Time-Driven Activity-Based Costing Demonstrates the Fiscal Superiority of Stereotactic Body Radiotherapy Compared to Protracted Radiotherapy Schemes or Other Therapies.

Abstract

Using modern cost-accounting methods, we track the "costs-to-deliver” a specific cancer care pathway (breast, localized prostate and early stage operable lung cancer). For breast and prostate, we examine three, clinically iso-effective, fractionation schemes and normalize costs to the conventional/protracted pathway. For early stage, operable lung cancer we track costs for surgery and Stereotactic Body Radiotherapy (SBRT), within the VALOR clinical trial (NCT02984761), and normalize to surgical pathway costs. Baseline intervention costs include up to 36 months follow-up tracking. We deploy the Time-Driven Activity-Based Costing (TDABC) framework (R.S. Kaplan and S. R. Anderson, Harvard Business Review, 1-Nov-2004) to track "costs-to-deliver” a specific care pathway for the selected disease indications. TDABC while a relatively new methodology it is designed to capture costs in a variegated service/manufacturing environment or work setting, it is well placed to reflect "cost-to-deliver” in healthcare (M.E. Porter and R.S. Kaplan, Harvard business Review, July-Aug 2016). Importantly for us clinicians, TDABC requires only two specific inputs: (a) Unit Costs of Supplying Capacity (e.g., pay rate costs of a surgeon's time) and (b) Time needed to complete the activity within the care pathway. Using iso-effect clinical outcomes ( that is, tracked care pathways offer equivalent or non-inferior to the standard of care outcomes) based on the ICHOM Standard Sets for breast and for localize prostate cancer (<www.ichom.org>), we tracked the costs-to-deliver for conventional (39), hypofractionated (20) and SBRT (5) fractions for prostate Ca and for conventional ( 25), hypofractionated (15) and SBRT ( 5) fractions for breast Ca. For the early stage, operable lung cancer we used the VALOR trial criteria congruent to ICHOM Standard Set, and normalized to the surgical costs. For the Prostate RT schemes above, TDABC for CF = 100, HF = 62.3 and SBRT = 35.1; for Breast RT, TDABC for CF = 100, HF = 73.2 and SBRT = 40.1. For early stage, operable lung cancer, a la VALOR, TDABC for surgery = 100, SBRT = 73.4. Overall SBRT appears fiscally superior when compared to fractionation older schemes or to surgery. TDABC, a modern, robust and accurate cost-accounting framework has been used to capture the costs-to-deliver care within radiotherapy pathways (comparing iso-effective fractionation schemes in breast and prostate RT) while also comparing two distinct, specialty-agnostic, care pathways (surgery vs SBRT) for the same medical condition. Our early results indicate the fiscal and value (outcomes over costs) superiority of SBRT. These early results if further verified, have implications for (a) US and other high-income countries as they enter the bundled payment era; (b) for Low-Medium Income countries as a tantalizing promise for a cost-effective leapfrogging into modern Radiotherapy, akin to the introduction of mobile telephone networks twenty years ago.