Enhancing the value of the oncology thoracic surgery care pathway: a TDABC and ABC analysis

Abstract

Background

Time-driven activity-based costing (TDABC) and activity-based costing (ABC) are methods used in the healthcare sector to assess the costs of patient care pathways. These methods help identify opportunities for optimizing and reducing activity times without compromising the quality of care. TDABC is recommended in the Value-Based Healthcare (VBHC) model to assess the outcomes of care pathways in relation to their associated costs. By focusing on the creation of value for patients, TDABC helps identify the interventions and processes that provide the most value in terms of clinical outcomes and patient satisfaction. This enables healthcare organizations to make informed decisions on improvements that will maximize value for patients. The aim of the study is to evaluate the cost of the oncology thoracic surgery care pathway prior to and following the implementation of digital health solution.

Methods

We have chosen to use the TDABC and ABC methods to calculate the costs of care pathway for oncology patients undergoing thoracic surgery in two healthcare establishments prior to and following the implementation of a digital health solution. By using these methods, we were able to calculate the costs associated with each stage of the patients’ care pathway. This has given us a clearer picture of the costs associated with each activity and a better understanding of the sources of expenditure.

Results

The results show that implementing the digital health solution and applying the principles of the VBHC model have provided tangible benefits in terms of reviewing processes and the roles of the various players involved, eliminating unnecessary or non-value-added activities, automating administrative or repetitive tasks, and improving coordination between the two healthcare establishments and between healthcare professionals. These improvements have contributed to better patient care.

Conclusions

Given the success observed in this pilot project, decision-makers chose to persistently implement this digital health solution for specific care pathways over the long term. Additionally, there is a commitment to further enhance the platform to align closely with the needs and the expectations of healthcare professionals. This proactive approach aims to ensure optimal utilization of resources, ultimately providing the best care to patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-024-11829-9.

Background

Healthcare systems around the world are facing growing financial challenges. Inefficient care pathway management can result in wasted resources, additional costs, and an increased financial burden on healthcare systems. Better management of care pathways can help streamline processes, avoid unnecessary duplication, and optimize the use of available resources. This is why hospitals and healthcare professionals are constantly seeking innovations to improve processes for different pathologies and patient care management, while increasing efficiency in healthcare and reducing delays, hospital stays and, ultimately, the costs associated with care pathways [1–3] .

Many countries around the world have implemented the activity-based funding (ABF) method to evaluate and finance the healthcare services provided by hospitals. The adoption of ABF demonstrates the governments’ desire to increase the productivity of healthcare establishments and better control the costs of care pathways, while seeking to ensure optimal quality of care for patients [4].

Over the past decade, Quebec has seen a trend in the implementation of ABF. ABF is a funding model that aims to remunerate healthcare services based on activities performed, rather than providing overall operating funding [5]. In Quebec, it was initially introduced in 12 hospitals offering radiation oncology therapy [6]. However, at the time of this initial integration, the Quebec government’s intention was to gradually extend the ABF model to the entire healthcare network and to different care pathways to promote more efficient resource management and foster increased productivity.

In conjunction with ABF, care pathway costing methods are essential tools for managers, providing them with key information to identify costly activities, optimize resources and make informed decisions to improve care pathways while controlling costs [7–10].

The present study was carried out with this in mind. This study is linked to the implementation of a new digital health solution to optimize both non-oncology and oncology thoracic surgery care pathways between the Centre intégré de santé et des services sociaux de l’Outaouais (CISSSO) and the McGill University Health Centre (MUHC). The goal is to improve safety and streamline the planning, coordination, and continuity of care throughout the patient’s journey.

One of the objectives of this comprehensive study was to evaluate the cost of the oncology thoracic surgery care pathway prior to and following the implementation of Akinox’s web platform in January 2021. The assessment utilized two distinct calculation methods: Time-Driven Activity-Based Costing (TDABC) and Activity-Based Costing (ABC). Once the costs of the care pathway had been determined using these methods, the implementation of the platform was evaluated in terms of its actual impact on costs in the specific context of the study.

Using the TDABC and ABC methods to gain a good understanding of the costs of the care pathway before implementing a platform can be beneficial. These methods make it possible to analyse care processes and identify activities that present opportunities for optimization and reduction of activity times. Then, once we have determined which activities can be optimized, implementation of the platform can promote better patient care by reducing the time and costs associated with the care pathway [1, 10–12].

Managing care pathways through cost control.

