artanorg Costing Hospital Surgery Services: The Method Matters @PLOS|ONE Costing Hospital Surgery Services: The Method Matters Abstract Accurate hoapal costs ar require or poicy- makers, hospi managers and ciriins to mproveeieny ad tanspareny Fowover ern mahoos a used aloes eect coos ana the grooms pootyundertod Tea of fos Susy os tb asses te agreomontbetweon botomap an op-own al cot fe ape of cugaloperatone na enc ean centre. Two thousand one hundred and thy consecutive procedures performed between January and October 2010 were analysed. Top- clown costs were basec on pre-determined weigh, while bottom-up costs were caleulated through an activiy-hased costing (ABC) ‘model. The agreement was assessed using corelation coofciets and the Bland and Altman method. Variables associated wit the diference between methods were identified wit bivariate ané multivariate near regressions. ‘The correlation coefiient amounted to 0.73 (969%CI: 0.72; 0.78). The overall agreement botwoen methods was poor In a multivariate analysis, the cost ference was independently associated with age (Seta=~2.4; p=0.02), ASA score (Beta 76.3 'p<0.001), RCI (Beta=S 5; p<0,00'), stating level (Beta=4870, p<0,001) and intervention duration (Beta=—10-5; 0.001), ‘The ability of the current method to provide relevant information to managers, clinicians and payers is questionable. Asin other European countries, a shit towards ime-driven acivty-based costing should be advocated Citation: Mercier G, Naro G (2014) Costing Hospital Surgery Services: The Method Matters. PLOS ONE 9(5): £97280. htips:idol or!10.137 vjournal pane.0087290 Editor: Taltha L. Feenstra, National Institute for Public Health and the Enviconment, Netherlands Received: September 28, 2013; Accepted: April 18, 2014; Published: May 9, 2014 Copyright: © 2014 Mercier, Naro. This is an open-access article distriouted under the terms ofthe Creative Commons Auton License, which permits unresticted use, distibulon, and reproduction in any medium, provided the orginal author ‘and source are credited Funding: This work has been pally funced by a research grant from the Univesity Montpelier 1 (BOR UM1 11118117), (blo wvw.univemantpt ft), The funder had no eo in study design, data collection and analysis, decision to publish, 0° Preparation of the manuscript, No additional extemal funding was received for this study. Competing interests: The authors have declared that no competing interests exit Introduction Healthcare reforms worldwide have led to an increased reliance on hospital accounting practices. Ina resource-constained environment, accurately estimating the cost of hosptal services is ofthe utmost importance in the pursul of efficiency and ransparency. Hospitals are anced through ORG (Diagnosis Related Group)-based prospective payment systems in most high- Income countries [1]. In this context, hospitals have to locate and alminateinefciences, i., services for which the production cost Is sign‘ieanty higher than the price (2. Hence, hospitals need reliable patient-level cost estimates to accurately measure resource Ullsaton [3], [4] [5] Accurate and relevant coat nfarmation an haspital services a the patient levels therefore fundamental for policy makers, payers and hospitals. However, costing is particularly dificult in the hospital setting due to case heterogeneity labour intensity and the complexity ofthe production processes. Evidence shows considerable cost variation for a given service which can result from provider and patient charactristes, th efficiency evel, the underlying clinical actly and, mast importantly, the costing method [6], htpsfournals pls. org/plosonearticle?id=10.197 journal pone. 0097290 veartanorg Costing Hospital Surgery Services: The Method Matters ‘Allocating hospital costs to patients (or groups of patients) typicaly involves three steps [Z| the allocation of hospital overhead costs to departments the allocaton of department averhead costs to patient, and the allocation of department direc cost to pation. Tho focus ofthis work on the third stop Indeed, various costing methods are used to allocate department drect costs to Patients, and there is a lack of standardisation (] [8] A two-step classification process of hasptal costing methodologies based on the level of accuracy has been proposed [10]. First, cost components are ldenttied ether atthe aggregate level (gross costing) or atthe patient level (riracosting). Then, cost components are valued ether by alloting costs from comprehensive sources (to)- {own approach), or by daniying resource consumption at the patient level (botlom-up approach). According to this classifcaton, top-down microcosting