- Email: [email protected]
Cost Comparison of In-Suite Versus Portable Tunneled Femoral Central Line Placements in Children Using Time-Driven Activity-Based Costing
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ORIGINAL ARTICLE
Cost Comparison of In-Suite Versus Portable Tunneled Femoral Central Line Placements in Children Using Time-Driven Activity-Based Costing Q16
Q2
Shireen E. Hayatghaibi, MA, MPH a,b , Alex Chau a, Ellen G. Wadler b, Matt H. Levine a, Alberto J. Hernandez a, Robert C. Orth c Abstract Objective: Compare the cost of placing tunneled femoral central lines in the interventional radiology suite to portable bedside placement using time-driven activity-based costing. Methods: Detailed process maps were created using information generated from interviews with frontline staff, direct shadowing of patient procedures (19 patients—8 in suite, 11 portable; patient age 4 days to 37 months; 6 males, 13 females), and electronic medical record review (80 patients—44 in suite, 36 portable; patient age 1 day to 20 months; 42 males, 38 females) who underwent a tunneled femoral central line placement at a tertiary care pediatric hospital from January 1, 2018, to June 30, 2018. Procedures were conducted in suite using fluoroscopy guidance or portably at the patient’s bedside using ultrasound. Capacity cost rates for each resource in the process maps were calculated for personnel, equipment, facilities, and supply costs. Costs for each process step were then calculated by multiplying the capacity cost rate by the mean duration of each step. Stepwise costs were summed for the entire process to generate a cost for each tunneled femoral central line placement pathway. Results: Total pathway time for tunneled femoral central lines placement in suite was 123 to 134 min (nonsedated) and 120 to 131 min (sedated) for a cost of $923 to $990 and $1,262 to $1,386, respectively. Total pathway time for tunneled femoral central lines placed portably were 117 to 119 min (nonsedated) and 115 to 147 min (sedated) for a cost of $1,060 to $1,066 and $1,379 to $1,393, respectively. Conclusion: Total costs of tunneled femoral central lines placed in suite were similar to total costs for lines placed portably. Cost should not be a primary consideration when deciding upon tunneled femoral central line approach in these patients. Key Words: Cost, economic, interventional J Am Coll Radiol 2019;-:---. Copyright ª 2019 American College of Radiology
INTRODUCTION Placement of central venous catheters is a commonly performed procedure in children for the management of infections, malignancies, and other chronic illnesses. The femoral vein is the preferred site of placement for patients with congenital cardiac diseases in which the upper extremity cannot be accessed, critically ill patients unstable for
a
Department of Radiology, Texas Children’s Hospital, Houston, Texas. University of Texas, School of Public Health, Houston, Texas. c Q 3 Department of Radiology, Children’s Hospital of Wisconsin, Wisconsin. Corresponding author and reprints: Shireen E. Hayatghaibi, MA, MPH, 6701 Fannin St, Houston, TX 77030; e-mail: [email protected]. The authors state that they have no conflict of interest related to the maQ 4 terial discussed in this article. b
transport, and infants. Central venous catheters can be placed in the interventional radiology (IR) suite using fluoroscopic guidance, which requires transporting patients from their inpatient location, or the lines can be performed portably, at patients’ bedside using ultrasound guidance. Portable placement is typically performed for critically ill patients when transport is not a viable option. In a recent retrospective study, bedside tunneled femoral central line (TFCL) placement, as an alternative approach for patients with high transfer risk, was not found to increase infection or complication risks compared with TFCL placement in suite [1]. Value-based health care, an approach to medical service delivery, was designed to address cost escalation while improving the quality of patient care. Value in health care
Copyright ª 2019 American College of Radiology 1546-1440/19/$36.00 n https://doi.org/10.1016/j.jacr.2019.11.004
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can be defined as health-related outcomes achieved per dollar spent [2]. The effect of improved clinical outcomes on value is well documented in the literature, but only recently have studies specifically focused on cost measurement been published in the imaging literature [3-8]. Although determining the relative safety of placing TFCLs in different settings and using varying technologies (in suite versus portable; fluoroscopy versus ultrasound guidance) is an essential first step for performing value comparisons, these outcomes only address the numerator of the value equation. To fully quantify value, both the outcome achieved and the cost of achieving that outcome must be measured [9]. For TFCL placements, regardless of approach, the true cost from the provider perspective remains largely unknown. The purpose of this study is to compare the cost of TFCL placements in the IR suite using fluoroscopic guidance to portable placements with ultrasound-guidance using time-driven activity-based costing (TDABC).
MATERIALS AND METHODS This HIPAA-compliant study was approved by the local institutional review board, and the need for written informed consent was waived. Detailed process maps were created using information generated from interviews with frontline staff, direct shadowing of patient procedures (19 patients—8 in suite, 11 portable; patient age 4 days to 37 months; 6 male, 13 female), and electronic medical record review (80 patients—44 in suite, 36 portable; patient age 1 day to 20 months; 42 male, 38 female) of patients who underwent TFCL placement at a tertiary care pediatric hospital from January 1, 2018, to June 30, 2018. Procedures were conducted in suite using fluoroscopic guidance or portable at the patient’s bedside using ultrasound.