The notion of a care pathway is widespread throughout the healthcare sector. Care pathways are care plans detailing the specific steps for managing the care of a patient with a specific pathology, in order to ensure high quality, consistent and continuous care [13]. Care pathways are designed to optimize the coordination and continuity of care, namely by detailing the different steps of the care pathway, the healthcare professionals involved, the necessary examinations, the recommended treatments, as well as any preventive and follow-up interventions. According to Campbell, “They have been proposed as a way of encouraging the translation of national guidelines into local protocols and their subsequent application to clinical practice” (p.133) [14].

It is common practice in some studies to determine the costs associated with care pathways on an aggregate basis using methods such as dividing the total costs of a department or the total specific costs of care pathways by the number of care pathways [1]. This approach provides a general idea of ​​whether costs have been reduced, but it is difficult, if not impossible, to pinpoint which activities within a care pathway have been more or less costly [15]. Thus, it is not possible to concretely determine where the savings are within a given care pathway. Based solely on total costs and without looking at specific care pathways, it is difficult to precisely determine the origin of the cost savings. In fact, total costs can be influenced by various factors, including pathway management or another organizational reform, in which case a more detailed and specific analysis is required [16].

Activity-based funding

Currently, Activity-Based Funding (ABF) is the funding method most frequently adopted in healthcare systems around the world. This method was introduced in the United States in the 1980s for the payment of care pathways for patients over the age of 65 [17]. It has since been adopted by many countries and regions worldwide, including some Canadian provinces such as Ontario and British Columbia [18].

This method enables the government to remunerate hospitals based on a predetermined fixed amount for a type of treatment or a specific care pathway. This remuneration is based on outputs, i.e., the activities and the services provided to patients. A standard is established for each type of care pathway. This standard represents the planned or expected cost to provide the necessary care to a patient with certain common medical characteristics. If the actual cost of the care provided exceeds this standard, unnecessary cost overruns will not be remunerated [19]. One of this method’s issues lies in the classification of patients [20]. Developing clear and objective criteria is crucial to determining which patients with common medical characteristics are more likely to incur the same cost.

The United States developed Diagnosis-Related Groups (DRGs) in 1980; these groups were implemented as part of the Medicare programme in 1983 [21]. Each DRG represents a group of patients with similar medical characteristics and treatment needs, and therefore a common treatment cost. Each DRG is allocated a lump sum representing the expected hospital costs for an average patient in the group [18]. In Canada, a Case Mix Group (CMG) is a measure developed to classify patients as part of ABF. It is similar to the DRGs used in the United States [22]. The ABF method used in healthcare has several objectives that may vary according to the context and the healthcare system. Here are the seven common objectives of ABF:

1. “Stimulating productivity and efficiency;

2. Reducing hospital waiting lists;

3. Increasing competition between hospitals to improve quality;

4. Encouraging monitoring and benchmarking;

5. Reducing excess capacity, increasing transparency in hospital funding;

6. Facilitating patient choice; and

7. Harmonizing payment mechanisms between public and private providers.” [5]

Studies on the contributions of ABF and DRGs in different countries come to differing conclusions as to their impact on the costs and efficiency of patient treatment. Some studies observed increased cost control, others highlighted decreased efficiency and increased patient treatment costs [23]. Furthermore, in some healthcare systems, there may be financial incentives for managers to favour patients with care pathways considered to be more cost-effective, while limiting access to those with less profitable care pathways [24, 25].

Quebec is also assessing the broader implementation of the ABF method. Some pathways are already being remunerated based on the activities carried out for each patient, rather than on the basis of an overall budget. Quebec has chosen a different designation for the method, namely Patient-Focused Funding (PFF) [26]. As ABF or PFF is a funding method, it must be based on an assessment of the cost of activities in order to determine the cost of care pathways. Therefore, it is necessary to use an appropriate costing method to assign the actual costs associated with the care provided to patients and eventually use these data to establish the funding for care pathways.

ABC and TDABC methods in a healthcare setting

In the healthcare sector, ABC is one of the methods commonly used to assess the cost of processes, activities or care pathways related to a specific pathology. ABC was introduced in the 1980s and has enabled many manufacturing companies to determine more accurate costing for goods sold than traditional methods [27–30]. ABC has facilitated better analysis of the costs associated with specific activities and has enabled more informed decision-making in terms of setting prices, allocating resources, and improving operational efficiency [29]. However, its application in a healthcare setting can be complex without monitoring and appropriate software. ABC requires detailed collection and analysis of activity- and cost-related data, which can be a long-term challenge in a complex environment such as a healthcare setting.

This is why, in the early 2000s, Kaplan and Anderson developed a cost analysis approach called TDABC, which aims to overcome the shortcomings and difficulties demonstrated by ABC over the years [31]. At the time, the authors intended to reduce the implementation and maintenance problems experienced when using the ABC method, which requires a great deal of resources and effort from organizations. TDABC is intended to be a less complex alternative. In fact, TDABC makes it possible to induce the costs of resources to the activities by using a single driver, time. Once an organization is able to determine the cost of resources and the time required for activities, it is able to apply TDABC.

