counseling to patients before treatment. Our microlevel approach can identify specific cost drivers and reveal national billing features that reduce coding costs. It illustrates a valuable pathway for future research in understanding and mitigating administrative costs in health care.
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Affiliation(s)
| | | | | | | | | | - Igna Bonfrer
- Igna Bonfrer, Erasmus University, Rotterdam, Netherlands
| | - Brian Golden
- Brian Golden, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Daniel Cehic
- Daniel Cehic, Genisis Care, Sydney, New South Wales, Australia
| | - Garry Crispin
- Garry Crispin, St. Andrews Hospital, Adelaide, South Australia, Australia
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Berthelot S, Mallet M, Blais S, Moore L, Guertin JR, Boulet J, Boilard C, Fortier C, Huard B, Mokhtari A, Lesage A, Lévesque É, Baril L, Olivier P, Vachon K, Yip O, Bouchard M, Simonyan D, Létourneau M, Pineault A, Vézo A, Stelfox HT. Adaptation of time‐driven activity‐based costing to the evaluation of the efficiency of ambulatory care provided in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12778. [PMID: 35865131 PMCID: PMC9292471 DOI: 10.1002/emp2.12778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/20/2022] [Accepted: 06/16/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives The aim of this study was: (1) to adapt the time‐driven activity‐based costing (TDABC) method to emergency department (ED) ambulatory care; (2) to estimate the cost of care associated with frequently encountered ambulatory conditions; and (3) to compare costs calculated using estimated time and objectively measured time. Methods TDABC was applied to a retrospective cohort of patients with upper respiratory tract infections, urinary tract infections, unspecified abdominal pain, lower back pain and limb lacerations who visited an ED in Québec City (Canada) during fiscal year 2015–2016. The calculated cost of care was the product of the time required to complete each care procedure and the cost per minute of each human resource or equipment involved. Costing based on durations estimated by care professionals were compared to those based on objective measurements in the field. Results Overall, 220 care episodes were included and 3080 time measurements of 75 different processes were collected. Differences between costs calculated using estimated and measured times were statistically significant for all conditions except lower back pain and ranged from $4.30 to $55.20 (US) per episode. Differences were larger for conditions requiring more advanced procedures, such as imaging or the attention of ED professionals. Conclusions The greater the use of advanced procedures or the involvement of ED professionals in the care, the greater is the discrepancy between estimated‐time‐based and measured‐time‐based costing. TDABC should be applied using objective measurement of the time per procedure.
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Affiliation(s)
- Simon Berthelot
- CHU de Québec‐Université Laval Québec Canada
- Département de médecine familiale et de médecine d'urgence Faculté de médecine Québec Canada
| | | | | | - Lynne Moore
- CHU de Québec‐Université Laval Québec Canada
- Département de médecine sociale et préventive Faculté de médecine Université Laval Québec Canada
| | - Jason R. Guertin
- CHU de Québec‐Université Laval Québec Canada
- Département de médecine sociale et préventive Faculté de médecine Université Laval Québec Canada
| | | | | | | | | | | | | | | | - Laurence Baril
- CHU de Québec‐Université Laval Québec Canada
- Département de médecine familiale et de médecine d'urgence Faculté de médecine Québec Canada
| | | | | | - Olivia Yip
- CHU de Québec‐Université Laval Québec Canada
| | | | | | | | | | - Adrien Vézo
- CHU de Québec‐Université Laval Québec Canada
| | - Henry T. Stelfox
- Department of Critical Care and the O'Brien Institute for Public Health McCaig Tower University of Calgary Calgary Alberta Canada
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Hoda D, Richards R, Faber EA, Deol A, Hunter BD, Weber E, DiFilippo H, Henderson-Clark T, Meaux L, Crivera C, Riccobono C, Garrett A, Jackson CC, Fowler J, Theocharous P, Stewart R, Lorden AL, Porter DL, Berger A. Process, resource and success factors associated with chimeric antigen receptor T-cell therapy for multiple myeloma. Future Oncol 2022; 18:2415-2431. [PMID: 35583358 DOI: 10.2217/fon-2022-0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Chimeric antigen receptor T-cell (CAR-T) therapy represents a new frontier in multiple myeloma. It is important to understand critical success factors (CSFs) that may optimize its use in this therapeutic area. Methods: We estimated the CAR-T process using time-driven activity-based costing. Information was obtained through interviews at four US oncology centers and with payer representatives, and through publicly available data. Results: The CAR-T process comprises 13 steps which take 177 days; it was estimated to include 46 professionals and ten care settings. CSFs included proactive collaboration, streamlined reimbursement and CAR-T administration in alternative settings when possible. Implementing CSFs may reduce episode time and costs by 14.4 and 13.2%, respectively. Conclusion: Our research provides a blueprint for improving efficiencies in CAR-T therapy, thereby increasing its sustainability for multiple myeloma.
