Abstract：
OBJECTIVE: Time-driven activity-based costing (TDABC) is a method used in cost accounting that has gained traction in health economics to identify value optimization initiatives. It measures time, assigns value to time increments spent on a patient, and integrates the cost of material and human resources utilized in each episode of care. In this study, the authors report the first use of TDABC to evaluate costs in a pediatric neurosurgical practice.
METHODS: A clinical pathway was developed with a multifunction team. A time survey among each care team member, including surgeons, medical assistants (MAs), and patient service representatives (PSRs), was carried out prospectively over a 10-week period at a pediatric neurosurgery clinic. Consecutive patient encounters for Chiari malformation (CM), hydrocephalus, or tethered cord syndrome (TCS) were included. Encounters were categorized as new or established. Relative annual personnel costs, using the salary of a PSR as a reference (i.e., 1.0-unit cost), were calculated for all members using departmental financial data after adjustments. The relative capacity cost rates (minute-1) for each personnel, a representation of per capita cost per minute, were then derived, and the relative costs per visit were calculated.
RESULTS: A total of 110 visits (24 new, 86 established) were captured, including 40% CM, 41% hydrocephalus, and 19% TCS encounters. Surgeons had the highest relative capacity cost rate (118.4 × 10-6), more than 10-fold higher than that of an MA or PSR (10.65 × 10-6 and 9.259 × 10-6, respectively). Surgeons also logged more time with patients compared with the rest of the care team in nearly all visits (p ≤ 0.002); consequently, the total visit costs were primarily driven by the surgeon cost (p < 0.0001). Overall, surgeon cost constituted the vast majority of the total visit cost (92%-93%), regardless of whether the visits were new or established. Visit costs did not differ by diagnosis. On average, new visits took longer than established visits (p < 0.001). This difference was largely driven by new CM visits (44.3 ± 13.7 minutes), which were significantly longer than established CM visits (29.8 ± 9.2 minutes; p = 0.001).
CONCLUSIONS: TDABC may reveal opportunities to maximize value by highlighting instances of variability and high cost in each module of care delivery. Physician leaders in pediatric neurosurgery may be able to use this information to allocate costs and streamline value care pathways.
METHODS: A clinical pathway was developed with a multifunction team. A time survey among each care team member, including surgeons, medical assistants (MAs), and patient service representatives (PSRs), was carried out prospectively over a 10-week period at a pediatric neurosurgery clinic. Consecutive patient encounters for Chiari malformation (CM), hydrocephalus, or tethered cord syndrome (TCS) were included. Encounters were categorized as new or established. Relative annual personnel costs, using the salary of a PSR as a reference (i.e., 1.0-unit cost), were calculated for all members using departmental financial data after adjustments. The relative capacity cost rates (minute-1) for each personnel, a representation of per capita cost per minute, were then derived, and the relative costs per visit were calculated.
RESULTS: A total of 110 visits (24 new, 86 established) were captured, including 40% CM, 41% hydrocephalus, and 19% TCS encounters. Surgeons had the highest relative capacity cost rate (118.4 × 10-6), more than 10-fold higher than that of an MA or PSR (10.65 × 10-6 and 9.259 × 10-6, respectively). Surgeons also logged more time with patients compared with the rest of the care team in nearly all visits (p ≤ 0.002); consequently, the total visit costs were primarily driven by the surgeon cost (p < 0.0001). Overall, surgeon cost constituted the vast majority of the total visit cost (92%-93%), regardless of whether the visits were new or established. Visit costs did not differ by diagnosis. On average, new visits took longer than established visits (p < 0.001). This difference was largely driven by new CM visits (44.3 ± 13.7 minutes), which were significantly longer than established CM visits (29.8 ± 9.2 minutes; p = 0.001).
CONCLUSIONS: TDABC may reveal opportunities to maximize value by highlighting instances of variability and high cost in each module of care delivery. Physician leaders in pediatric neurosurgery may be able to use this information to allocate costs and streamline value care pathways.
摘要：
目标：时间驱动的基于活动的成本核算（TDABC）是一种用于成本核算的方法，在卫生经济学中获得了牵引力，以确定价值优化计划。它衡量时间，将价值分配给花费在患者身上的时间增量，并整合每集护理中使用的材料和人力资源成本。在这项研究中,作者报告了首次使用TDABC评估儿科神经外科手术的费用.
方法：由多功能团队开发临床路径。每个护理团队成员的时间调查，包括外科医生,医疗助理（MA），和病人服务代表(PSRs)，在儿科神经外科诊所进行了为期10周的前瞻性研究。连续患者遭遇Chiari畸形（CM），脑积水,或脊髓栓系综合征（TCS）包括在内。相遇被归类为新的或已建立的。相对年度人员成本，使用PSR的工资作为参考(即，1.0-单位成本)，使用调整后的部门财务数据为所有成员计算。每个人员的相对容量成本率(分钟-1)，表示每分钟的人均成本，然后得出，并计算了每次就诊的相对费用。
结果：共110次就诊（24次新，86个已建立)被捕获，包括40%CM，41%脑积水，和19%的TCS遭遇。外科医生的相对容量成本率最高(118.4×10-6)，比MA或PSR高10倍以上（分别为10.65×10-6和9.259×10-6）。在几乎所有就诊中，与其他护理团队相比，外科医生在患者身上的时间也更多（p≤0.002）；因此，总就诊费用主要由外科医生费用驱动(p<0.0001).总的来说,外科医生费用占总就诊费用的绝大部分(92%-93%)，不管访问是新的还是既定的。就诊费用因诊断而异。平均而言,新访视时间长于既定访视时间(p<0.001).这种差异主要是由新的CM访问（44.3±13.7分钟）驱动的，显着长于已建立的CM访问（29.8±9.2分钟；p=0.001）。
结论：TDABC可能通过突出每个护理提供模块中的可变性和高成本的实例来揭示最大化价值的机会。儿科神经外科的医师领导者可能能够使用这些信息来分配成本并简化价值护理途径。
方法：由多功能团队开发临床路径。每个护理团队成员的时间调查，包括外科医生,医疗助理（MA），和病人服务代表(PSRs)，在儿科神经外科诊所进行了为期10周的前瞻性研究。连续患者遭遇Chiari畸形（CM），脑积水,或脊髓栓系综合征（TCS）包括在内。相遇被归类为新的或已建立的。相对年度人员成本，使用PSR的工资作为参考(即，1.0-单位成本)，使用调整后的部门财务数据为所有成员计算。每个人员的相对容量成本率(分钟-1)，表示每分钟的人均成本，然后得出，并计算了每次就诊的相对费用。
结果：共110次就诊（24次新，86个已建立)被捕获，包括40%CM，41%脑积水，和19%的TCS遭遇。外科医生的相对容量成本率最高(118.4×10-6)，比MA或PSR高10倍以上（分别为10.65×10-6和9.259×10-6）。在几乎所有就诊中，与其他护理团队相比，外科医生在患者身上的时间也更多（p≤0.002）；因此，总就诊费用主要由外科医生费用驱动(p<0.0001).总的来说,外科医生费用占总就诊费用的绝大部分(92%-93%)，不管访问是新的还是既定的。就诊费用因诊断而异。平均而言,新访视时间长于既定访视时间(p<0.001).这种差异主要是由新的CM访问（44.3±13.7分钟）驱动的，显着长于已建立的CM访问（29.8±9.2分钟；p=0.001）。
结论：TDABC可能通过突出每个护理提供模块中的可变性和高成本的实例来揭示最大化价值的机会。儿科神经外科的医师领导者可能能够使用这些信息来分配成本并简化价值护理途径。