results in average unit costs por patient, whereas bottom-up microcosting leads to patient-specific unt costs. Countries apply either method, mainly depencing on the avalailly of paientlavel cost data. For instance, Finland, Germany, the Netherlands and Sweden apply a bollor-up approach, while England, Estonia and France rely an a top-down ‘method [7], All othor things being equal, the choice of costing method might significantly affect the cost estimates (1), [1], [12]. Few studios have investigated the agreement between botton-up and top-down microcosting on large samples, which seems to be moderate at best 12} In the hosptal setting, bottom-up microcostng Is considered to be more accurate and relevant than top-down methods TZ]. (10), thas been recommended to apply @ bottom-up microcosting method for nospial services having a large proportion of ‘and overhead [14]. However, identifying costs at an Individual patent level's time consuming and expensive [14] Is therefore aavocated to restrict the tse of bottom-up micracostng forthe cost components having a signifeant impact on the total cost, namely labour costs and labour-intensive services (10) nthe context of international clical rials, diferent methods might lead to diferent estimates of average treatment costs (18), (18), (17) [18 In France, the curent costing method for surgical services is top-down microcosting, which consists of allocating aggregate costs to individual operations according to the surgical procedure performed on a work unt desis called relative cost index (RCI) [19], (20) Consequenly, @ gven procedure performed ina given setting will aways be allocated the same cost. Intuively, the main limitation otis approach les inthe fact thatitignores the variation in resource consumption occurring forte indlvidval patient, as reflectes for instance by the variation in procedure durations or by the varaton in the number of medical and non-medical personnel Involves. Activiy-based costing (ABC) isa wellknown botiom-up microcosting method that has been used in the service gactor since the 1980s [21] and, more recently, to cost surgery services (13), [221 23, [24]. [25], [28]. ABC estimates the cost of individual hospital services by assessing the actual amount of speci rescurces that contribute to produce each service. In contrast la top-down rmierocosting, actvity-based costing accounts forthe individual within-procedure variation in resource use. Similaly to other bottom. Up microcosting methods, is main limitations le inthe complexity and cost of implementation, which might explain alow adoption rate in the hospital sector [27], ‘This study focuses on the costing of abdominal surgery pracadures fortwo reasons. Fist seems reasonable fo assume that surgery procedures are among the most labour-intensive healthcare services. Second, surgical care has been shown to exhibit the lowest agreement between top-down and Doltomup cost estimates [13] The aims of the study were (1) to assess the agreement between the two costing methods and (2) o identity variables cost ditferences. Materials and Methods The study tok place in the abdominal surgery department ofthe Montpelier University Hospital, a French 2 150-bed tertiary centre. ll consecutive inpatient surgical procedures performed during the year 2070 in this Gapartment were included. Total hospital expenses incurred from the ent ino th operating room untl the ext from the postanaesthosia care unt were considered, including those related tothe preparation, cleaning and management ofthe operating theatres. Three categories of fexpenses were considered ang provided by the hasplal accounting department () medieal, nurse ang administrative sta, i) tugs and medical equipment (including depreciation and maintenance) an (i) overhead costs (supplies, taxes, insurance, ules and oan ilorast. Prostheses and other single-use materials were nt considered, as our purpose was to focus on expenses that ‘are potentially subjected to allocation errors. Dala on resource use in the operating room were provided by a computerised ‘operating room register. Indvidual unit costs were estimated twice atthe patent level using the curent top-down method and the bottor-up method. Clinical information was extracted rom electronic medical records, The accounting database, the operaling room req'ster and medical racords were inked using an anonymous patient ID. Using such information for research purposes is allowed by French law Individual unit costs for the same sample of surgical procedures were estimated withthe current top-down microcosting method. ‘The caleuaton folowad the national guidalnes issued by te Franch Ministry of