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Affiliation(s)
- Daanish Hoda
- Intermountain Healthcare, Salt Lake City, UT, USA
| | - Robert Richards
- Cell Therapy & Transplant Program, Division of Hematology-Oncology & Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Edward A Faber
- Transplant & Cellular Therapy Program, Oncology/Hematology Care, USA.,Adult BMT & Cellular Therapy Program, University of Cincinnati, 2600 Clifton Ave, Cincinnati, OH 45221, USA
| | - Abhinav Deol
- Karmanos Cancer Center, 4100 John R St, Detroit, MI 48201, USA
| | | | - Elizabeth Weber
- Cell Therapy & Transplant Program, Division of Hematology-Oncology & Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Heather DiFilippo
- Cell Therapy & Transplant Program, Division of Hematology-Oncology & Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - Linda Meaux
- Intermountain Healthcare, Salt Lake City, UT, USA
| | - Concetta Crivera
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560, USA
| | - Carrie Riccobono
- US Medical Affairs, Legend Biotech, 2101 Cottontail Lane Somerset, NJ 08873, USA
| | - Ashraf Garrett
- US Medical Affairs, Legend Biotech, 2101 Cottontail Lane Somerset, NJ 08873, USA
| | - Carolyn C Jackson
- Janssen Pharmaceutical Research & Development, 1125 Trenton-Harbourton Road, Titusville, NJ 08560, USA
| | - Jessica Fowler
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560, USA
| | | | - Raj Stewart
- Evidera
- PPD, 7101 Wisconsin AvenueSuite 1400Bethesda, MD 20814, USA
| | - Andrea L Lorden
- Evidera
- PPD, 7101 Wisconsin AvenueSuite 1400Bethesda, MD 20814, USA
| | - David L Porter
- Cell Therapy & Transplant Program, Division of Hematology-Oncology & Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ariel Berger
- Evidera
- PPD, 7101 Wisconsin AvenueSuite 1400Bethesda, MD 20814, USA
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Doyle GA, O'Donnell S, Cullen K, Quigley E, Gibney S. Understanding the cost of care of type 2 diabetes mellitus - a value measurement perspective. BMJ Open 2022; 12:e053001. [PMID: 35027420 PMCID: PMC8762124 DOI: 10.1136/bmjopen-2021-053001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES We explore the cost of care of type 2 diabetes mellitus (T2DM) using time-driven activity-based costing (TDABC) and connect that cost to resulting patient health outcomes. DESIGN We construct six care pathways varying from low-risk to high-risk patients over a 12-month cycle of care. We collect time, resource and cost data on activities in each care pathway and compute a time-driven estimate of cost. Use of patient outcome data highlights the health outcomes achieved. SETTING Primary, secondary and tertiary care. PARTICIPANTS Medical staff involved in the care of patients with T2DM. PRIMARY AND SECONDARY MEASURES Primary: resources consumed to provide T2DM care. Secondary: health outcomes for representative patient within each patient category. RESULTS By computing cost of T2DM care and associated complications of chronic kidney disease, active foot disease, moderate risk of active foot disease and myocardial infarction, we show that when patients develop acute complications, significant costs are incurred, as compared with the cost of maintaining a patient at low or moderate risk. Variance analysis further informs decision making by showing the need to have the right personnel doing the right tasks at the right time to control costs. CONCLUSIONS A TDABC approach facilitates an understanding of the drivers of cost in chronic illness care. Our paper highlights the stages in the care pathway where different settings, decision making and a more optimal use of resources could assist with achievement of better patient outcomes.
