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MP32-15: Care Pathway Variation and Surgical Cost Measurement for Percutaneous Nephrolithotomy with Time-Driven Activity-Based Costing

Saturday, May 13
9:30 AM - 11:30 AM
Location: BCEC: Room 252

Presentation Authors: Ian Metzler*, Dylan Issac, Manint Usawachintachit, Matthew Hudnall, Kazumi Taguchi, David Tzou, Tom Chi, San Francisco, CA

Introduction: The majority of health care cost data are based on charges or reimbursements, but these approaches fail to accurately represent the money hospitals actually spend to provide services. Time-driven activity-based costing (TDABC) provides a methodology to better understand true costs of providing a health care service and the variations in cost based on variance in timing. We applied TDABC analysis to a percutaneous nephrolithotomy (PCNL) care pathway.

Methods: The care pathway for PCNL was defined as the time from patient arrival to the preoperative area to discharge from post anesthesia care unit (PACU) to the hospital floor. Process maps were created with perioperative stakeholders to define the activities involved in PCNL. Stop-watch timing was performed for eleven PCNL cases. The cost rate for attending urologists was calculated using publicly available salaries and estimated capacity, additional cost rates were estimated using a ratio of the averaged salaries for each staff position.

Results: The activities demonstrating the greatest time variance were PACU recovery, preoperative holding, and stone clearance (214±100.3, 99±67.2 and 36±28.2 minutes respectively). The activities with the least variation were anesthesia extubation, nephrostomy tube placement and patient repositioning (13±3.9, 9±4.3, 16±6.3 minutes respectively). Total cost including disposables and overhead for the average PCNL was $5319. Preoperative care accounted for $470 (7%), intraoperative care accounted for $4351 (84%) and post-operative care accounted for $353 (9%) of the total. Thirty-seven percent of cost was attributable to disposables. Theoretical modeling with an attending performing all perioperative activities (rather than a resident) increased the human resource cost by 31%. Removing the highest time outliers from each activity reduced the cost by 21%.

Conclusions: Although utilizing the operative room is the most cost intensive activity for PCNL, variation exists during different phases of care. Opportunities for standardization to reduce cost is greatest in the pre- and post-operative areas. The TDABC methodology allows for estimation of true costs for PCNL and modeling of care pathway variation in order to understand health care costs and target areas for increased care value.


Source Of Funding: None

Ian Metzler

I am a urology resident in fourth year at University of California San Francisco. Interested in global urology, cost measurement and bioengineering. I will be starting a Master's of Translational Medicine degree at the Berkeley School of Bioengineering in July. At AUA 2017 I will be presenting on Time Driven Activity Based Costing project of percutaneous nephrolithotomy.

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