Introduction
Methods for identifying cost components
Gross-costing: Involves identifying cost components at a highly aggregated level (e.g. costing an intervention based only on the associated inpatient days) [11]. | |
Micro-costing: A precise method, where an attempt is made to identify every input consumed in the treatment of a particular patient [11].
Methods for valuing cost components
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Top-down costing: An approach where relative value units such as hospital days or some other metric are used to separate out relevant costs from comprehensive sources (e.g. the finance department’s annual accounts) and apportion them to individual services or procedures [12]. For example, the sum of the annual budget of an intensive care unit and hospital overhead may be divided by the number of patient days to estimate an average cost per patient per day [34]. | |
Bottom-up costing: An approach where cost components are valued by identifying resource use directly employed for a patient, resulting in patient-specific unit costs [14]. |
Methods
Eligibility Criteria
Information Sources, Search and Data Collection
Data Items
Assessment of Accuracy, Reliability and Comprehensiveness
Synthesis of Results
Results
Study Selection
Study Characteristics
Author [ref] currency yeara
| Study design and population | Type(s) of bariatric surgery | Data collection methods | Cost components included | Total procedural cost | Cost component one | Cost component two | Cost component three | Cost component four | Cost component five |
---|---|---|---|---|---|---|---|---|---|---|
Studies using charge (not cost data) | ||||||||||
Cooney [30] USD 2000 | June 1998 to March 1999 16 GB procedures performed by single surgeon at Penn State Hershey Medical Center (Pre group) compared to 12 GB procedures performed by same surgeon April to December 1999 (Post group) | Pre-pathway GB (n = 16) and post-pathway GB (n = 12) | Costs of care obtained from hospital financial information system using cost/charge ratios; OR costs obtained from OR information system | Room and board, OR, supplies, laboratory and radiology and miscellaneous costs; OR time divided into anaesthesia time, patient preparation time, surgical time and ‘wake up’ time | Pre: $10,176 SD $789 Post: $8511 SD $763 | Hospital room charge for LOS Pre: $3641 SD $398 Post: $2389 SD $347 | Operating room costs Pre: $3467 SD $253 Post: $4251 SD $152 | Supply costs during in hospital stay Pre: $1152 SD $194 Post: $679 SD $107 | In-house laboratory studies and radiology examinations Pre: $629 SD $84 Post: $312 SD $112 | Other miscellaneous costs Pre: $1098 SD $122 Post: $878 SD $179 |
Muhlmann [27] USD 2002 | Case series of 10 robotic-assisted laparoscopic procedures compared to 10 CLP during the learning curve | Robotic and CLP each had: SAGB (n = 4), IGS (n = 4), revisional bariatric surgery (n = 2) | Itemised charges calculated by the institutional billing department; personnel charges, OR time and staff estimated using charge rate per minute based on median time for procedures routinely documented in the OR database | Procedural costs included operation time, special instruments and consumables (details of other costs not reported) | Robotic: $9505 CLP: $6260 | Operation time Robotic: $1576 CLP: NR | Special instruments Robotic: $1487 CLP: NR | Consumables Robotic: $182 CLP: NR | NA | NA |
Scally [32] USD 2003–2010 | Analysis of Medicare claims from 2003 to 2010 for patients who underwent bariatric surgery to determine impact of NCD on costs | Patients (n = 72,117) identified using ICD-9 codes and DRG payment codes for bariatric surgery | 30-day episode payments abstracted from Medicare claims | Payments for index hospitalisation, re-admissions, physician services, outlier payments and post-discharge ancillary care | Pre-NCD: $14,283 Post-NCD: $14,720 | Index admission Pre-NCD: $10,865 Post-NCD: $10,980 | Physician services Pre-NCD: $1950 Post-NCD: $2292 | NA | NA | NA |
