McClintock TR. et al., 2021: Determining variable costs in the acute urolithiasis cycle of care through time-driven activity-based costing.
McClintock TR, Friedlander DF, Feng AY, Shah MA, Pallin DJ, Chang SL, Bader AM, Feeley TW, Kaplan RS, Haleblian GE.
Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Urology, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA; Harvard Business School, Boston, MA.
Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Harvard Business School, Boston, MA.
Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Harvard Business School, Boston, MA; The Institute for Cancer Care Innovation and Division of Anesthesiology and Critical Care, The University of Texas MD Anderson Cancer Center, Houston, TX.
Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
Abstract
Objective: To characterize full cycle of care costs for managing an acute ureteral stone using time-driven activity-based costing.
Methods: We defined all phases of care for patients presenting with an acute ureteral stone and built an overarching process map. Maps for sub-processes were constructed through interviews with providers and direct observation of clinical spaces. This facilitated calculation of cost per minute for all aspects of care delivery, which were multiplied by associated process times. These were added to consumable costs to determine cost for each specific step and later aggregated to determine total cost for each sub-process. We compared costs of eight common clinical pathways for acute stone management, defining total cycle of care cost as the sum of all sub-processes that comprised each pathway.
Results: Cost per sub-process included $920 for emergency department (ED) care, $1665 for operative stent placement, $2368 for percutaneous nephrostomy tube placement, $106 for urology clinic consultation, $238 for preoperative center visit, $4057 for ureteroscopy with laser lithotripsy (URS), $2923 for extracorporeal shock wave lithotripsy, $169 for clinic stent removal, $197 for abdominal x-ray, and $166 for ultrasound. The lowest cost pathway ($1388) was for medical expulsive therapy, whereas the most expensive pathway ($8002) entailed a repeat ED visit prompting temporizing stent placement and interval URS.
Conclusion: We found a high degree of cost variation between care pathways common to management of acute ureteral stone episodes. Reliable cost accounting data and an understanding of variability in clinical pathway costs can inform value-based care redesign as payors move away from pure fee-for-service reimbursement.
Urology. 2021 Aug 12:S0090-4295(21)00757-3. doi: 10.1016/j.urology.2021.05.102. Online ahead of print. PMID: 34391774
Comments 1
One of the most common questions asked when methods for stone removal are discussed is the cost-effectiveness. There are several answers found in the literature. In this regard this article is highly interesting. The authors have applied a time-driven activity-based analysis of the conditions relevant for the authors’ department in Boston. The index patient had a ureteral stone measuring 10 mm. The current report differs from other economic analyses because the time utilized for different procedures and the cost per minute are factors included.
There are of course some assumptions made in these calculations that can be discussed. First that the time allocated for SWL was set to 24 minutes. This is a consumption of time that certainly can vary considerably between different units, but so are also the 46 minutes for a URS-procedure.
The authors emphasize, that if stone-free rates are less than 60-64% for SWL and better than 56-76% for URS, then SWL would be less cost-effective. It must be mentioned that the hospital rented the shockwave lithotripter and did not have their own. Exactly how this situation influenced the result is not known.
Although it always is very difficult to compare costs between different health economic systems and the results shown in this article are from USA, the data nevertheless can serve as a rough guide when procedures for stone patients are compared. The article is worthwhile reading for surgeons, urologists, and health administrators.
Hans-Göran Tiselius