The TDABC method is also advocated by Porter and Lee [32] in the development of the Value-Based Healthcare (VBHC) model. This model emphasizes the quality of care provided to patients. It seeks to assess the outcomes of care pathways against associated costs, highlighting the interventions and processes that provide the most value to patients. The model is based on the following components: organize care into integrated practice units, measure outcomes and costs for every patient, make bundled payments for care cycles, integrate care delivery in separate facilities, expand excellent services across the territory, and build an information technology platform. To proceed with the second step of the model, which includes costing, the authors believe that the use of TDABC is an effective method to assess costs within the framework of the VBHC model [32, 33]. These same authors are of the opinion that several studies have demonstrated the benefits of TDABC in terms of reducing costs without having a negative impact on outcomes.

The TDABC method has been adopted by several authors in the field of healthcare to determine the cost of care pathways or activities related to the care management of certain types of patients. TDABC is an evolution of the traditional costing method that focuses on the time actually spent on each activity.This method can be used for various analyses, enabling widespread scientific use [34]. Some studies use it to compare the cost of a specific care pathway to the funding received from governments, which helps assess cost effectiveness and adequacy of funding [11, 35]. Other studies compare the cost of two different treatments for the same disease, which can help make informed decisions about treatment options [36]. TDABC can also be used to evaluate and analyse costs for a care sector or hospital department, thus enabling an in-depth understanding of expenditures and opportunities for improvement [37].

Furthermore, some research has shown that in addition to simplifying the calculation of care pathway costs, TDABC helps healthcare professionals to better understand care pathways and the cost of activities [38]. The method provides a less complex view of care processes and helps to identify inefficiencies, enabling managers to make informed decisions to reorganize the hospital’s activities and redistribute resources based on the activities that are carried out [12].

Methods

For this study, we chose to first use the TDABC method to determine the cost of human resources for the oncology thoracic surgery care pathway prior to and following the implementation of Akinox’s web platform. Then, a second analysis was performed using the ABC method. To do this, data was extracted from the PowerPerformance Manager (PPM) system. This system is used by the McGill University Health Centre (MUHC) to support the PFF application developed by the Quebec government. The system collects, stores and analyses data relating to patients’ care activities and care pathways. We chose to extract these data in order to analyse the average cost of the actual care pathway, based on a large number of patients. This approach provides a more robust and meaningful representation of the costs associated with the oncology thoracic surgery care pathway.

The TDABC method was initially applied to human resources, focusing mainly on time, because we believe that the impact of implementing the digital health solution will lead to changes in work processes and in the efficiency of human resources. TDABC also enables us to map out the overall care pathway and to determine the time required for each specific activity within that pathway. By gaining a better understanding of these activities and the time they require, healthcare establishments can optimize the care pathway by identifying areas where improvements can be made.

For all other costs, the care pathway is complex and includes various activities such as surgery or hospitalization, which can actually be considered as distinct pathways. As part of the TDABC analysis, we also decided to extract the data from the MUHC’s PPM system, focusing on specific patients and collecting information on the actual costs associated with their care. By collecting data on the actual costs for selected patients, we can obtain accurate and reliable data to assess the costs of each activity within the care pathway. In addition, we can calculate unit costs or average costs for each activity, taking into account the time required for each step.

To complement TDABC, the PPM system utilizes the ABC method, accounting for both direct and indirect costs, including materials, supplies, and other resources necessary for the care pathway. Data for this analysis were sourced from the PPM system, utilized by the MUHC to support the PFF framework developed by the Quebec government. The PPM system provided detailed information on patient care, including costs associated with DRGs, such as surgeries, hospitalizations, readmissions, other interventions, and adjustments for case complexity or high-cost case adjustments, which provide additional funding to hospitals for patients whose treatment costs significantly exceed the average for a given diagnostic group.

By combining the information obtained through TDABC and ABC, we can obtain a detailed and comprehensive view of the care pathway, the time spent by human resources on each activity as well as the specific costs for all the resources and materials used. This final analysis enables us to see whether there have been cost savings in the oncology thoracic surgery care pathways overall by including every type of direct or indirect cost.Finally, in the Quebec healthcare system, doctors are paid on a fee-for-service basis by the Régie de l’assurance maladie du Québec (RAMQ) rather than by hospitals. Since the costs of specific medical activities performed by doctors are not calculated as part of care pathway funding, their inclusion in the optimization of target care pathways may be limited.