Clinical Protocol TFCL placements consisted of patients with congenital cardiac conditions requiring maintenance of the upper extremity veins, patients with a history of complications resulting from an upper body central line, or critically ill patients unstable for transport to the IR in-suite. The decision to perform the TFCL procedure portably, at the patient’s bedside, was determined by any of the following: transportation contraindication such as airway or cardiopulmonary compromise, requirement for extracorporeal membrane oxygenation support, or oscillator ventilation. The bedside placement of TFCL primarily occurred in the intensive care unit with the primary team providing sedation for the procedure, or if indicated, the procedure was completed without sedation and included only local anesthesia. 2
Both the in-suite and portable procedures used standard sterile approaches, and the groin to the knee was prepared and draped. For procedures performed in the suite using the single-stick tunneled technique, placement of the femoral tunneled central venous catheter was performed with a 7cm, 21-gauge micropuncture needle (EchoTip; Cook, Bloomington, Indiana) under real-time ultrasound guidance (LOGIQ E L8 18-MHz high-frequency or 9 L–MHz linear transducers; GE Healthcare, Milwaukee, Wisconsin) from the medial thigh, above the knee. The needle was tunneled subcutaneously in a caudad-to-cranial approach to the common femoral vein, approximately 3 cm in length. Over the 0.018-inch wire, the access needle was exchanged for a peel-away sheath. The measuring wire was advanced approximately at or near (1 cm below) the inferior vena cava–right atrium junction. Final positioning was confirmed with fluoroscopy in the IR suite. For bedside TFCL placements, the catheter length measurement and final position confirmation were guided solely by ultrasound via the liver as a window. For both approaches, the catheter was secured with nonabsorbable suture material and a sterile dressing was applied over the access site. The catheter was packed with heparinized saline, typically 2 mL of 10 U/mL.
Time-Driven Activity-Based Costing The study estimated cost using TDABC. TDABC is a bottom-up, microcosting method that calculates the cost of a health care delivery process based on practical capacity units [10]. TDABC differs from a top-down method of cost accounting, such as relative value units, that relies upon set national average values for procedures, regardless of local process variation and resource input [11]. The cost to the institution calculated with bottom-up microcosting (ie, direct costing of inputs) allows for better understanding and use of excess capacity than a top-down method such as relative value units [12]. TDABC measures the cost of a patient’s treatment pathway by establishing detailed process maps, assigning time estimates through direct process shadowing and data capture, determining capacity costs rates, and summing all resource cost rates to calculate the true cost of care.
Process Mapping Two process maps were created—one for in-suite procedures and one for portable procedures. Both procedures began with the ordering team placing a request for vascular access consultation and concluded with finalization of the IR procedure report. Process maps were constructed through direct shadowing of 11 in-suite procedures and 8 portable bedside procedures by the study team. Maps were validated Journal of the American College of Radiology Volume - n Number - n Month 2019
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by a multidisciplinary team that consisted of registered nurses assigned to IR, interventional radiologists, anesthesiologists, certified registered nurse anesthetists, technologists, and administrative staff. Time durations (median) for each step were estimated through direct shadowing of procedures (n ¼ 19), time stamps acquired from the electronic patient records (n ¼ 80), or average estimates provided by clinical personnel with primary knowledge of the process. For each step in both processes, inputs such as personnel, resources consumed, and duration of the step were recorded. Allocation of resources was based on those directly involved in providing patient care along the pathway (derived through direct shadowing).
Costs The second phase of TDABC entailed calculating the cost for each step of both processes. This consisted of calculating the capacity cost rates of both personnel (cost of capacity supplied divided by practical capacity of resources supplied) and capital equipment and multiplying the respective capacity cost rates by the step duration [13]. The total cost of each step was then summed to calculate a time-driven cost for the entire process in the procedure cycle. The personnel cost for each staff type involved in the process was calculated by totaling the median personnel’s effective gross salary plus fringe benefits per year (Table 1). Practical capacity was calculated by using the total days per year minus vacation days, weekends, holidays, and training and meetings days. Hours per day were adjusted to only include hours specifically dedicated to clinical care (hours for meetings and breaks were subtracted). Personnel costs divided by the practical capacity were used to determine per-minute costs for each personnel type. Capital equipment costs were calculated for the biplane fluoroscopy unit used for the in-suite procedure and for the ultrasound unit used in both the in-suite and portable procedures. Total cost for equipment was calculated by combining the depreciation, maintenance, and service costs. Life cycle was calculated at 5 years for ultrasound and 7 years for biplane (per institutional policy of upgrading the machines at these intervals). Equipment cost per minute was multiplied by the number of minutes used in the procedure. Disposable supply costs were derived from institutional purchase prices of materials used such as catheter lines, peripherally inserted central catheter packs, dressings, and guide wires. Square footage was obtained for the IR suite and the patient room. Facility costs per square foot were multiplied by the relevant square footage obtained and included the overhead of environmental services for the facility. The summed cost of all steps plus administrative costs yielded a total cost for a given procedure.