Healln [28]. The top-down mathod involves two stops. Fist, staff costs are allocated to each procedure proportional to the pre-defined cost weights. Indeed, the French Classification of medical procedures is similar fo the ICD-10 Procedure Coding Syslam and assigns a relative waight lo each surgical procedure called a Relative Cost Index (RCI). RCls wore defined by medical expert panels in te early 1980s [28] ana were revised in 2003 [30]. They are updated yearly to incorporate new procedures. RCls aught to retlect the average resource ‘consumption intensity attached to eacn surgical procedure and should aim to cover al direct and inctect costs excepting ‘overheads. This calculation is made irespective of the day (weekday vs. weekendsinights) and of tre actual duration and staffing lavel of a given operation. The second step consists of allocating the remaining casts (drugs and medical equipment and overheads) proportionally fo the staff costs, and therefore, proportionally tothe RI as weil. together, the top-down microcosting ‘method relies solely and entrely on pre-determined cost weights (RCIs) htpsfournals pls. org/plosoneartile?id=10.197 journal pone. 0097290 28artanorg Costing Hospital Surgery Services: The Method Matters ‘The implementation of the ABC model folowed three standard steps: mapping activites, calculating the cost of each activity and calculating the unit cost of each procedure. The activity mapping consisted o fst systematically analysing the stancare operation procedures and then performing semi-structured interviews with administrative, nurse and medica sa ofthe surgery and intensive care wards, Eleven relevant, mutually exclisve and collectively exhaustive activities were defined. Seven primary activities ‘matched the chronological steps of performing a surgical procedure, from the admission ofthe palit inf the operating room unt ‘hoi ext from the post-anaesthesia care unt. These activites included the individual operating room setup, the pation’s postioning (on the operating table, the induction of anaesthesia, the surgical procedure itself, the wound dressing, the leaning and the recovery time in the post-anaesthesia care unl. Additonally four secondary actvlies were defined: daly operating roam selup and clearing, planning management, surgical management and anaesthetic management. Management achves included all other ‘asks performad by the surgery or anaesthatic staf but unrelated Io a given patient Actviy costs were calculated using cost drivers avaliable in the hospital information system: safing levels and duration of each step. The computerised operating room registor Brovided information onthe numberof professionals involved in each step ofa given individual procedure and on is duraion. The fverage time spent by administrate, nutee and medical staff on secondary activiles was assessed through sem-stuctured interviews. To account forthe actual stafing practices, the calculation distinguished between anaesthes ology and surgery staf 9s oll as betwen weekdays, nights or weekends. By weighting the cumulated curation of each actwty with ts stating level, we Calclated the total staff cost of each actly All nn-stalf cass, including overheads and equipment amorisation, were added propotionally to staff costs. Unit costs per individual patient were finally computed by inking each procedure to primary and ‘secondary activities through actual duratons, actual stating levels and the total numberof procedures. This calculation was Performed consecutively for anaesthetic and surgical costs and separately for weekdays ard weekendinight procedures. Unit costs were presented using means, standard deviations and quartiles as appropriate. The overall agreement between the two ‘methods was assessed using two complementary approaches: the Spearman non-parametric coefficient of correlation an the Bland and Allman methad [31]. Regaraing the corelation coetcient, values abave 0.6 are deemed satisfactory for group Comparisons (Le., comparisons of several stratogios based on pooled data fom mutiple pationts) and values above 0.9 are ‘adequate for individual assessments (ve, te cost estimation fora single patient) (13). The Bland and Allman method is wisely Used in clinical epidemiology when the same concept is measured by two diferent methods. The acceptably threshold was set at 2.000 Euros, i. the average unit cost per inpatient slay at Monipolier University hospital in 2010. The cost diference between the ‘wo methods was calculated as top-down cost minus bottom-up cost. Hence, a postive cost difference indicates that the top-down cost is greater than the bottom-up cost. To understand discrepancies, a