Circulation: Cardiovascular Interventions

RESEARCH LETTER

Catheterization Laboratory Activity-Based Costing

Subhash Banerjee , MD; Peter Monteleone, MD; Scott Novak, PhD

T
he terms cost and price are often used interchange-
ably. Whereas cost is the expense incurred to develop
a product or service, price is the amount charged to a
customer.1 Therefore, the commonly relied upon practice
of estimating health care costs based on fees charged
does not measure the actual system cost of treating
patients.2 The method of time-driven activity-based cost-
ing assesses the actual costs of all processes during a
particular episode of care.3 Both hospitals and physician
practices are challenged by third-party payers to provide
transparency in the costs associated with staff, equip-
ment, and facility overhead. Cardiovascular services are
consistently at the top of health care expenditures in the
United States and among the top financial contributors
to a hospital’s total revenue.4 The current study provides
a unique opportunity to identify the cost-drivers in 4 of
the most common interventional cardiology procedures.
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their costs were calculated per procedure. A summated
total was determined. Measured costs per procedure for
staff labor were calculated by multiplying standardized
actual Veterans Affairs labor category rates (eg, senior
physician, junior nurse, resident, fellow) by time spent on
each episode of care leading to the procedure, intrapro-
cedure and postprocedure. Site equipment costs were
calculated as the unit cost multiplied by the number of
units used in each procedure. Direct facility costs were
calculated using the standardized catheterization labo-
ratory overhead cost per procedure time. Within each
category, arithmetic means and standard errors were cal-
culated for comparisons. The procedural categories are
mutually exclusive per patient. Multiple procedures within
an episode of care were then categorized as primary,
secondary, or tertiary. PCI and PVI were always classi-
fied as primary. Comparisons were conducted using tests

Data were captured from a single Veterans Admin-
istration hospital in Dallas, Texas, from a sample of 100
randomly selected scheduled outpatients from July 1,
2019, to July 26, 2019. Study was determined by the
institutional review board to not require an approval.
These procedures were grouped as right or left heart
catheterization hemodynamic assessments (collectively
termed, right/left heart catheterization), coronary angi-
ography (coronary diagnostic), percutaneous coronary
intervention (PCI, inclusive of applicable diagnostic angi-
ography), and peripheral vascular interventions to non-
coronary arteries (PVI). A research intern prospectively
documented each aspect of care for these patients by
following a process map that began with the placement
of a catheterization laboratory consult and continued
until discharge or return to the hospital bed after pro-
cedure termination. Three specific cost-driver categories
were identified (staff labor, facility, and equipment), and
for mean differences within (t test) and between (ordi-
nary least squares regression contrasts) procedures and
cost-drivers. The authors declare that all supporting data
are available within the article.
The distribution of procedures used in this analysis
(Figure) is proportioned similarly to the per annum dis-
tribution of cases for this hospital, located in the South-
western United States. Most were coronary diagnostic
(64%) or PCI (23%). The remaining cases were distrib-
uted between PVI (7%) and right/left heart catheteriza-
tion (6%). The most expensive procedural subtypes were
PVI (mean=$10  035.57) and PCI (mean=$9122.08;
Figure), compared with coronary diagnostic ($1771.08)
and right/left heart catheterizations ($1035.18). Results
from multivariate general linear model contrasts, PCI and
PVI were statistically different (P<0.05) from coronary
diagnostic and right/left catheterization procedures.
The primary cost-driver within each procedure was

Key Words:  episode of care ◼ health care costs ◼ hospitals ◼ patients ◼ physician

 
Correspondence to: Subhash Banerjee, MD, University of Texas Southwestern Medical Center, Chief, Division of Cardiology & Director Cardiac Catheterization
Laboratory, Veterans Affairs N Texas Health Care System, Dallas, TX. Email subhash.banerjee@utsouthwestern.edu
This manuscript was sent to Ian C. Gilchrist, MD, Guest Editor, for review by expert referees, editorial decision, and final disposition.
For Sources of Funding and Disclosures, see page 365.
© 2021 American Heart Association, Inc.
Circulation: Cardiovascular Interventions is available at www.ahajournals.org/journal/circinterventions

Circ Cardiovasc Interv. 2021;14:e010228. DOI: 10.1161/CIRCINTERVENTIONS.120.010228 March 2021 364