Weiner [23] USD 2005 | Analysis of BlueCross BlueShield claims data; 29,820 privately insured patients | LB, LGBP, OGBP, other restrictive surgery and unknown | Adjudicated inpatient, outpatient and pharmacy claims on the index date of surgery (e.g. bariatric surgery hospitalisation period or day of outpatient surgery) | Combination of Medicare relative value units and actual charges: inpatient, physician and other services provided in office, pharmacy and non-inpatient services claims | All combined $27,833 LB $22,670 LGBP $28,685 OGBP $28,653 Other $26,592 Unknown $28,391 | Inpatient (institution and professional fees) LB $18,622 LGBP $28,237 OGBP $28,096 Other $25,429 Unknown $27,337 | Professional office (ambulatory services billed) LB $28 LGBP $170 OGBP $162 Other $301 Unknown $3975 | Outpatient and other (imaging, laboratory) LB $194 LGBP $314 OGBP $1050 Other $683 Unknown $46 | Pharmacy LB $85 LGBP $82 OGBP $52 Other $70 Unknown $301 | NA |
Frezza [33] USD 2006 | Charges for LGBP and LGB and cost of instruments at the Texas Tech University Health Science Center were evaluated | LGBP (n = 93) and LGB (n = 27) | Charges and costs were obtained from the hospital | Total charges, hospital and anaesthesiology charges; reusable and disposable instruments | Median total charges LGBP: $10,421 LGB: $10,491 | Median hospital charges LGBP: $5787 LGB: $5506 | Median anaesthesiology charges LGBP: $1714 LGB: $1369 | Reusable instruments (ultrasound, Omni retractor, camera, 45° 5 mm lens) Same cost for both procedures; not clear which one is correct $50,970 or $61,970 | Disposable instruments for LGB and LGBP are different, but lists of items are too detailed for summary LGBP: $3516 LGB: $4363 | NA |
Studies reporting costs for gastric bypass procedures | ||||||||||
Angus [28] USD 2001 | Retrospective analyses of 133 patients (59 privately insured and 74 publically insured) at the Nassau University Medical Center from January 2001 to December 2001 | LRYGBP (n = 11) and open RYGBP | No details provided concerning the collection of cost data other than charts were retrospectively reviewed | Direct (operative and hospital services) and indirect costs | LRYGBP: $6350 SD $75 Open RYGBP: $7894 SD $264 | Direct costs (operating room time, operating room supplies, post-anaesthesia care, nursing, pharmaceutical diagnostic and/or therapeutic radiologic studies) LRYGBP: $4180 SD $382 Open RYGBP: $3179 SD $101 | Indirect costs (housekeeping, overhead costs, insurance and employee benefits) LRYGBP: $1792 SD $263 Open RYGBP: $2137 SD $285 | NA | NA | NA |
Nguyen [29] USD 2001 | Between May 1999 and March 2001, 155 patients were randomly assigned to undergo either LGBP (n = 79) or OGBP (n = 76) | LGBP (n = 68) and OGBP (n = 68) | Costs were derived from the University of California, Davis, Medical Center’s decision support system database | Direct (operative and hospital services costs) and indirect costs | LGBP: $14,087 SD $5237 OGBP: $14,098 SD $8527 | Operative costs (operative time and supplies including amortisation of laparoscopic equipment and post-anaesthesia) LGBP: $4922 SD $1927 OGBP: $3591 SD $1000 | Hospital service costs (diagnostic, nursing, pharmaceutical, therapeutic and other) LGBP: $2519 SD $1712 OGBP: $3742 SD $3978 | Indirect costs (overhead costs including administrative, finance, housekeeping, payroll, insurance and employee benefits) LGBP: $6645 SD $2437 OGBP: $6765 SD $4077 | Detailed cost breakdowns of the components of operative (operative time/supplies and post-anaesthesia) and hospital service (diagnostic, nursing, pharmaceutical, therapeutic and other) costs are provided, but have not been summarised here due to space considerations | |
