Time-Driven Activity-Based Cost Analysis of CT-Guided Intraoperative High-Dose Rate Brachytherapy Versus Whole Breast Irradiation in the Treatment of Early Stage Breast Cancer

Abstract

To evaluate the health care delivery cost of single fraction CT-guided intraoperative high-dose rate brachytherapy (HDR-IORT) in early stage breast cancer using time-driven activity-based costing (TDABC). Process maps were created for each step of the radiation treatment process at our institution for early stage breast cancer. The capacity cost from consultation to completion of radiation was calculated for personnel, equipment, and consumable resource. Personnel costs were calculated using individual personnel time and salary data. Equipment costs were calculated to include cost of CT-simulation, treatment planning software, and treatment machine time. Consumable costs were limited to resources specific to the individual radiation treatment (e.g. multi-lumen balloon) of each patient and did not include diagnostic, surgical, or anesthesia costs associated with lumpectomy alone as patients treated with whole breast irradiation (WBI) incurred similar costs. Patients are treated with HDR-IORT on an ongoing prospective trial. The procedure includes lumpectomy and placement of a multi-lumen balloon applicator by the breast surgeon. Intraoperative CT on-rails is utilized for image confirmation of catheter placement, treatment planning and delivery of 12.5 Gy to 1 cm from the balloon surface. In comparison, whole breast irradiation (WBI) alone consisted of 42.56 Gy in 16 fractions, with consideration of a 4 fraction boost. The total health care cost to deliver HDR-IORT for a patient was $4,875. The total cost to deliver WBI alone was $2,832, with an additional $363 for a 4 fraction boost. Radiation oncology personnel accounted for $1,909 (39%) and $1,658 (59%) of the total IORT and WBI cost, respectively. Surgical attending physician time required an additional 30 minutes to allow for balloon placement and image-guided confirmation in the brachytherapy suite. During HDR-IORT, the anesthesia team spent an additional 315 minutes (accounting for multiple team members). Radiation oncology attending time was 16% less for HDR-IORT compared to WBI, 91 minutes versus 108 minutes respectively. Equipment cost was $216 (4%) and $1,174 (41%) for the total cost of HDR-IORT and WBI, respectively. The cost of the multi-lumen balloon applicator ($2,750 per patient) represented 56% of the total IORT cost. TDABC analysis demonstrates a higher cost of delivery for treatment with HDR-IORT compared to WBI, largely due to increased consumable costs. Our calculated total delivery cost ($4,875), which exceeds the current payment rates for other forms of breast IORT, should be considered for reimbursement decisions. These findings exemplify that a streamlined process and dedicated team can result in efficient delivery of HDR-IORT.