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Affiliation(s)
- Gerardine Anne Doyle
- College of Business, University College Dublin, National University of Ireland, Dublin, Ireland
- Geary Institute for Public Policy, University College Dublin, National University of Ireland, Dublin, Ireland
| | - Shane O'Donnell
- College of Business, University College Dublin, National University of Ireland, Dublin, Ireland
- Geary Institute for Public Policy, University College Dublin, National University of Ireland, Dublin, Ireland
| | - Kate Cullen
- College of Business, University College Dublin, National University of Ireland, Dublin, Ireland
| | - Etáin Quigley
- Applied Research for Connected Health, University College Dublin, National University of Ireland, Dublin, Ireland
| | - Sarah Gibney
- Geary Institute for Public Policy, University College Dublin, Dublin, Ireland
- Department of Health and Children, Dublin, Ireland
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da Silva Etges APB, Cruz LN, Schlatter R, Neyeloff J, Cardoso RB, Kopittke L, Nunes AA, Neto JA, Nogueira JL, de Assis RM, Tobias JSP, Marin-Neto JA, Moreira LB, Polanczyk CA. Time-driven activity-based costing as a strategy to increase efficiency: An analyses of interventional coronary procedures. Int J Health Plann Manage 2021; 37:189-201. [PMID: 34505319 DOI: 10.1002/hpm.3320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/16/2021] [Accepted: 08/23/2021] [Indexed: 11/07/2022] Open
Abstract
Monitoring the costs is one of the key components underlying value-based health care. This study aimed to evaluate the cost-saving opportunities of interventional coronary procedures (ICPs). Data from 90 patients submitted to elective ICP were evaluated in five Brazilian hospitals. Time-driven activity-based costing, that guides the cost estimates using the time consumed and the capacity cost rates per resource as the data input, was used to assess costs and the time spent over the care pathway. Descriptive cost analyses were followed by a labour cost-saving estimate potentially achieved by the redesign of the ICP pathway. The mean cost per patient varied from $807 to $2639. The length of the procedure phase per patient was similar among the hospitals, while the post-procedure phase presented the highest variation in length. The highest direct cost saving opportunities are concentrated in the procedure phase. By comparing the benchmark service with the most expensive one, it was estimated that redesigning physician practices could decrease 51% of the procedure cost. This application is pioneered in Brazil and demonstrates how detailed cost information can contribute to driving health care management to value by identifying cost-saving opportunities.
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Affiliation(s)
- Ana Paula Beck da Silva Etges
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Rio Grande do Sul, Brazil
- Programa de Pós-graduação em Epidemiologia da Escola de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- School of Technology, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- The TDABC in Healthcare Consortium, Porto Alegre, Rio Grande do Sul, Brazil
| | - Luciane Nascimento Cruz
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Rio Grande do Sul, Brazil
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Rosane Schlatter
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Rio Grande do Sul, Brazil
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jeruza Neyeloff
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Rio Grande do Sul, Brazil
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Ricardo Bertoglio Cardoso
- Programa de Pós-graduação em Epidemiologia da Escola de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- The TDABC in Healthcare Consortium, Porto Alegre, Rio Grande do Sul, Brazil
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Luciane Kopittke
- Grupo Hospitalar Nossa Senhora da Conceição, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - José Alburquerque Neto
- Hospital Universitário Presidente Dutra da Universidade Federal do Maranhão, São Luís, Maranhão, Brazil
| | - José Luiz Nogueira
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Renata Melo de Assis
- Hospital Universitário Presidente Dutra da Universidade Federal do Maranhão, São Luís, Maranhão, Brazil
| | | | - José Antonio Marin-Neto
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, São Paulo, Brazil
| | | | - Carisi Anne Polanczyk
- National Institute of Science and Technology for Health Technology Assessment (IATS)- CNPq/Brazil (project: 465518/2014-1), Porto Alegre, Rio Grande do Sul, Brazil
- Programa de Pós-graduação em Epidemiologia da Escola de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- The TDABC in Healthcare Consortium, Porto Alegre, Rio Grande do Sul, Brazil
- Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Programa de Pós-graduação em Cardiologia da Escola de Medicina da Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Antonacci G, Lennox L, Barlow J, Evans L, Reed J. Process mapping in healthcare: a systematic review. BMC Health Serv Res 2021; 21:342. [PMID: 33853610 PMCID: PMC8048073 DOI: 10.1186/s12913-021-06254-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 03/08/2021] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare. METHODS We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach. RESULTS The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions. CONCLUSION The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM. TRIAL REGISTRATION Prospero ID: CRD42017082140.
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Affiliation(s)
- Grazia Antonacci
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) Northwest London, London, UK
- Business School, Centre for Health Economics and Policy Innovation (CHEPI), Imperial College London, London, UK
| | - Laura Lennox
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) Northwest London, London, UK
| | - James Barlow
- Business School, Centre for Health Economics and Policy Innovation (CHEPI), Imperial College London, London, UK
| | - Liz Evans
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, London, UK
| | - Julie Reed
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, London, UK
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10
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Berthelot S, Breton M, Guertin JR, Archambault PM, Berger Pelletier E, Blouin D, Borgundvaag B, Duhoux A, Harvey Labbé L, Laberge M, Lachapelle P, Lapointe-Shaw L, Layani G, Lefebvre G, Mallet M, Matthews D, McBrien K, McLeod S, Mercier E, Messier A, Moore L, Morris J, Morris K, Ovens H, Pageau P, Paquette JS, Perry J, Schull M, Simon M, Simonyan D, Stelfox HT, Talbot D, Vaillancourt S. A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study. JMIR Res Protoc 2021; 10:e25619. [PMID: 33616548 PMCID: PMC7939947 DOI: 10.2196/25619] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. OBJECTIVE The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. METHODS A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. RESULTS Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. CONCLUSIONS The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/25619.