Table 1. Capacity cost rates of TFCL approaches: in IR suite vs portable placement
Personnel IR technologist Floor physician Respiratory therapist IR nurse Anesthesiologist APP Interventional radiologist Capital equipment Ultrasound Fluoroscopy biplane Supplies† Facilities APP office IR room or control room IR staff gowning Inpatient room
IR Suite Capacity Cost Rate ($/min)*
Portable Capacity Cost Rate ($/min)*
1.23 1.30 1.32 5.68 1.86 5.64
1.23 4.12 1.32 5.68 1.86 5.64
0.16
0.06 -
257.00
257.00
0.11 0.66
0.11 0.66
0.14 -
0.14 .08
Source: institutional data. APP ¼ advanced practice provider; IR ¼ interventional radiology; TFCL ¼ tunneled femoral central line. *Units in US$. † Supplies costs are a flat fee (not a capacity cost rate).
Q13
Q14
RESULTS The in-suite and portable line placement procedures each followed one of four routes, which included two sedation pathways and a nonsedation pathway (Fig. 1a and 1b). The greatest contributor to cost for both TFCLs performed the IR suite and portably were personnel costs, which constituted 68% to 75% of overall costs for TFCLs performed in the IR suite and 74% to 80% of overall costs for portable line placement procedures. Space and equipment costs did not substantially contribute to the overall cost of the TFCL procedure, representing 4.8% to 5% of costs for procedures performed in the IR suite and 1% to 2% of costs for portable line placement procedures (Fig. 2a and 2b).
In-Suite TFCL Placement The total time for TFCL in-suite placement was dependent on three decision points: (1) initial consent and whether the parent or guardian was readily available for consent, (2) whether sedation was required, and (3) if a respiratory
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Fig 1. (a) Process map for tunneled femoral line placement in the interventional radiology (IR) suite. Capital letters represent individual steps. Circled numbers represent mean or median amount of time spent within each step, and colors correspond to the primary person performing the step as denoted in the legend. Noncolored steps represent decision points within the pathway. (b) Process map for tunneled femoral line placement performed portably. Capital letters represent individual steps. Circled numbers represent mean or median amount of time spent within each step, and colors correspond to the primary person performing the step as denoted in the legend. Noncolored steps represent decision points within the pathway. APP ¼ advanced practice provider; pt ¼ patient; SBAR ¼ ---; TFCL ¼ tunneled femoral central line; US ¼ ultrasound.
therapist was required to prepare and transport the patient to the IR suite for the procedure. Based on the decision points, a total of four possible pathways existed for the insuite TFCL placement. Total pathway time for patients undergoing TFCLs placed in suite ranged from 123 to 134 min for nonsedated patients and 120 to 131 min for sedated patients (Table 2). Total costs for TFCLs placed in suite for nonsedated patients ranged from $665 to $732 without disposable supplies and $923 to $990 with disposable supplies. Total costs for TFCLs placed in suite for sedated patients ranged from $1,004 to $1,128 without disposable supplies and $1,262 to $1,386 with disposable supplies (Table 2). The use of sedation for the TFCLs placed in suite represented a 27% to 29% increased cost compared with procedures performed without sedation. 4
Portable TFCL Placement The total time for TFCL placement performed portably was dependent on three decision points: (1) coordination with cardiovascular anesthesia, (2) parent availability for consent, (3) and use of sedation. Total pathway time ranged from 117 to 119 min for nonsedated patients with the lower bound representing patients whose parents or guardians were readily available for consent. Total pathway time for sedated patients was 115 to 147 min. Total costs for TFCLs placed portably for nonsedated patients ranged from $802 to $808 without disposable supplies and $1,060 to $1,066 with disposable supplies. Total costs for TFCLs placed portably for sedated patients included $1,121 to $1,135 without disposable supplies and $1,379 to $1,393 with disposable supplies (Table 2). The use of sedation for the TFCLs placed portably represented a 23.1% to 23.4% Journal of the American College of Radiology Volume - n Number - n Month 2019
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Fig 1. Continued
increased cost when compared with procedures conducted without the need for procedural sedation.
DISCUSSION This study calculated the cost of TFCL placements in infants and young children in the IR suite with fluoroscopic guidance versus portably with ultrasound guidance at the patient’s bedside. Overall, costs for TFCLs did not vary substantially based on whether the placement occurred in suite versus portably, with the exception that nonsedated TFCL placements in suite were slightly less costly. This relative cost similarity in part reflects a trade-off between the higher equipment costs for in-suite placements and the increased length of time the interventional radiologist spends on portable TFCL placements. This trade-off is important because it demonstrates that despite the shorter median procedural time for TFCLs placed in the IR suite compared with portable placements, the shorter procedure time did not translate into a lower costs. Several studies in the current literature focus on measuring the efficiency of IR procedures using procedure
duration as an outcome measure [14,15]. Criss et al examined the effect of using ultrasound guidance on safety and operative time for central line placement [15]. Their study of 2,010 tunneled central lines in patients less than 5 years of age concluded that ultrasound guidance was associated with a shorter operative time. The study further suggested that decreased procedure time may have implications on cost. Bakker et al state that the total Q 5 duration of the procedure may be used as an efficiency measure with a time-action analysis [11]. Their study used time-action analysis on 30 vascular and interventional procedures; however, resource use and a calculation of cost was not included. In the current study, TFCLs placed in the IR suite were associated with less operative time, but this did not convert into a cost savings. This study negates the assumption that a shorter procedure time will always equate to a decreased cost and further demonstrates that resource use is a significant contributor to cost. Kaplan and Anderson advocate using Q 6 TDABC to enhance lean management, using cost data in conjunction with process duration time to identify inefficiencies [13]. In the current study, by using TDABC to
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Fig 2. (a) Tornado diagram depicting cost drivers of tunneled femoral central line placed in the interventional radiology (IR) suite with sedated vs nonsedated patients. (b) Tornado diagram depicting cost drivers of tunneled femoral central line placed portably with sedated vs nonsedated patients.