Salgado [24] BRL (R$) 2004/2007 | Retrospective analysis of direct and indirect costs in 2004 and 2007 at the University Hospital of the Faculty of Medicine of Ribeirao Preto-USP | Roux-en-Y gastric bypass by the standard route (n = 9 in 2004 and n = 7 in 2007) | Data obtained from the Technical Advisory Office of the Hospital | Hospitalisation, surgery centre, examinations, medications and materials | 2004: R$6845 SD R$280 2007: R$7526 SD R$435 | Hospitalisation 2004: R$2777 2007: R$2020 | Surgery centre (includes anaesthesia) 2004: R$1917 2007: R$3043 | Examinations (pre- and postoperative laboratory and imaging) 2004: R$201 2007: R$211 | Medications (used before and after surgery) 2004: R$398 2007: R$271 | Materials (staplers and catheters) 2004: R$1552 2007: R$1988 |
Hagen [18] USD 0.91 CHF 2011 | Case series of gastric bypass patients at the University Hospital Geneva from June 1997 to July 2010 | 524 OGBP, 323 LGBP and 143 RGBP patients | Decision analytic model used to model average costs; complications and hospitalisation, OR times collected prospectively; ICU stay captured retrospectively; instrument use documented, material from OR protocols; costs from finance departments | OR materials, postoperative ICU stay, overall hospitalisation and amortisation of the robotic system | OGBP: $23,000 LGBP: $21,697 RGBP: $19,363 | ICU stay OGBP: $7144 LGBP: $2143 RGBP: $714 | Hospitalisation OGBP: $14,137 LGBP: $14,267 RGBP: $9598 | Operating time OGBP: NR LGBP: $3241 RGBP: $4609 | OR materials (list of items too detailed for summary) OGBP: $2251 LGBP: $5494 RGBP: $5427 | Robotic amortisation purchase price: $1,592,500; yearly maintenance fee 10%; interest rate 5%; duration of use of 7 years |
Ismail [17] US$1.3345 = €1 2014 | Between January and December 2012 86 RGBP performed at Strasbourg’s University Hospital | RGBP (n = 86) | Instrument costs and operative times provided by the IGMISIS; personnel and medical devices’ costs retrieved from Strasbourg’s University Hospital | Medical devices, personnel, re-usables and disposables | $10,734 | Medical devices $4320 (amortised purchase price and maintenance) | Personnel $1245 (mean duration per person in OR and total payroll costs; adjusted for effective working hours) | Re-usables $1459 (accounts for sterilisation costs and life span of instrument) | Disposables $3630 (number of units used multiplied by purchase price) | NA |
Studies reporting costs for gastric banding procedures | ||||||||||
Van Gemert [31] USD (converted from € no conversion rate provided) 1998 | 21 morbidly obese patients | VBG (n = 21) | Costs were based on real prices | Per-patient performances were counted, including operation, revisional surgery, diagnostic and therapeutic procedures, management of surgical complications, outpatient visits and hospital bed days | $5865 | Operations (time of surgeon, resident, anaesthesiologist, nursing staff; supplies, equipment, costs of housing, feeding, administration and management) $2601 | Laboratory/radiology $300/$219 | Endoscopy $22 | Physiotherapy $25 | Hospital stay/out-patient visits $2192/$506 |
Keating [25] AUD 2006 | Within-trial surgery costs of 30 patients (note other intervention costs reported in the study were over a 2-year period and therefore only surgery costs are reported) | LAGB | Cost data obtained from a private medical specialist and private hospital; resource use documented on patient case record forms by hospital clinical staff | Specialist medical personnel, hospital personnel, LAGB prosthesis, theatre supplies, non-theatre supplies and other expenses | Mean total surgery costs $8527 | Specialist medical personnel (surgeon, surgical assistant, anaesthetist) $3000 | Hospital personnel $903 | LAGB prosthesis $3264 | Theatre supplies, non-theatre supplies and other expenses $1654 | NA |