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Affiliation(s)
- Simon Berthelot
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
| | - Mylaine Breton
- Department of Community Health sciences, Université de Sherbrooke, Campus de Longueuil, Longueuil, QC, Canada
- Centre de recherche Charles-Le Moyne - Saguenay-Lac-Saint-Jean sur les innovations en santé, Longueuil, QC, Canada
| | - Jason Robert Guertin
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Patrick Michel Archambault
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Elyse Berger Pelletier
- Ministère de la santé et des services sociaux, Gouvernement du Québec, Québec, QC, Canada
| | - Danielle Blouin
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Bjug Borgundvaag
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
| | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada
| | - Laurie Harvey Labbé
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Maude Laberge
- Operations and Decision Systems Department, Faculty of Administrative Sciences, Université Laval, Québec, QC, Canada
| | - Philippe Lachapelle
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Géraldine Layani
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Gabrielle Lefebvre
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Myriam Mallet
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Deborah Matthews
- Ministry of Health and Long Term Care, Government of Ontario, Toronto, ON, Canada
| | - Kerry McBrien
- Departments of Family Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Shelley McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Eric Mercier
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
| | - Alexandre Messier
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Lynne Moore
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Judy Morris
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
- Hôpital du Sacré-Coeur-de-Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de Montréal, Montréal, QC, Canada
| | - Kathleen Morris
- Canadian Institute for Health Information, Ottawa, ON, Canada
| | - Howard Ovens
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
| | - Paul Pageau
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jean-Sébastien Paquette
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Laboratoire ARIMED, GMF-U de Saint-Charles-Borromée, Québec, QC, Canada
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Michael Schull
- Department of Emergency Medicine, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Mathieu Simon
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, Canada
| | - David Simonyan
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Denis Talbot
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Samuel Vaillancourt
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
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11
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Go JA, Weng CY. Process Mapping and Activity-Based Costing of the Intravitreal Injection Procedure. Curr Eye Res 2020; 46:694-703. [PMID: 32940071 DOI: 10.1080/02713683.2020.1825747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE/AIM OF THE STUDY To quantify the cost of performing an intravitreal injection (IVI) utilizing activity-based costing (ABC), which allocates a cost to each resource involved in a manufacturing process. MATERIALS AND METHODS A prospective, observational cohort study was performed at an urban, multi-specialty ophthalmology practice affiliated with an academic institution. Fourteen patients scheduled for an IVI-only visit with a retina ophthalmologist were observed from clinic entry to exit to create a process map of time and resource utilization. Indirect costs were allocated with ABC and direct costs were estimated based on process map observations, internal accounting records, employee interviews, and nationally-reported metrics. The primary outcome measure was the cost of an IVI procedure in United States dollars. Secondary outcomes included operating income (cost subtracted from revenue) of an IVI and patient-centric time utilization for an IVI. RESULTS The total cost of performing an IVI was $128.28; average direct material, direct labor, and overhead costs were $2.14, $97.88, and $28.26, respectively. Compared to the $104.40 reimbursement set by the Centers for Medicare and Medicaid Services for Current Procedural Terminology code 67028, this results in a negative operating income of -$23.88 (-22.87%). The median clinic resource-utilizing time to complete an IVI was 32:58 minutes (range [19:24-1:28:37]); the greatest bottleneck was physician-driven electronic health record documentation. CONCLUSIONS Our study provides an objective and accurate cost estimate of the IVI procedure and illustrates how ABC may be applied in a clinical context. Our findings suggest that IVIs may currently be undervalued by payors.