estimate cost, we calculated the true cost of both procedural approaches as an outcome metric. By using only time duration as an outcome metric, the most cost-efficient procedure approach would not be apparent. Although the portable procedure duration was shorter, it was associated
with a higher cost, due to the interventional radiologist devoting more time compared with TFCLs completed in suite. Our study identifies the use of anesthesia as a significant contributor to the cost of TFCL placement. For infants
Table 2. Total times and costs for TFCLs placed in IR suite and portable placement IR Suite
Portable
Nonsedated
Sedated
Nonsedated
Sedated
Time range (min)
123-134
120-131
117-119
115-147
Cost range ($)*
923-990
1,262-1,386
1,060-1,066
1,379-1,393
IR ¼ interventional radiology; TFCL ¼ tunneled femoral central line. *Units in US$.
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weighing less than 10 kg, anesthesia was not performed (per institutional protocol), bypassing a major cost driver. Martin et al conducted a study that calculated cost using TDABC for carpal tunnel release in the operating room compared with an outpatient procedure room [10]. Their study demonstrated that anesthesia composed 27.6% ($156 of $564) of the overall cost of carpal tunnel release conducted in the operating room compared with an outpatient procedure room [10]. Lewis et al also found that anesthesia staffing costs were a major driver and potentially modifiable cost in thoracic duct embolization, as the overall amount of time the anesthesiologist was present for the procedures was highly variable by case [16]. These studies had similar results to the current study in that anesthesiologist time was the greatest labor factor that contributed to overall costs. Our study has a number of limitations that may impact precise cost estimates. Total scan times may be underestimated by using time stamps from the electronic health record, particularly in the case of portable TFCLs that require ultrasound when the technologist may be scanning the patient for some length of time before or after capturing the first or last image of vessel access. In our experience, using time stamps from the electronic medical record as the sole basis for cost estimation would bias the cost estimations. For instance, in comparing the procedure time duration for our shadowed cases to the time stamps in the electronic medical record, the IR suite case procedure times were relatively accurate. However, in comparing procedure durations for the portably placed TFCLs, the time stamps from the electronic medical record varied from those acquired through direct shadowing and were subject to missing start time values. This finding validated that direct shadowing is the preferred method for deriving time duration [12,13]. Other limitations include that capacity cost rates and maintenance costs for ultrasound and biplane equipment may vary by vendor and institutional contracts. Detailed processes and resource utilization are institution specific and may not be applicable to other pediatric tertiary academic institutions. Further studies calculating costs at multiple institutions are necessary to determine generalizability.
CONCLUSION Q 15
The use of TDABC revealed that the total cost of TFCLs placed in the IR suite with fluoroscopic guidance did not differ from TFCLs placed portably with ultrasound guidance at the patient’s bedside. Therefore, cost should not be the determining factor when deciding between the two procedure approaches.
TAKE-HOME POINTS -
TFCLs placed in the IR suite were associated with less operative (procedure) time.
-
The use of TDABC revealed that total costs of TFCLs placed in the IR suite with fluoroscopic guidance did not differ from TFCLs placed portably using ultrasound guidance at the patient’s bedside.
-
The use of anesthesia is a significant contributor to the cost of TFCL placements.
-
Cost should not be the determining factor when deciding between the two procedure approaches.
