Massachusetts Chapter of the American College of Surgeons

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Time-driven, Activity-based Costing of Pre-Surgical Infant Orthopedics: A Critical Component of Establishing Value of Latham Appliance and Nasoalveolar Molding
Ingrid M. Ganske,MD MPA1;Karl Sanchez,BA1;Elliot Le,MD MBA3,4;Olivia C. Langa,BA1;Banafsheh Sharif-Askary,MD3;Elizabeth Ross,DMD1;Pedro Santiago,DMD2;John G. Meara,MD, DMD, MBA1;Bonnie L. Padwa,DMD, MD1; Alexander C. Allori,MD, MPH2
1Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School 2Division of Plastic, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, NC 3School of Medicine, Duke University, Durham, NC 4Fuqua School of Business, Duke University, Durham, NC

Background: Value-based health-care reform requires assessment of outcomes and costs of medical interventions. In cleft care, pre-surgical infant orthopedics (PSIO) is still being evaluated for clinical benefits and risks; however, cost of these procedures has been largely ignored. This study employs robust accounting methods to quantify the cost of providing two types of PSIO: Latham and nasoalveolar molding (NAM).
Methods: This is a prospective study of patients with non-syndromic cleft lip and/or palate (CL/P) who underwent PSIO from 2017-2019 at two academic centers. Costs were measured using time-driven activity-based costing (TDABC). Personnel costs, facility costs (operating room, clinic, and inpatient ward), and equipment costs were included. Travel expenses were incorporated as an estimate of direct costs borne by the family, but indirect costs (e.g., time off from work) were not considered.
Results: Twenty-three patients were treated with Latham and 14 with NAM. For Latham, average total cost was $7553/patient ($1041 for personnel, $637 for equipment, $4871 for facility, and $1004 for travel over 6.5 visits). Unilateral and bilateral costs were $6891 and $8860, respectively. For NAM, average cost totaled $2541 ($364 for personnel, $151 for equipment, $300 for facility, and $1726 for travel over 13 visits); $2120 for unilateral and $3048 for bilateral treatment.
Conclusion: The major difference in cost is attributable to operative placement of the Latham device. Travel cost for NAM is often higher due to frequent clinical encounters required. Future investigation should focus on whether outcomes achieved by PSIO justify the $2100-$8900 expenditure for these adjunctive procedures.


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