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Affiliation(s)
- Jonathan A Go
- School of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Christina Y Weng
- Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA.,Department of Ophthalmology, Ben Taub General Hospital, Harris Health System, Houston, Texas, USA
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12
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Etges APBDS, Ruschel KB, Polanczyk CA, Urman RD. Advances in Value-Based Healthcare by the Application of Time-Driven Activity-Based Costing for Inpatient Management: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:812-823. [PMID: 32540239 DOI: 10.1016/j.jval.2020.02.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/31/2019] [Accepted: 02/12/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Implementation of value-based initiatives depends on cost-assessment methods that can provide high-quality cost information. Time-driven activity-based costing (TDABC) is increasingly being used to solve the cost-information gap. This study aimed to review the use of the TDABC methodology in real-world settings and to estimate its impact on the value-based healthcare concept for inpatient management. METHODS This systematic review was conducted by screening PubMed/MEDLINE and Scopus databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including all studies up to August 2019. The use of TDABC for inpatient management was the main eligibility criterion. A qualitative approach was used to analyze the different methodological aspects of TDABC and its effective contribution to the implementation of value-based initiatives. RESULTS A total of 1066 studies were retrieved, and 26 full-text articles were selected for review. Only studies focused on surgical inpatient conditions were identified. Most of the studies reported the types of activities on a macrolevel. Professional and structural cost variables were usually assessed. Eighteen studies reported that TDABC contributed to value-based initiatives, especially cost-saving findings. TDABC was satisfactorily applied to achieve value-based contributions in all the studies that used the method for this purpose. CONCLUSIONS TDABC could be a strategy for increasing cost accuracy in real-world settings, and the method could help in the transition from fee-for-service to value-based systems. The results could provide a clearer idea of the costs, help with resource allocation and waste reduction, and might support clinicians and managers in increasing value in a more accurate and transparent way.
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Affiliation(s)
| | - Karen Brasil Ruschel
- National Institute of Science and Technology for Health Technology Assessment, Porto Alegre, Brazil
| | - Carisi Anne Polanczyk
- National Institute of Science and Technology for Health Technology Assessment, Porto Alegre, Brazil; Graduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA.
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13
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Are cost advantages from a modern Indian hospital transferable to the United States? Am Heart J 2020; 224:148-155. [PMID: 32402701 PMCID: PMC7194861 DOI: 10.1016/j.ahj.2020.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/14/2020] [Indexed: 11/24/2022]
Abstract
Background Multiple modern Indian hospitals operate at very low cost while meeting US-equivalent quality accreditation standards. Though US hospitals face intensifying pressure to lower their cost, including proposals to extend Medicare payment rates to all admissions, the transferability of Indian hospitals’ cost advantages to US peers remains unclear. Methods Using time-driven activity-based costing methods, we estimate the average cost of personnel and space for an elective coronary artery bypass graft (CABG) surgery at two American hospitals and one Indian hospital (NH). All three hospitals are Joint Commission accredited and have reputations for use of modern performance management methods. Our case study applies several analytic steps to distinguish transferable from non-transferable sources of NH’s cost savings. Results After removing non-transferable sources of efficiency, NH’s residual cost advantage primarily rests on shifting tasks to less-credentialed and/or less-experienced personnel who are supervised by highly-skilled personnel when perceived risk of complications is low. NH’s high annual CABG volume facilitates such supervised work “downshifting.” The study is subject to limitations inherent in case studies, does not account for the younger age of NH’s patients, or capture savings attributable to NH’s negligible frequency of re-admission or post-acute care facility placement. Conclusions Most transferable bases for a modern Indian hospital’s cost advantage would require more flexible American states’ hospital and health professional licensing regulations, greater family participation in inpatient care, and stronger support by hospital executives and clinicians for substantially lowering the cost of care via regionalization of complex surgeries and weekend use of costly operating rooms.
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14
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da Silva Etges APB, Cruz LN, Notti RK, Neyeloff JL, Schlatter RP, Astigarraga CC, Falavigna M, Polanczyk CA. An 8-step framework for implementing time-driven activity-based costing in healthcare studies. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:1133-1145. [PMID: 31286291 DOI: 10.1007/s10198-019-01085-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 06/24/2019] [Indexed: 05/20/2023]
Abstract
Micro-costing studies still deserving for methods orientation that contribute to achieve a patient-specific resource use level of analysis. Time-driven activity-based costing (TDABC) is often employed by health organizations in micro-costing studies with that objective. However, the literature shows many deviations in the implementation of TDABC, which might compromise the accuracy of the results obtained. One reason for that can be attributed to the non-existence of a step-by-step orientation to conduct cost analytics with the TDABC specific for micro-costing studies in healthcare. This article aimed at exploring the literature and practical cases to propose an eight-step framework to apply TDABC in micro-costing studies for health care organizations. The 8-step TDABC framework is presented and detailed exploring online spreadsheets already coded to demonstrate data structure and math formula building. A list of analyses that can be performed is suggested, including an explanation about the information that each analysis can provide to increase the organization capability to orient decision making. The case study developed show that actual micro-costing of health care processes can be achieved with the 8-step TDABC framework and its use in future researches can contribute to increase the number of studies that achieve high-quality level in cost information, and consequently, in health resource evaluation.
