Introduction: The evaluation, management, and clinical guidelines surrounding vesicoureteral reflux (VUR) remain highly variable despite being a common pediatric diagnosis, all of which make costing unpredictable. Time-Driven Activity-Based Costing (TDABC) is a novel costing methodology that is purported to provide a rapid and more accurate calculation of total costs vs. traditional costing methods. It also frames granular insights into cost drivers and savings opportunities for a given diagnosis. The aim of the study is to employ TDABC to characterize institutional costs for three management pathways for VUR.
Methods: We developed detailed process maps for VUR management based on practice guidelines applicable to a hypothetical female VUR index patient with grade 3 unilateral reflux without bowel-bladder dysfunction at our tertiary-care center institution. The cost of three management pathways were described: observation with continuous antibiotic prophylaxis (OCAP); minimally-invasive endoscopic surgery (EDP) with dextranomer/hyaluronic acid; and open re-implantation surgery (ORP). Costs for each pathway were calculated using the capacity cost rate ($/minute) for institutional resources and time estimates of resource utilization captured through direct observation and EMR data. The three pathways engaged the full spectrum of possible follow-up visits, diagnostic imaging, and interventions in VUR management.
Results: A substantial range of total costs was observed for all pathways: OCAP ($1,683.58 - $2,041.12), EDP ($2,262.37 - $4,012.89), and ORP ($3,317.76 - $3,924.82). On average, variation in diagnostic imaging accounted for an average of $558.81 to the cost of management pathways. Moreover, total costs for a single DMSA scan accounted for 8%-15% of any pathway’s overall costs. Material costs for VCUG imaging and endoscopic surgery were high at 59% and 64%-76% of their individual total costs, respectively. For open-reimplantation surgery, higher costs were attributable to the longer use of operating room space (vs. EDP) and inpatient post-operative stay, the latter accounting for 21.7% of total costs of ORP.
Conclusions: To our knowledge, this is the first application of TDABC to describe the cost of services delivered in pediatric urology. TDABC demonstrates significant cost variability in VUR treatment modalities and identified local cost drivers to target. This type of analysis can be useful for other potential patients with various grades, laterality, age and sex of VUR, as well as in other complex management situations. Source of
Funding: This project was supported by the AUA Medical Student Fellowship