bivariate analys's ofthe cost cference was performed Using near regrossion models withthe folowing varables. gondor, age, anaesthotic sk, staffing level (numberof surgeons performing the procedure), satus ofthe responsible surgeon (senior vs. junior surgeon), duration of the Intervention phase, relative Cost index (RI, eccurrence of an anaesthetic complication during the procedure, emergency context and procedure parfarmed ‘uring on call periods (weekends or night). The indvidual anaesthetic risk was assessed tough the American Society of [Anacsthesiologists score (ASA), which measures the physical stale of patients before surgery [32], The ASA score ranges from 1 (fll neath) to 6 (brain-dead patient). Age, ASA score, RCI, stafing level and intervention duration were analysed as continuous Variables. Then, a multivariate analysis of the cost ference was implemented using a multiple linear regression model. Only Variables signiicanty associated with the cost ference in bivariate analysis were included in the multivariate model. Al stalstical tests wore porformad using a 5% type-ane risk. Statistical analyses wore porformed wih the statistical sofware SAS version 9.2, (GAS Insitute, Cary, NC) Results Between January and October 2010, 2 943 consecutive procedures were performed. Of these, 813 (28%) were non-surgical procedures (central venous catheter placements, resuscitation procedures and endoscopies) and were therefore included inthe Costing process but excluded from the slalstcal analyss. These vory shor and low-cost procedures would have unnecessary Increasee the data heterogenely. The statistical analysis was conducted on a sub-sample of 2130 surgical procedures, of which 422 (18.8%) had been performed in an emergency context and 238 (11 2%) had been performed during weekends or nights (Table 1), Patients wore 54 years ald on average, and 975 (48%) were female, The total cost ofthe 2 130 surgical procedures was. provided by the accounting department as « 962 900 Euras, of which 88% was for non-medical staf, 23% for macieal staff, 16% for {rugs and medical equipment and 5% for overheads, The relative cost index (RCI) ofthe 2 130 procedures ranges from 14 (minor Superficial surgery under local anaesthesia) to 1 298 (total nepatectomy). According tothe top-down method, the average cost per Individual procedure was 2 331 Euros (SD=1 720) and ranged from 73 to 16 721 Euros (Zable 1). According to the ABC bottom-up ‘method, primary aciviios amounted to 87% ofthe total expenses (Table 2). The average cost per incvidual procedure was 2 186 Euros ($0=1 381) and ranged from 648 to 14 516 Euros (Table 1). Table 2 shows detailed duration, cast diver, unt costs and total cost per activi Table. Sample characteristic, hitpsfournals pls. org/plosoneartile?id=10.197 journal pone.0097290 aeartanorg Costing Hospital Surgery Services: The Method Matters ‘tesla org/10-1371ournal pone.0087290.1001 2. Activity duration, cot divers, value of ui cost and costs staf costs only), los tioorq/10.137 Vjgurnal pone.0097290 1002 ‘The Spearman non-parametric cosfcient of coreation amounted to 0.73 (95%CI: 0.72; 0.76), which is adequate for a group comparison but not for an individual assessment, The mean diference between bollom-up and top-down costs was 144 Euros (SD. 4168). The Bland ang Altman graph shows an overall poor agreement between the two costing methods, 2s the vast majonty of poinis le above or below the central ine. The lower and upper agreement ints are equal fo -2 146 and 2 494 Euros, respectively (igure 1). There is no obvious fixed bias but rather a clear proportionate one: te size ofthe difference between the methods Increases with ine mean cost Each dot represents an individual procedure; the dotted ine shows the ordinary least squares regression, llasido’org/10.137 journal pone.0097290, 001 ‘The bivariate analysis suggested that the cost ference was positively associated with age, female sex, ASA score, RCI and staffing level and was negatively assocated with junior surgeon and interverton éuration (Table 3). Thus, variables included inthe analysis, the cost afference was independently associated with age (Beta (Geta=5.5; p<0.001), stating level (sta~=437.0; pe0.001) and intervention duraton (Bet Salus wore nat signifeantly associated wih cost difference As the cos éference was calculated as the top-down cost minus the bottor-up cost, the former cost was significantly higner than the later when patienis were female and nad a higher anaesthetic Fisk, ween the RC! ofthe procedure was higher and wien the numer ef surgeons (staffing level) was higher. By contrast, the top- ‘own cost was signifiany lower when