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Affiliation(s)
- Ana Paula Beck da Silva Etges
- National Health Technology Assessment Institute, CNPq, Porto Alegre, RS, Brazil
- School of Technology, PUCRS, Porto Alegre, RS, Brazil
- Hospital de Cliń icas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Luciane Nascimento Cruz
- National Health Technology Assessment Institute, CNPq, Porto Alegre, RS, Brazil
- Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
| | | | - Jeruza Lavanholi Neyeloff
- National Health Technology Assessment Institute, CNPq, Porto Alegre, RS, Brazil
- Hospital de Cliń icas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Rosane Paixão Schlatter
- National Health Technology Assessment Institute, CNPq, Porto Alegre, RS, Brazil
- Hospital de Cliń icas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Claudia Caceres Astigarraga
- Hospital de Cliń icas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
- Hospital Moinhos de Vento, Porto Alegre, RS, Brazil
- Unit of Hematology, HCPA, Porto Alegre, RS, Brazil
| | | | - Carisi Anne Polanczyk
- National Health Technology Assessment Institute, CNPq, Porto Alegre, RS, Brazil.
- Hospital de Cliń icas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.
- Hospital Moinhos de Vento, Porto Alegre, RS, Brazil.
- Department of Cardiology, School of Medicine, UFRGS, Porto Alegre, RS, Brazil.
- National Health Technology Assessment Institute, Universidade Federal Do Rio Grande Do Sul (UFRGS), Ramiro Barcelos, 2350, Building 21-507, Porto Alegre, 90035-903, Brazil.
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15
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Burns KE, Haysom HE, Higgins AM, Waters N, Tahiri R, Rushford K, Dunstan T, Saxby K, Kaplan Z, Chunilal S, McQuilten ZK, Wood EM. A time-driven, activity-based costing methodology for determining the costs of red blood cell transfusion in patients with beta thalassaemia major. Transfus Med 2018; 29:33-40. [PMID: 29637650 DOI: 10.1111/tme.12523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 02/22/2018] [Accepted: 03/02/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To describe the methodology to estimate the total cost of administration of a single unit of red blood cells (RBC) in adults with beta thalassaemia major in an Australian specialist haemoglobinopathy centre. BACKGROUND Beta thalassaemia major is a genetic disorder of haemoglobin associated with multiple end-organ complications and typically requiring lifelong RBC transfusion therapy. New therapeutic agents are becoming available based on advances in understanding of the disorder and its consequences. Assessment of the true total cost of transfusion, incorporating both product and activity costs, is required in order to evaluate the benefits and costs of these new therapies. METHODS We describe the bottom-up, time-driven, activity-based costing methodology used to develop process maps to provide a step-by-step outline of the entire transfusion pathway. Detailed flowcharts for each process are described. Direct observations and timing of the process maps document all activities, resources, staff, equipment and consumables in detail. The analysis will include costs associated with performing these processes, including resources and consumables. Sensitivity analyses will be performed to determine the impact of different staffing levels, timings and probabilities associated with performing different tasks. RESULTS Thirty-one process maps have been developed, with over 600 individual activities requiring multiple timings. These will be used for future detailed cost analyses. CONCLUSIONS Detailed process maps using bottom-up, time-driven, activity-based costing for determining the cost of RBC transfusion in thalassaemia major have been developed. These could be adapted for wider use to understand and compare the costs and complexities of transfusion in other settings.