REFERENCES 1. Chau A, Hernandez JA, Pimpalwar S, Ashton D, Kukreja K. Equivalent success and complication rates of tunneled common femoral venous catheter placed in the interventional suite vs. at patient bedside. Pediatr Radiol 2018;48:889-94. 2. Porter ME. What is value in health care? N Engl J Med 2010;363:2477-81. 3. Hagedorn KN, Hayatghaibi SE, Levine MH, Orth RC. Cost comparison of ultrasound versus MRI to diagnose adolescent female patients presenting with acute abdominal/pelvic pain using time-driven Q7 activity-based costing. Acad Radiol 2019. 4. Husereau D, Drummond M, Petrou S, et al. Consolidated health economic evaluation reporting standards (CHEERS) statement. Cost Eff Resour Alloc 2013;11:6. 5. Keel G, Savage C, Rafiq M, Mazzocato P. Time-driven activity-based costing in health care: a systematic review of the literature. Health Policy 2017;121:755-63. 6. Koehler DM, Balakrishnan R, Lawler EA, Shah AS. Endoscopic versus open carpal tunnel release: a detailed analysis using time-driven activity-based costing at an academic medical center. J Hand Surg Am 2019;44 62.e1-9. 7. Shankar PR, Parikh KR, Heilbrun ME, et al. Cost implications of oral contrast administration in the emergency department: a time-driven activity-based costing analysis. J Am Coll Radiol 2019;16:30-8. 8. Zhou A, Yousem DM, Alvin MD. Cost-effectiveness analysis in radiology: a systematic review. J Am Coll Radiol 2018;15:1536-46. 9. Hayatghaibi SE, Davenport MS, Trout AT, Dillman JR. Quantifying Q8 value-based imaging. J Am Coll Radiol 2019. 10. Martin JA, Mayhew CR, Morris AJ, Bader AM, Tsai MH, Urman RD. Using time-driven activity-based costing as a key component of the value platform: a pilot analysis of colonoscopy, aortic valve replacement and carpal tunnel release procedures. J Clin Med Res 2018;10:314. 11. Rubin GD. Costing in radiology and health care: rationale, relativity, rudiments, and realities. Radiology 2017;282:333-47. 12. Kaplan RS, Porter ME. How to solve the cost crisis in health care. Harv Bus Rev 2011;89:46-52. 13. Kaplan RS, Anderson SR. Time-driven activity-based costing: a simpler and more powerful path to higher profits. Harvard Business Press; 2007. Q 9 14. Bakker NH, Tanase D, Reekers JA, Grimbergen CA. Evaluation of vascular and interventional procedures with time–action analysis: a pilot study. J Vasc Interv Radiol 2002;13:483-8. 15. Criss CN, Gadepalli SK, Matusko N, Jarboe MD. Ultrasound guidance improves safety and efficiency of central line placements. J Pediatr Q 10 Surg 2018. 16. Lewis SB, Srinivasa RN, Shankar PR, Bundy JJ, Gemmete JJ, Chick JFB. Thoracic duct embolization—value analysis using a timedriven activity-based costing approach: a single institution experience. Q 11 Curr Probl Diagn Radiol 2018.
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ORIGINAL ARTICLE
Cost Comparison of In-Suite Versus Portable Tunneled Femoral Central Line Placements in Children Using Time-Driven Activity-Based Costing Q16
Q2
Shireen E. Hayatghaibi, MA, MPH a,b , Alex Chau a, Ellen G. Wadler b, Matt H. Levine a, Alberto J. Hernandez a, Robert C. Orth c Abstract Objective: Compare the cost of placing tunneled femoral central lines in the interventional radiology suite to portable bedside placement using time-driven activity-based costing. Methods: Detailed process maps were created using information generated from interviews with frontline staff, direct shadowing of patient procedures (19 patients—8 in suite, 11 portable; patient age 4 days to 37 months; 6 males, 13 females), and electronic medical record review (80 patients—44 in suite, 36 portable; patient age 1 day to 20 months; 42 males, 38 females) who underwent a tunneled femoral central line placement at a tertiary care pediatric hospital from January 1, 2018, to June 30, 2018. Procedures were conducted in suite using fluoroscopy guidance or portably at the patient’s bedside using ultrasound. Capacity cost rates for each resource in the process maps were calculated for personnel, equipment, facilities, and supply costs. Costs for each process step were then calculated by multiplying the capacity cost rate by the mean duration of each step. Stepwise costs were summed for the entire process to generate a cost for each tunneled femoral central line placement pathway. Results: Total pathway time for tunneled femoral central lines placement in suite was 123 to 134 min (nonsedated) and 120 to 131 min (sedated) for a cost of $923 to $990 and $1,262 to $1,386, respectively. Total pathway time for tunneled femoral central lines placed portably were 117 to 119 min (nonsedated) and 115 to 147 min (sedated) for a cost of $1,060 to $1,066 and $1,379 to $1,393, respectively. Conclusion: Total costs of tunneled femoral central lines placed in suite were similar to total costs for lines placed portably. Cost should not be a primary consideration when deciding upon tunneled femoral central line approach in these patients. Key Words: Cost, economic, interventional J Am Coll Radiol 2019;-:---. Copyright ª 2019 American College of Radiology
INTRODUCTION Placement of central venous catheters is a commonly performed procedure in children for the management of infections, malignancies, and other chronic illnesses. The femoral vein is the preferred site of placement for patients with congenital cardiac diseases in which the upper extremity cannot be accessed, critically ill patients unstable for
a
Department of Radiology, Texas Children’s Hospital, Houston, Texas. University of Texas, School of Public Health, Houston, Texas. c Q 3 Department of Radiology, Children’s Hospital of Wisconsin, Wisconsin. Corresponding author and reprints: Shireen E. Hayatghaibi, MA, MPH, 6701 Fannin St, Houston, TX 77030; e-mail: [email protected]. The authors state that they have no conflict of interest related to the maQ 4 terial discussed in this article. b
transport, and infants. Central venous catheters can be placed in the interventional radiology (IR) suite using fluoroscopic guidance, which requires transporting patients from their inpatient location, or the lines can be performed portably, at patients’ bedside using ultrasound guidance. Portable placement is typically performed for critically ill patients when transport is not a viable option. In a recent retrospective study, bedside tunneled femoral central line (TFCL) placement, as an alternative approach for patients with high transfer risk, was not found to increase infection or complication risks compared with TFCL placement in suite [1]. Value-based health care, an approach to medical service delivery, was designed to address cost escalation while improving the quality of patient care. Value in health care
Copyright ª 2019 American College of Radiology 1546-1440/19/$36.00 n https://doi.org/10.1016/j.jacr.2019.11.004
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107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158
can be defined as health-related outcomes achieved per dollar spent [2]. The effect of improved clinical outcomes on value is well documented in the literature, but only recently have studies specifically focused on cost measurement been published in the imaging literature [3-8]. Although determining the relative safety of placing TFCLs in different settings and using varying technologies (in suite versus portable; fluoroscopy versus ultrasound guidance) is an essential first step for performing value comparisons, these outcomes only address the numerator of the value equation. To fully quantify value, both the outcome achieved and the cost of achieving that outcome must be measured [9]. For TFCL placements, regardless of approach, the true cost from the provider perspective remains largely unknown. The purpose of this study is to compare the cost of TFCL placements in the IR suite using fluoroscopic guidance to portable placements with ultrasound-guidance using time-driven activity-based costing (TDABC).
