Comparison of COVID-19 hospitalization costs across care pathways: a patient-level time-driven activity-based costing analysis in a Brazilian hospital

(2023) 23:198 Cardoso et al. BMC Health Services Research https://doi.org/10.1186/s12913-023-09049-8 BMC Health Services Research Open Access RESEARCH Comparison of COVID‑19 hospitalization costs across care pathways: a patient‑level time‑driven activity‑based costing analysis in a Brazilian hospital Ricardo Bertoglio Cardoso1,2, Miriam Allein Zago Marcolino1,2, Milena Soriano Marcolino3, Camila Felix Fortis1, Leila Beltrami Moreira4,5, Ana Paula Coutinho5, Nadine Oliveira Clausell4,5, Junaid Nabi6, Robert S. Kaplan6, Ana Paula Beck da Silva Etges1,2,7 and Carisi Anne Polanczyk1,2,4,5*    Abstract Background The COVID-19 pandemic raised awareness of the need to better understand where and how patientlevel costs are incurred in health care organizations, as health managers and other decision-makers need to plan and quickly adapt to the increasing demand for health care services to meet patients’ care needs. Time-driven activitybased costing offers a better understanding of the drivers of cost throughout the care pathway, providing information that can guide decisions on process improvement and resource optimization. This study aims to estimate COVID-19 patient-level hospital costs and to evaluate cost variability considering the in-hospital care pathways of COVID-19 management and the patient clinical classification. Methods This is a prospective cohort study that applied time-driven activity-based costing (TDABC) in a Brazilian reference center for COVID-19. Patients hospitalized during the first wave of the disease were selected for their data to be analyzed to estimate in-hospital costs. The cost information was calculated at the patient level and stratified by hospital care pathway and Ordinal Scale for Clinical Improvement (OSCI) category. Multivariable analyses were applied to identify predictors of cost variability in the care pathways that were evaluated. Results A total of 208 patients were included in the study. Patients followed five different care pathways, of which Emergency + Ward was the most followed (n = 118, 57%). Pathways which included the intensive care unit presented a statistically significant influence on costs per patient (p <  0.001) when compared to Emergency + Ward. The median cost per patient was I$2879 (IQR 1215; 8140) and mean cost per patient was I$6818 (SD 9043). The most expensive care pathway was the ICU only, registering a median cost per patient of I$13,519 (IQR 5637; 23,373) and mean cost per patient of I$17,709 (SD 16,020). All care pathways that included the ICU unit registered a higher cost per patient. Conclusions This is one of the first microcosting study for COVID-19 that applied the TDABC methodology and demonstrated how patient-level costs vary as a function of the care pathways followed by patients. These findings can be used to develop value reimbursement strategies that will inform sustainable health policies in middle-income countries such as Brazil. *Correspondence: Carisi Anne Polanczyk Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Cardoso et al. BMC Health Services Research (2023) 23:198 Page 2 of 11 Keywords Cost and cost analysis, Health care costs, Microcosting, Time-driven activity-based costing, TDABC, COVID-19 Background COVID-19 was detrimental to the financial well-being of healthcare systems. Hospitals used varying strategies to increase their capacity to care for the influx of COVID-19 patients [1]. A study of COVID-19 related care at 10 hospitals in Brazil showed high variability in inpatient care management and resource needs [2]. Having valid patient-level costs for COVID-19 care is necessary to inform and evaluate hospitals’ resource allocations and care delivery decisions. Little evidence currently exists about the cost of inpatient care for COVID-19 patients. Time-driven activity-based costing (TDABC) is a microcosting technique applied to generate accurate patient-level cost information within the episode of care by estimating two factors: the capacity cost rate (CCR) of a resource and the period in which the resource is used [3–6]. TDABC offers a better understanding of the drivers of cost throughout the care pathway, providing information that can guide decisions on process improvement and resource optimization [7–10]. The literature recommends the use of TDABC not only because of its capability to drive cost evaluations but also because it can be a strong tool with which to identify inefficiencies and opportunities to improve patients’ flow of care and resource utilization [6, 11]. Brazil provides public health coverage (Sistema Único de Saúde – SUS) ensuring universal access to health. SUS is financed through tax collection without any patient co-payment or flat-rate and payments to hospitals are based on a government reference table [12], which lists all procedures/treatments reimbursement values. With the increasing use of contracts which include global budgets for public health care providers, the reimbursement table does not necessarily reflect either SUS’ expenditure or provider’s costs [13]. In this context, micro-costing studies in the perspective of public health reference centers are probably the best estimative of the real cost of a technology for the Public Health System [13]. The COVID-19 pandemic raised awareness of the need to better understand where and how patientlevel costs are incurred in health care organizations, as health managers and other decision-makers need to plan and quickly adapt to the increasing demand for health care services to meet patients’ care needs [2, 14]. Although reference hospitals for COVID-19 treatment were able to take sufficient measures to ensure bed availability in the ICU and general infirmary during the first wave of the pandemic, they were not able to prevent health services to be overwhelmed during the second wave [15]. The aim of this study w (...truncated)