 Banerjee et al
Figure. Catheterization laboratory procedure costs.
Depicts types of cathlab procedures and cost in US dollars. Three specific cost-driver categories were identified and calculated per procedure:
Staff Labor, Facility, and Equipment, and a summated total. Average physician revenue based units for the study period was 6.13. Lt indicates
left; and Rt, right.
equipment, which accounted for 85% of the total costs
for PCI and 80% for PVI. These percentages were also
significantly different from catheterization and coronary
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diagnostic procedures. The percentage of total costs
incurred by staff costs were highest for coronary diag-
nostic angiography and right/left heart catheterization
(39%, 45%) procedures and lowest among PCI and PVI
(14%, 18%). Mean total time in care with respect to the
catheterization laboratory staff effort was also compared
by primary diagnosis. PVI and PCI were the highest (18
hours 7 minutes versus 12 hours 3 minutes). Right/
left heart catheterization and coronary diagnostic angi-
ography (4 hours 47 minutes versus 6 hours 48 min-
utes) were the lowest. These were significantly different
(F=77, 496 df, P<0.001) from each other except for
coronary diagnostic and right/left heart catheterization
(P=0.366). The contribution of resident or fellow mean
labor time was also compared, although accounted for
a fairly small percentage of the overall labor time for
coronary diagnostic (13%), right/left heart catheteriza-
tion (9%), PCI (16%), and PVI (22%). These differences
were statistically significant within the general linear
model contrasts (f=106.62, 496 df, P<0.001). The only
2 pairwise contrasts from the general linear model that
were not statistically significant were between coronary
diagnostic angiography and right/left heart catheteriza-
tion (P=0.282), also between PCI and PV (P=0.059).
Studies investigating medical costs associated with
common catheterization laboratory procedures are
typically limited to third-party payer (ie, claims).2,5 This
Circ Cardiovasc Interv. 2021;14:e010228. DOI: 10.1161/CIRCINTERVENTIONS.120.010228
Cath Lab ABC
is among the first studies examining the real costs for
procedural performance. The primary limitations include
these data are derived from a single site with a narrow
patient population composed of US veterans. Work is
underway to expand the study data to other hospital
organizations and payer structures. The key takeaways
from this study are the (1) reported actual incurred time-
derived activity-based costings for invasive cardiac cath-
eterization laboratory procedures; (2) the percentage of
total costs incurred by staff costs were highest for diag-
nostic procedures, such as coronary angiography and
right/left heart catheterization procedures and lowest
among PCI and PVI; (3) equipment costs represented
over half of the incurred cost for coronary angiography
and right/left heart catheterization procedures, and an
even larger percentage of approximately three-fourths of
the total costs for PCI and PVI.
ARTICLE INFORMATION
Affiliations
University of Texas Southwestern Medical Center and Veterans Affairs North
Texas Health Care System, Dallas (S.B.). University of Texas at Austin Dell Medi-
cal School, Austin (P.M.). Kingfish Statistics & Data Analytics, Durham, NC (S.N.).
Sources of Funding
None.
Disclosures
Dr Banerjee receives honoraria from Medtronic, Cordis, Livmor, AngioSafe and
Institutional Research Grants from Boston Scientific Corporation, Chiesi. Disclo-
sures provided by Dr Banerjee in compliance with American Heart Association’s
annual Journal Editor Disclosure Questionnaire are available at https://www.aha-
March 2021 365
 Banerjee et al
journals.org/pb-assets/policies/COI_09_2020-1600719273583.pdf. Dr Novak
is a consultant at Medtronic, Cardinal Health (formerly Johnson & Johnson).
Dr Monteleone is a consultant for Medtronic; Biotronik; receives Institutional
Research Grant from Medtronic; and noncompensated research data-sharing
agreement with Abbott Vascular.
REFERENCES
1. Applegate R, Sacrinty M, Schafer P, Smith J, Gandhi S, Kutcher M, Santos R,
Cecile A, Little W. Cost effectiveness of radial access for diagnostic car-
diac catheterization and coronary intervention. Catheter Cardiovasc Interv.
2013;82:E375–E384. doi: 10.1002/ccd.24696
Downloaded from http://ahajournals.org by on November 20, 2022
Circ Cardiovasc Interv. 2021;14:e010228. DOI: 10.1161/CIRCINTERVENTIONS.120.010228
Cath Lab ABC
2. Bansal M, Molian VA, Maldonado JR, Aldoss O, Ochoa LA, Law IH. Cost
analysis of combining congenital cardiac catheterization and electrophysiol-
ogy procedures in an outpatient setting. Pacing Clin Electrophysiol. 2018;
41:1428–1434. doi: 10.1111/pace.13477
3. Kaplan RS, Anderson SR. Time-driven activity-based costing. Harv Bus Rev.
2004;82:131–138, 150.
4. Chandra C, Kumar S, Ghildayal NS. Hospital cost structure in the USA:
what’s behind the costs? A business case. Int J Health Care Qual Assur.
2011;24:314–328. doi: 10.1108/09526861111125624
5. Cheng HM, Chiou LJ, Chen TC, Sung SH, Chen CH, Lang HC. Real-world
cost-effectiveness of drug-eluting stents vs. bare-metal stents for coronary
heart disease-A five-year follow-up study. Health Policy. 2019;123:229–
234. doi: 10.1016/j.healthpol.2018.11.010
March 2021 366