MATERIALS AND METHODS This HIPAA-compliant study was approved by the local institutional review board, and the need for written informed consent was waived. Detailed process maps were created using information generated from interviews with frontline staff, direct shadowing of patient procedures (19 patients—8 in suite, 11 portable; patient age 4 days to 37 months; 6 male, 13 female), and electronic medical record review (80 patients—44 in suite, 36 portable; patient age 1 day to 20 months; 42 male, 38 female) of patients who underwent TFCL placement at a tertiary care pediatric hospital from January 1, 2018, to June 30, 2018. Procedures were conducted in suite using fluoroscopic guidance or portable at the patient’s bedside using ultrasound.
Clinical Protocol TFCL placements consisted of patients with congenital cardiac conditions requiring maintenance of the upper extremity veins, patients with a history of complications resulting from an upper body central line, or critically ill patients unstable for transport to the IR in-suite. The decision to perform the TFCL procedure portably, at the patient’s bedside, was determined by any of the following: transportation contraindication such as airway or cardiopulmonary compromise, requirement for extracorporeal membrane oxygenation support, or oscillator ventilation. The bedside placement of TFCL primarily occurred in the intensive care unit with the primary team providing sedation for the procedure, or if indicated, the procedure was completed without sedation and included only local anesthesia. 2
Both the in-suite and portable procedures used standard sterile approaches, and the groin to the knee was prepared and draped. For procedures performed in the suite using the single-stick tunneled technique, placement of the femoral tunneled central venous catheter was performed with a 7cm, 21-gauge micropuncture needle (EchoTip; Cook, Bloomington, Indiana) under real-time ultrasound guidance (LOGIQ E L8 18-MHz high-frequency or 9 L–MHz linear transducers; GE Healthcare, Milwaukee, Wisconsin) from the medial thigh, above the knee. The needle was tunneled subcutaneously in a caudad-to-cranial approach to the common femoral vein, approximately 3 cm in length. Over the 0.018-inch wire, the access needle was exchanged for a peel-away sheath. The measuring wire was advanced approximately at or near (1 cm below) the inferior vena cava–right atrium junction. Final positioning was confirmed with fluoroscopy in the IR suite. For bedside TFCL placements, the catheter length measurement and final position confirmation were guided solely by ultrasound via the liver as a window. For both approaches, the catheter was secured with nonabsorbable suture material and a sterile dressing was applied over the access site. The catheter was packed with heparinized saline, typically 2 mL of 10 U/mL.
Time-Driven Activity-Based Costing The study estimated cost using TDABC. TDABC is a bottom-up, microcosting method that calculates the cost of a health care delivery process based on practical capacity units [10]. TDABC differs from a top-down method of cost accounting, such as relative value units, that relies upon set national average values for procedures, regardless of local process variation and resource input [11]. The cost to the institution calculated with bottom-up microcosting (ie, direct costing of inputs) allows for better understanding and use of excess capacity than a top-down method such as relative value units [12]. TDABC measures the cost of a patient’s treatment pathway by establishing detailed process maps, assigning time estimates through direct process shadowing and data capture, determining capacity costs rates, and summing all resource cost rates to calculate the true cost of care.
Process Mapping Two process maps were created—one for in-suite procedures and one for portable procedures. Both procedures began with the ordering team placing a request for vascular access consultation and concluded with finalization of the IR procedure report. Process maps were constructed through direct shadowing of 11 in-suite procedures and 8 portable bedside procedures by the study team. Maps were validated Journal of the American College of Radiology Volume - n Number - n Month 2019
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by a multidisciplinary team that consisted of registered nurses assigned to IR, interventional radiologists, anesthesiologists, certified registered nurse anesthetists, technologists, and administrative staff. Time durations (median) for each step were estimated through direct shadowing of procedures (n ¼ 19), time stamps acquired from the electronic patient records (n ¼ 80), or average estimates provided by clinical personnel with primary knowledge of the process. For each step in both processes, inputs such as personnel, resources consumed, and duration of the step were recorded. Allocation of resources was based on those directly involved in providing patient care along the pathway (derived through direct shadowing).