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Affiliation(s)
- K E Burns
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - H E Haysom
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - A M Higgins
- Centre for Research Excellence in Patient Blood Management in Critical Illness and Trauma, Monash University, Melbourne, Victoria, Australia
| | - N Waters
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - R Tahiri
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - K Rushford
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - T Dunstan
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - K Saxby
- Centre for Health Economics, Monash University, Melbourne, Victoria, Australia
| | - Z Kaplan
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - S Chunilal
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Z K McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Centre for Research Excellence in Patient Blood Management in Critical Illness and Trauma, Monash University, Melbourne, Victoria, Australia.,Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - E M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
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16
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Tseng P, Kaplan RS, Richman BD, Shah MA, Schulman KA. Administrative Costs Associated With Physician Billing and Insurance-Related Activities at an Academic Health Care System. JAMA 2018; 319:691-697. [PMID: 29466590 PMCID: PMC5839285 DOI: 10.1001/jama.2017.19148] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 01/17/2018] [Indexed: 11/14/2022]
Abstract
Importance Administrative costs in the US health care system are an important component of total health care spending, and a substantial proportion of these costs are attributable to billing and insurance-related activities. Objective To examine and estimate the administrative costs associated with physician billing activities in a large academic health care system with a certified electronic health record system. Design, Setting, and Participants This study used time-driven activity-based costing. Interviews were conducted with 27 health system administrators and 34 physicians in 2016 and 2017 to construct a process map charting the path of an insurance claim through the revenue cycle management process. These data were used to calculate the cost for each major billing and insurance-related activity and were aggregated to estimate the health system's total cost of processing an insurance claim. Exposures Estimated time required to perform billing and insurance-related activities, based on interviews with management personnel and physicians. Main Outcomes and Measures Estimated billing and insurance-related costs for 5 types of patient encounters: primary care visits, discharged emergency department visits, general medicine inpatient stays, ambulatory surgical procedures, and inpatient surgical procedures. Results Estimated processing time and total costs for billing and insurance-related activities were 13 minutes and $20.49 for a primary care visit, 32 minutes and $61.54 for a discharged emergency department visit, 73 minutes and $124.26 for a general inpatient stay, 75 minutes and $170.40 for an ambulatory surgical procedure, and 100 minutes and $215.10 for an inpatient surgical procedure. Of these totals, time and costs for activities carried out by physicians were estimated at a median of 3 minutes or $6.36 for a primary care visit, 3 minutes or $10.97 for an emergency department visit, 5 minutes or $13.29 for a general inpatient stay, 15 minutes or $51.20 for an ambulatory surgical procedure, and 15 minutes or $51.20 for an inpatient surgical procedure. Of professional revenue, professional billing costs were estimated to represent 14.5% for primary care visits, 25.2% for emergency department visits, 8.0% for general medicine inpatient stays, 13.4% for ambulatory surgical procedures, and 3.1% for inpatient surgical procedures. Conclusions and Relevance In a time-driven activity-based costing study in a large academic health care system with a certified electronic health record system, the estimated costs of billing and insurance-related activities ranged from $20 for a primary care visit to $215 for an inpatient surgical procedure. Knowledge of how specific billing and insurance-related activities contribute to administrative costs may help inform policy solutions to reduce these expenses.
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Affiliation(s)
- Phillip Tseng
- Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Kevin A. Schulman
- Harvard Business School, Boston, Massachusetts
- Duke Clinical Research Institute and Department of Medicine, Durham, North Carolina
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Doyle G, O'Donnell S, Quigley E, Cullen K, Gibney S, Levin-Zamir D, Ganahl K, Müller G, Muller I, Maindal HT, Chang WP, Van Den Broucke S. Patient level cost of diabetes self-management education programmes: an international evaluation. BMJ Open 2017; 7:e013805. [PMID: 28583913 PMCID: PMC5623445 DOI: 10.1136/bmjopen-2016-013805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 02/01/2017] [Accepted: 03/09/2017] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The objective of this study was to examine the value of time-driven activity-based costing (TDABC) in understanding the process and costs of delivering diabetes self-management education (DSME) programmes in a multicountry comparative study. SETTING Outpatient settings in five European countries (Austria, Denmark, Germany, Ireland, UK) and two countries outside Europe, Taiwan and Israel. PARTICIPANTS Providers of DSME programmes across participating countries (N=16) including healthcare professionals, administrators and patients taking part in DSME programmes. PRIMARY AND SECONDARY MEASURES Primary measure: time spent by providers in the delivery of DSME and resources consumed in order to compute programme costs. Secondary measures: self-report measures of behavioural self-management and diabetes disease/health-related outcomes. RESULTS We found significant variation in costs and the processes of how DSME programmes are provided across and within countries. Variations in costs were driven by a combination of price variances, mix of personnel skill and efficiency variances. Higher cost programmes were not found to have achieved better relative outcomes. The findings highlight the value of TDABC in calculating a patient level cost and potential of the methodology to identify process improvements in guiding the optimal allocation of scarce resources in diabetes care, in particular for DSME that is often underfunded. CONCLUSIONS This study is the first to measure programme costs using estimates of the actual resources used to educate patients about managing their medical condition and is the first study to map such costs to self-reported behavioural and disease outcomes. The results of this study will inform clinicians, managers and policy makers seeking to enhance the delivery of DSME programmes. The findings highlight the benefits of adopting a TDABC approach to understanding the drivers of the cost of DSME programmes in a multicountry study to reveal opportunities to bend the cost curve for DSME.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ingrid Muller
- Department of Psychology, University of Southampton, Southampton, UK
| | | | - Wushou Peter Chang
- School of Public Health, Taipei Medical University, Taipei, Taiwan
- Department of Occupational Medicine, Shuang Ho and Taipei Medical University Hospital, Taipei, Taiwan
| | - Stephan Van Den Broucke
- Universite catholique de Louvain, Psychological Sciences Research Institute, Louvain, Belgium
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Haas DA, Kaplan RS. Variation in the cost of care for primary total knee arthroplasties. Arthroplast Today 2017; 3:33-37. [PMID: 28378004 PMCID: PMC5365411 DOI: 10.1016/j.artd.2016.08.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/03/2016] [Accepted: 08/06/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The study examined the cost variation across 29 high-volume US hospitals and their affiliated orthopaedic surgeons for delivering a primary total knee arthroplasty without major complicating conditions. The hospitals had similar patient demographics, and more than 80% of them had statistically-similar Medicare risk-adjusted readmission and complication rates. METHODS Hospital and physician personnel costs were calculated using time-driven activity-based costing. Consumable supply costs, such as the prosthetic implant, were calculated using purchase prices, and postacute care costs were measured using either internal costs or external claims as reported by each hospital. RESULTS Despite having similar patient demographics and readmission and complication rates, the average cost of care for total knee arthroplasty across the hospitals varied by a factor of about 2 to 1. Even after adjusting for differences in internal labor cost rates, the hospital at the 90th percentile of cost spent about twice as much as the one at the 10th percentile of cost. CONCLUSIONS The large variation in costs among sites suggests major and multiple opportunities to transfer knowledge about process and productivity improvements that lower costs while simultaneously maintaining or improving outcomes.