Ayloo [26] USD 2006–2009 | Retrospective review of a prospectively maintained database between March 2006 and October 2009 from University of Illinois at Chicago | LAGB (n = 121) and LESS (n = 25) | Data entered into dedicated bariatric database; all procedures performed by one surgeon; depreciation estimated; consumable costs represent costs to replace items | Operative time, consumables and laparoscopic tower depreciation | LAGB: $20,346 SD $2069 LESS: $20,502 SD $1885 | Operative time LAGB: $3630 SD $662 LESS: $3793 SD $565 | Specialised consumables (band, disposable standard or low profile trocars, sutures and other instruments like harmonic scalpel) LAGB: $15,077 SD $1643 LESS: $14,591 SD $1793 | Depreciation of laparoscopic tower equipment; based on 5-year life with 200 cases per year | NA | NA |
Author [ref] currency year | Type(s) of bariatric surgery | Original total cost estimate | Inflated, adjusted, 2016 USD total costs estimate | ||||||
---|---|---|---|---|---|---|---|---|---|
Studies using charge (not cost data) | |||||||||
Cooney [30] USD 2000 | Pre-pathway GB | Post-pathway GB | $10,176 | $8511 | $13,468 | $11,265 | |||
Muhlmann [27] USD 2002 | Robotic | CLP | $9505 | $6260 | $12,390 | $8160 | |||
Weiner [23] USD 2005 | All types combined | $27,833 | $33,541 | ||||||
Frezza [33] USD 2006 | LGBP | LGB | $10,421 | $10,491 | $12,184 | $12,265 | |||
Scally [32] USD 2010 | Pre-NCD | Post-NCD | $14,283 | $14,720 | $15,642 | $16,120 | |||
Studies reporting total costs for gastric bypass procedures | |||||||||
Angus [28] USD 2001 | LRYGBP | Open RYGBP | $6350 | $7894 | $8405 | $10,567 | |||
Nguyen [29] USD 2001 | LGBP | OGBP | $14,087 | $14,098 | $18,645 | $18,659 | |||
Salgado [24] BRL (R$) 2004/2007 | RYGB in 2004 | RYGB in 2007 | R$6845 | R$7526 | $8359 | $9191 | |||
Hagen [18] US$ = 0.91 CHF 2011 | OGBP | LGBP | RGBP | ₣20,930 | ₣19,744 | ₣17,620 | $15,575 | $14,692 | $13,112 |
Ismail [17] US$1.3345 = €1 2014 | RGBP | €14,325 | $17,751 | ||||||
Studies reporting total costs for gastric banding procedures | |||||||||
Van Gemert [31] USD (from € no rate provided) 1998 | VGB | $5865 | $8244 | ||||||
Keating [25] AUD 2006 | LAGB | AU$8527 | $7423 | ||||||
Ayloo [26] USD 2009 | LAGB | LESS | $20,346 | $20,502 | $22,554 | $22,727 | |||
Mean total cost estimate (all studies) (n = 23) | $14,389 SD $6110 | ||||||||
Mean Total Cost Estimate (Only cost data) (n = 14) | $13,993 SD $5441 | ||||||||
Mean total cost estimate for gastric bypass procedures (only cost data) (n = 10) | $13,496 SD $4171 | ||||||||
Mean total cost estimate for gastric banding procedures (only cost data) (n = 4) | $15,237 SD $8556 |
Inclusion of ‘Important’ Cost Components
Study | Costs not charges assessed | OR costs separate from hospital admission costs | Medical devicea costs reported | Personnel costs reported | Re-usable instrumentb costs reported | Disposable instrumentc costs reported | Overhead costs reported |
---|---|---|---|---|---|---|---|
Cooney [30] | Charges and costs | Yes | No | No | Yes, but not clear if re-usable or disposable | No | |
Muhlmann [27] | Charges | Yes | Yes | No | Yes | Yes | No |
Weiner [23] | Charges | No | No | No | No | No | No |
Frezza [33] | Charges (costs for re-usable and disposable equipment) | No | Yes | No | Yes | Yes | No |
Scally [32] | Charges | No | No | Yes | No | No | No |
Angus [28] | Costs | Yes | No | No | No | No | Yes |
Nguyen [29] | Costs | Yes | Yes | Yes | Yes, but not clear if re-usable or disposable | Yes | |
Salgado [24] | Costs | Yes | No | No | Yes, but not clear if re-usable or disposable | No | |
Hagen [18] | Costs | Yes | Yes | No | Yes, but not clear if re-usable or disposable | No | |
Ismail [17] | Costs | Yes | Yes | Yes | Yes | Yes | No |
Van Gemert [31] | Costs | Yes | No | No | No | No | No |
Keating [25] | Costs | Yes | No | Yes | Yes, but not clear if re-usable or disposable | No | |
Ayloo [26] | Costs | Yes | Yes | No | No | Yes | No |
Totals | Costs—8 Charges—3 Both—2 | Yes—10 No—3 | Yes—6 No—7 | Yes—4 No—9 | Yes—3 Yes, but NS—5 No—5 | Yes—4 Yes, but NS—5 No—4 | Yes—2 No—11 |