Costs The second phase of TDABC entailed calculating the cost for each step of both processes. This consisted of calculating the capacity cost rates of both personnel (cost of capacity supplied divided by practical capacity of resources supplied) and capital equipment and multiplying the respective capacity cost rates by the step duration [13]. The total cost of each step was then summed to calculate a time-driven cost for the entire process in the procedure cycle. The personnel cost for each staff type involved in the process was calculated by totaling the median personnel’s effective gross salary plus fringe benefits per year (Table 1). Practical capacity was calculated by using the total days per year minus vacation days, weekends, holidays, and training and meetings days. Hours per day were adjusted to only include hours specifically dedicated to clinical care (hours for meetings and breaks were subtracted). Personnel costs divided by the practical capacity were used to determine per-minute costs for each personnel type. Capital equipment costs were calculated for the biplane fluoroscopy unit used for the in-suite procedure and for the ultrasound unit used in both the in-suite and portable procedures. Total cost for equipment was calculated by combining the depreciation, maintenance, and service costs. Life cycle was calculated at 5 years for ultrasound and 7 years for biplane (per institutional policy of upgrading the machines at these intervals). Equipment cost per minute was multiplied by the number of minutes used in the procedure. Disposable supply costs were derived from institutional purchase prices of materials used such as catheter lines, peripherally inserted central catheter packs, dressings, and guide wires. Square footage was obtained for the IR suite and the patient room. Facility costs per square foot were multiplied by the relevant square footage obtained and included the overhead of environmental services for the facility. The summed cost of all steps plus administrative costs yielded a total cost for a given procedure.
Table 1. Capacity cost rates of TFCL approaches: in IR suite vs portable placement
Personnel IR technologist Floor physician Respiratory therapist IR nurse Anesthesiologist APP Interventional radiologist Capital equipment Ultrasound Fluoroscopy biplane Supplies† Facilities APP office IR room or control room IR staff gowning Inpatient room
IR Suite Capacity Cost Rate ($/min)*
Portable Capacity Cost Rate ($/min)*
1.23 1.30 1.32 5.68 1.86 5.64
1.23 4.12 1.32 5.68 1.86 5.64
0.16
0.06 -
257.00
257.00
0.11 0.66
0.11 0.66
0.14 -
0.14 .08
Source: institutional data. APP ¼ advanced practice provider; IR ¼ interventional radiology; TFCL ¼ tunneled femoral central line. *Units in US$. † Supplies costs are a flat fee (not a capacity cost rate).
Q13
Q14
RESULTS The in-suite and portable line placement procedures each followed one of four routes, which included two sedation pathways and a nonsedation pathway (Fig. 1a and 1b). The greatest contributor to cost for both TFCLs performed the IR suite and portably were personnel costs, which constituted 68% to 75% of overall costs for TFCLs performed in the IR suite and 74% to 80% of overall costs for portable line placement procedures. Space and equipment costs did not substantially contribute to the overall cost of the TFCL procedure, representing 4.8% to 5% of costs for procedures performed in the IR suite and 1% to 2% of costs for portable line placement procedures (Fig. 2a and 2b).
In-Suite TFCL Placement The total time for TFCL in-suite placement was dependent on three decision points: (1) initial consent and whether the parent or guardian was readily available for consent, (2) whether sedation was required, and (3) if a respiratory
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Fig 1. (a) Process map for tunneled femoral line placement in the interventional radiology (IR) suite. Capital letters represent individual steps. Circled numbers represent mean or median amount of time spent within each step, and colors correspond to the primary person performing the step as denoted in the legend. Noncolored steps represent decision points within the pathway. (b) Process map for tunneled femoral line placement performed portably. Capital letters represent individual steps. Circled numbers represent mean or median amount of time spent within each step, and colors correspond to the primary person performing the step as denoted in the legend. Noncolored steps represent decision points within the pathway. APP ¼ advanced practice provider; pt ¼ patient; SBAR ¼ ---; TFCL ¼ tunneled femoral central line; US ¼ ultrasound.
therapist was required to prepare and transport the patient to the IR suite for the procedure. Based on the decision points, a total of four possible pathways existed for the insuite TFCL placement. Total pathway time for patients undergoing TFCLs placed in suite ranged from 123 to 134 min for nonsedated patients and 120 to 131 min for sedated patients (Table 2). Total costs for TFCLs placed in suite for nonsedated patients ranged from $665 to $732 without disposable supplies and $923 to $990 with disposable supplies. Total costs for TFCLs placed in suite for sedated patients ranged from $1,004 to $1,128 without disposable supplies and $1,262 to $1,386 with disposable supplies (Table 2). The use of sedation for the TFCLs placed in suite represented a 27% to 29% increased cost compared with procedures performed without sedation. 4
Portable TFCL Placement The total time for TFCL placement performed portably was dependent on three decision points: (1) coordination with cardiovascular anesthesia, (2) parent availability for consent, (3) and use of sedation. Total pathway time ranged from 117 to 119 min for nonsedated patients with the lower bound representing patients whose parents or guardians were readily available for consent. Total pathway time for sedated patients was 115 to 147 min. Total costs for TFCLs placed portably for nonsedated patients ranged from $802 to $808 without disposable supplies and $1,060 to $1,066 with disposable supplies. Total costs for TFCLs placed portably for sedated patients included $1,121 to $1,135 without disposable supplies and $1,379 to $1,393 with disposable supplies (Table 2). The use of sedation for the TFCLs placed portably represented a 23.1% to 23.4% Journal of the American College of Radiology Volume - n Number - n Month 2019
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Fig 1. Continued
increased cost when compared with procedures conducted without the need for procedural sedation.