te patient was clder and when the intervertion phase was longer. On average, a one year increase in age was associated wit a 24 Euros decrease in cost difference. a one point increase in the ASA score was associated vith a 78.3 Euros increase in the diforence; a one point increase in the procedure RCI was associated wih a 5.5 Euros increase; {and a one minute increase in the duration ofthe Intervention phase was associated with a 10.5 Euros decrease. The model R- ‘Square was equal fo 0.63. ‘nes lidoorg/10,171fournal pone, 00972901003 Discussion htpsfournals. pls. org/plosonearticle?id=10.197 journal pone. 0097290 48artanorg Costing Hospital Surgery Services: The Method Matters This study aimed to investigate the senstvty of the patient-level cost of surgical services to te costing method. On a consecutive sample of2 130 surgical procedures performad in a French feriary centr, te overall agreement between top-down ard bottom-up Imierocosting appears tobe poor. Indeed, the correlation coeticient amounted to 0.73 (85%4CI: 0.72: 0.76), which might be sucient for group comparisons (valve>0 50) as part ofa cost-atectivenses analysis but not for patient-level analysis (valve<0.90), According to the Bland and Altman method, the upper ana lower limits of agreement both exceed 2 000 Euros in absolute value, Wich means that 95% of the true differences between the microcosting methods would be lower than that amount. Given the ‘average unit cost at Montpelier University Hospital in 2010 (2 052 Euros), this amount is obviously substantial. These findings corroborate previous work highlighting the senstiviy of inpatient cost estimates to the costing method (8), [1] [13], [14]. Wo focused on surgery services, while most published stucies do not distinguish between surgery and non-surgery services. Nonetheless, our results strongly euppor the fact that bottom-up mieracasting signiicanly depars from top-down methods i |oour-intensive services (10) In the mutivariato analysis, the cost aference between methods was independently associated wih age, ASA score, procedure FCI, staffing evel and intervention duration. The magnitude is paricularly high regarding procedure RCI (Bela=5.5) and Intervention duration (Beta=~10.5) Indeed, a one-standard deviation increase in the RCI a In the intervention duration would ranslate to a 1 061 Euros increase or a 1 165 decrease, respectively, in he cost ference. Stafing level and intervention duration Wore used in the botlam-ap costing method, while the procedure RCI was the main cost driver inthe top-down method. All thre Srvers are somehow related tothe complexity of surgical procedures. However, RCls are cost weights efined a priv to reflect ‘average resource consumption levels [30], As RCls are constant for a given surgical pracedur, they do not account forint procedure variatons due to patient-level factors. In this study, the duration might reflect surgery complex as it excludes in ‘operating room wating times, but the relationship isnot straightforward. Indeed, the intervention curation is strongly liked with surgery complexity, and curation and complexiy are somelmes considered to be the same concept [33], The stafing level can be fan indvect marker of surgery complexty and a marker of organisational performance [34], Age and ASA score reflect surgery Comploxily related to underving paientlevel factors. Patant sex, surgoon slalus, onal period, emergency context and anaesthetic complications were not sgnfcanty associated with the cost ifference, This Outcome might be due to collinearity and {o.alack of power. For instance, the ASA score is strongly associated with the risk of anaesthetic complication, and there were only £56 (2.8%) procedures performed by junior surgeons. ‘The methods compared in this work are both microcostng approaches, but the bottom-up approach is more accurate at the pationt level 5, [21 {10}. Indeed, using patient-level factors such as actual duration and staffing level allows the cost to reflec Inavidual resource consumption variations [21]. Consequently, the ABC bottom-up cost can be laken for a proxy ofthe tue oppartunty cost, ‘and any deviation from this cost might be intrpreted as a cross subsideaton, The current top-down mleracosting method tends to ‘overestimate the cost of procedures performed an patients with a high ASA score involving more staff and having 2 high RCI NNovertnoloss, this method underestimates the cost of longer procedures performed on alder patients. Those patentaly conficting findings might be partially explained by the fact that staing levels and RCI are poorly associated with surgical complexity (30), (34) However, these assumplions