Challenges of costing a surgical procedure: a case study on hysterectomy

Abstract

INTRODUCTION: It is vital to enquire in to cost of healthcare to ensure that maximum value for money is obtained with available resources. However, there is a dearth of information on cost of healthcare in lower-middle income countries. Our aim was to study the costs for three routes of hysterectomy in benign uterine conditions; total abdominal (TAH), non-descent vaginal (NDVH) and total laparoscopic hysterectomy (TLH). METHOD: A societal perspective with a micro-costing approach was applied to find out direct and indirect costs. Patients were recruited from a district general hospital (Mannar) and an urban tertiary care hospital (Ragama). The total cost incurred during pre-operative, operative, post-operative periods and convalescence included direct costs of labour, equipment, investigations, medications and utilities. Indirect costs included of out-of-pocket expenses, productivity losses, carer costs and travelling. Time-driven activity-based costing was used for labour costs and top down micro-costing was used for utilities. RESULTS: The median direct cost [(interquartile range), number] of TAH was Rs. 43054 [(41604 - 46243), n=24] versus Rs. 39430 [(37690 - 43054), n=25] (Mann-Whitney U test, p<0.01), NDVH was Rs. 40590 [(36965 - 44793), n=23] versus Rs.40155 [(36676 - 43779), n=26] (Mann-Whitney U test, p=0.984) and TLH was Rs. 47258 [(44359 - 51897), n=24] versus Rs. 53056 [(48128 - 55811), n=25] (Mann-Whitney U test, p=0.16) at Mannar and Ragama respectively. The median indirect cost (interquartile range) of TAH was Rs. 4204 (2174 12757) versus Rs. 9857 (5219 - 17251) (Mann-Whitney U test, p<0.05), NDVH was Rs.4349 (2174 - 8263) versus Rs. 10872 (5943 - 34646) (Mann-Whitney U test, p<0.01) and TLH was Rs. 6668 (2754 - 12902) versus Rs. 7538 (4929 - 21454) (MannWhitney U test, p=0.28) at Mannar and Ragama respectively. Sensitivity analysis using the best case scenario and a minimum wage of Rs. 1500 per day till time to recovery for TAH, NDVH and TLH showed a total cost of Rs. 87557, 78715 and 79150 respectively. CONCLUSION: Time-driven activity-based costing for labour and top down micro-costing of utilities helped to overcome logistical difficulties. Indirect costs at Ragama were significantly more than that at Mannar. Sensitivity analysis adjusted for the best case scenario and minimum wage suggested that NDVH and TLH may in fact be cheaper than TAH. The costing method used in this study is a simple and reproducible way of calculating costs of a surgical procedure which will serve as a guide for clinicians and policy makers in similar settings.