DISCUSSION This study calculated the cost of TFCL placements in infants and young children in the IR suite with fluoroscopic guidance versus portably with ultrasound guidance at the patient’s bedside. Overall, costs for TFCLs did not vary substantially based on whether the placement occurred in suite versus portably, with the exception that nonsedated TFCL placements in suite were slightly less costly. This relative cost similarity in part reflects a trade-off between the higher equipment costs for in-suite placements and the increased length of time the interventional radiologist spends on portable TFCL placements. This trade-off is important because it demonstrates that despite the shorter median procedural time for TFCLs placed in the IR suite compared with portable placements, the shorter procedure time did not translate into a lower costs. Several studies in the current literature focus on measuring the efficiency of IR procedures using procedure
duration as an outcome measure [14,15]. Criss et al examined the effect of using ultrasound guidance on safety and operative time for central line placement [15]. Their study of 2,010 tunneled central lines in patients less than 5 years of age concluded that ultrasound guidance was associated with a shorter operative time. The study further suggested that decreased procedure time may have implications on cost. Bakker et al state that the total Q 5 duration of the procedure may be used as an efficiency measure with a time-action analysis [11]. Their study used time-action analysis on 30 vascular and interventional procedures; however, resource use and a calculation of cost was not included. In the current study, TFCLs placed in the IR suite were associated with less operative time, but this did not convert into a cost savings. This study negates the assumption that a shorter procedure time will always equate to a decreased cost and further demonstrates that resource use is a significant contributor to cost. Kaplan and Anderson advocate using Q 6 TDABC to enhance lean management, using cost data in conjunction with process duration time to identify inefficiencies [13]. In the current study, by using TDABC to
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Fig 2. (a) Tornado diagram depicting cost drivers of tunneled femoral central line placed in the interventional radiology (IR) suite with sedated vs nonsedated patients. (b) Tornado diagram depicting cost drivers of tunneled femoral central line placed portably with sedated vs nonsedated patients.
estimate cost, we calculated the true cost of both procedural approaches as an outcome metric. By using only time duration as an outcome metric, the most cost-efficient procedure approach would not be apparent. Although the portable procedure duration was shorter, it was associated
with a higher cost, due to the interventional radiologist devoting more time compared with TFCLs completed in suite. Our study identifies the use of anesthesia as a significant contributor to the cost of TFCL placement. For infants
Table 2. Total times and costs for TFCLs placed in IR suite and portable placement IR Suite
Portable
Nonsedated
Sedated
Nonsedated
Sedated
Time range (min)
123-134
120-131
117-119
115-147
Cost range ($)*
923-990
1,262-1,386
1,060-1,066
1,379-1,393
IR ¼ interventional radiology; TFCL ¼ tunneled femoral central line. *Units in US$.
6
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575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 626
627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678
weighing less than 10 kg, anesthesia was not performed (per institutional protocol), bypassing a major cost driver. Martin et al conducted a study that calculated cost using TDABC for carpal tunnel release in the operating room compared with an outpatient procedure room [10]. Their study demonstrated that anesthesia composed 27.6% ($156 of $564) of the overall cost of carpal tunnel release conducted in the operating room compared with an outpatient procedure room [10]. Lewis et al also found that anesthesia staffing costs were a major driver and potentially modifiable cost in thoracic duct embolization, as the overall amount of time the anesthesiologist was present for the procedures was highly variable by case [16]. These studies had similar results to the current study in that anesthesiologist time was the greatest labor factor that contributed to overall costs. Our study has a number of limitations that may impact precise cost estimates. Total scan times may be underestimated by using time stamps from the electronic health record, particularly in the case of portable TFCLs that require ultrasound when the technologist may be scanning the patient for some length of time before or after capturing the first or last image of vessel access. In our experience, using time stamps from the electronic medical record as the sole basis for cost estimation would bias the cost estimations. For instance, in comparing the procedure time duration for our shadowed cases to the time stamps in the electronic medical record, the IR suite case procedure times were relatively accurate. However, in comparing procedure durations for the portably placed TFCLs, the time stamps from the electronic medical record varied from those acquired through direct shadowing and were subject to missing start time values. This finding validated that direct shadowing is the preferred method for deriving time duration [12,13]. Other limitations include that capacity cost rates and maintenance costs for ultrasound and biplane equipment may vary by vendor and institutional contracts. Detailed processes and resource utilization are institution specific and may not be applicable to other pediatric tertiary academic institutions. Further studies calculating costs at multiple institutions are necessary to determine generalizability.
CONCLUSION Q 15
The use of TDABC revealed that the total cost of TFCLs placed in the IR suite with fluoroscopic guidance did not differ from TFCLs placed portably with ultrasound guidance at the patient’s bedside. Therefore, cost should not be the determining factor when deciding between the two procedure approaches.
TAKE-HOME POINTS -
TFCLs placed in the IR suite were associated with less operative (procedure) time.
-
The use of TDABC revealed that total costs of TFCLs placed in the IR suite with fluoroscopic guidance did not differ from TFCLs placed portably using ultrasound guidance at the patient’s bedside.
-
The use of anesthesia is a significant contributor to the cost of TFCL placements.
-
Cost should not be the determining factor when deciding between the two procedure approaches.
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