are not easily testable and must therefore be considered cautiously. ‘These results might be analysed considering that the top-down method allocates indirect charges only based onthe RCI. Hence, this method does not have the same abil to reflect patient-level factors. Ths sitvalion reinforces the hypothesis thal the lop-down method imperfectly captures the complexity of procedures [20] ‘Atogathor, the agroomant between bottom-up ans top-down microcosting s poor, bottom-up costs reveal cross-subsiasation, and the eiference between both methods is explained by patien-sevel factors. ‘These findings have potential implications for hospital transparency and efficiency, in most high and middle income counties, hospitals are increasingly paid through prospectively defined DRGs tars, which are Usually based on national average costs calculated on a sample of voluntoer hospitals [1]. One of tho underlying assumptions is ‘hat cost varaton betwoen hospitals reacts heterogeneity in endogenaus facors over which hospitals have contro. I not, some DRGs may De artfcially more profitable than others. and the allocative efficiency ofthe system willbe threatened [25]. Our results ‘sugges! that some palientiovel cos factors are heterogeneous, namely the individual anaesthetic risk level (ASA Score) and age. ‘These factors are not reflects by the top-down service costs If the dstriotion ofthese non-controlable factors isnot equal across hospitals, then the faimess and efficiency ofthe financing system are questionable. ‘This study suggests that top-down costing methods do not reflect some important potentially controllable factors such as medical and nursing staffing levels and, to some extent, intervention duration. Consequenly, hospitals might fal to identify ane target inefficient processes. ‘An improvement could be to shi from the current top-down costing method towards a bottom-up method in France. As actvity= based costing in the hospital setting 's considerably resource-consuming [1], implementing @ stepwise strategy towards a long- term objective of ime-drven actvly-based costing isa more reals option [S], Regarding Surgery services, one crucal change Is 0 allocate operating-room charges using surgery and anaesthesia durations instead of predefined weights such as RCI. In doing, 9, the French mathod would pally converge towards olher European hospital casting eysteme such as te English and German systems [3 ‘This study suffers soveal limitations. A large and exhaustive sample of operations was included but within single surgery partment in a single hospital. This approach could hinder the generalisabily of our findings. Nevertheless, tis plausible that allocating staf costs to individual medical procedures entails the same sleps and the same iseues no mattor the setting Consequently, the poor agreement between top-down and bottom-up costing methods might be generalisable to a certain extent. [As deecrined in previous papars reporting the implementation of ABC model, the cost of dala caplure and analysis i vey high [22]. However, our method relates to time-driven actity-based costing (TD-ABC) In that most of the activly and resource drivers ‘are durations (26). TO-ABLC has been shown tobe less resource-ntensive than ABC (27), end our work might therefore be more htpsfournals. pls. org/plosonearticle?id=10.197 journal pone. 0097290 seartanorg Costing Hospital Surgery Services: The Method Matters easily generaisable to other settings. In the actvty-based costing, non-staf costs have been allocated proportional to staff. cost, hich might not necessarly reflect the actual resource consumption. Nevertheless, we have done so in order to be consistent with ‘he top-down costng method, and our approach tends to reduce ary diffrence between the two methods. Conclusion Accurate patientlovel costing is crical to improve efficiency and transparency n the hospilal sattng. Based ona large sample of Consecutive surgical procedures in a French teriary contro, this study conv the overall poor agreoment betwoen top-down and bottor-up methods. The current top-down mettod falls fo reveal patient-level resource-use variatons and leads to considerable ‘ross-susiisations. Hence, the ably of the current method to provide relevant information to managers, clnc:ans and payers is (questionable. Asin other European counties, @ shit towards time-drven actvy-based costing should be advocated, Acknowledgments: We would lke to thank Dr Prete Aubas (CHU de Montpelier) for his helpful comments. ‘Author Contributions Conceived and designed the experiments: GM GN. Performed the experiments: GM. 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