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Affiliation(s)
- Derek A. Haas
- Harvard Business School, Boston, MA, USA
- Avant-garde Health, Boston, MA, USA
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Anzai Y, Heilbrun ME, Haas D, Boi L, Moshre K, Minoshima S, Kaplan R, Lee VS. Dissecting Costs of CT Study: Application of TDABC (Time-driven Activity-based Costing) in a Tertiary Academic Center. Acad Radiol 2017; 24:200-208. [PMID: 27988200 DOI: 10.1016/j.acra.2016.11.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 11/01/2016] [Indexed: 11/17/2022]
Abstract
RATIONALE AND OBJECTIVES The lack of understanding of the real costs (not charge) of delivering healthcare services poses tremendous challenges in the containment of healthcare costs. In this study, we applied an established cost accounting method, the time-driven activity-based costing (TDABC), to assess the costs of performing an abdomen and pelvis computed tomography (AP CT) in an academic radiology department and identified opportunities for improved efficiency in the delivery of this service. MATERIALS AND METHODS The study was exempt from an institutional review board approval. TDABC utilizes process mapping tools from industrial engineering and activity-based costing. The process map outlines every step of discrete activity and duration of use of clinical resources, personnel, and equipment. By multiplying the cost per unit of capacity by the required task time for each step, and summing each component cost, the overall costs of AP CT is determined for patients in three settings, inpatient (IP), outpatient (OP), and emergency departments (ED). RESULTS The component costs to deliver an AP CT study were as follows: radiologist interpretation: 40.1%; other personnel (scheduler, technologist, nurse, pharmacist, and transporter): 39.6%; materials: 13.9%; and space and equipment: 6.4%. The cost of performing CT was 13% higher for ED patients and 31% higher for inpatients (IP), as compared to that for OP. The difference in cost was mostly due to non-radiologist personnel costs. CONCLUSIONS Approximately 80% of the direct costs of AP CT to the academic medical center are related to labor. Potential opportunities to reduce the costs include increasing the efficiency of utilization of CT, substituting lower cost resources when appropriate, and streamlining the ordering system to clarify medical necessity and clinical indications.
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Affiliation(s)
- Yoshimi Anzai
- Department of Radiology, University of Utah School of Medicine Health Sciences, 30 North 1900 East #1A071, Salt Lake City, UT 84132.
| | - Marta E Heilbrun
- Department of Radiology, University of Utah School of Medicine Health Sciences, 30 North 1900 East #1A071, Salt Lake City, UT 84132
| | - Derek Haas
- Harvard Business School, Boston, Massachusetts; Avant-garde Health, Boston, Massachusetts
| | - Luca Boi
- Department of Value Engineer, University of Utah School of Medicine Health Sciences, Salt Lake City, Utah
| | - Kirk Moshre
- Department of Radiology, University of Utah School of Medicine Health Sciences, 30 North 1900 East #1A071, Salt Lake City, UT 84132
| | - Satoshi Minoshima
- Department of Radiology, University of Utah School of Medicine Health Sciences, 30 North 1900 East #1A071, Salt Lake City, UT 84132
| | | | - Vivian S Lee
- Department of Radiology, University of Utah School of Medicine Health Sciences, 30 North 1900 East #1A071, Salt Lake City, UT 84132
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