Application of TDABC to human resources activities that are directly related to care pathways

The TDABC method is used in a variety of settings, including healthcare and other types of organizations, to analyse and evaluate the costs of processes and activities. Here are the nine steps that are generally followed when applying this method and which we will use in this study [8, 10–12, 39–41]:

1. Develop a patient care process map. This map should include the activities that a patient must undergo to complete the care pathway.

2. Breakdown each activity into tasks or sub-activities.

3. Estimate the time to complete each of the steps and enter this time (in minutes) directly into the care pathway map.

4. Identify the different groups of resources needed to perform each activity. In healthcare, it is common to group resources based on the different types of personnel and care (surgeon, type x nurse, type x technician, etc.).

5. Estimate the total cost of the different resource groups.

6. Estimate the practical capacity of each resource group or actual time to complete each activity.

7. Calculate the unit cost of each resource group by dividing the total cost by the total practical capacity.

8. Multiply the total unit cost of each group of resources by the estimated time used for each step included in the activities.

9. Charge the costs of other human resources who are not directly involved in care pathways, but whose work is necessary to the performance of activities.

For the purposes of this study, we limited our focus to human resources, direct resources (i.e. direct supplies) and indirect service costs for the application of the TDABC method and the extraction of data from the PPM system. Although the TDABC method generally requires the analysis of all costs, i.e., the cost of human resources, the cost of fixed assets (premises, equipment, furniture, etc.), the cost of maintenance and the cost of day-to-day use of premises and space [10], it was difficult and less relevant to do so here.

In a hospital setting where many fixed assets have been acquired in different ways (through donations from certain foundations, funding from different levels of government, etc.), it is a complex process to determine the exact cost of a fixed asset, especially if it was acquired or built many years ago. Finance departments are generally responsible for keeping accurate records of fixed asset costs, but they are not always required to make a detailed allocation of all expenditures associated with each fixed asset.

In most cases, finance departments focus on the direct costs and recurring expenses associated with fixed assets in their financial statements. This often includes the costs of human resources and supplies as well as indirect costs such as maintenance and energy. In addition, reducing time required to complete care pathways in a hospital setting has no direct impact on the depreciation of fixed assets. The time to complete a care pathway refers to the length of time it takes to provide medical care to a patient from the moment of their admission to their discharge from the hospital. By analysing the impact on time and on the hospital’s costs, we are able to see the care pathway-related cost savings; if we know that the duration of these care pathways is shorter, we can also say that care pathway-related fixed asset or maintenance costs will be lower.

In order to complete the steps 1 to 4 of the TDABC model, we conducted interviews of key personnel (e.g., care staff and managers) in two healthcare establishments. Consent was obtained from all participants in this study prior to the start of any discussion. A total of 17 interviews were conducted, each lasting between 30 and 60 min. A copy of the interview guide can be found as a supplementary material.

Extracting data from the PowerPerformance Manager system

As the MUHC uses the PPM system, which helps develop PFF, we were able to extract data related to the cost of the oncology thoracic surgery care pathway. The system makes it possible to calculate the cost of the care pathway using the ABC method. As previously discussed, this method is complementary to TDABC in the field of healthcare, because it helps assign a cost to each selected patient and to each activity in a care pathway. In addition to being based on the time used by human resources for each intervention, it uses other cost drivers such as the number of patients.

In addition to assigning a cost to all patients, the PPM system also provides the length of patients’ stay. This information may be important to determine the costs associated with hospitalization and to help understand the impact of the length of stay on the total cost of the oncology thoracic surgery care pathway. By having access to the length of patients’ stay, we know how long patients remain in hospital to receive the necessary care. This helps measure the efficiency of care processes and identify areas of improvement to reduce timescales and associated costs. By combining data on length of stay with other financial data, such as the cost of human resources, it is possible to conduct an in-depth analysis of the costs of the care pathway.

Sampling

With regard to data sampling, we selected patients from the Centre intégré de santé et des services sociaux de l’Outaouais (CISSSO) who already had a care pathway prior to the implementation of the platform, i.e., from 2016 to 2019. We had an initial sample of 420 oncology patients who had undergone thoracic surgery.

During a final analysis of the pathway, we observed that some of the 420 patients deviated from the typical patients profiled using the TDABC method. Certain patients were hospitalized for a longer period of time and others ended up in intensive care or had to undergo more than one medical intervention. We decided to perform a second exclusion, resulting in 377 oncology patients. For the purposes of the study, we will present the results of the oncology patients who underwent thoracic surgery (n = 377).

Results

Developing care pathway process map prior to and following the implementation of the digital health solution

Steps 1 and 2 of the TDABC model presented in the previous section suggest creating a care pathway map by dividing each activity of the pathway into different sub-activities. Figure 1 displays the map detailing the care pathway for patients undergoing oncology thoracic surgery prior to the implementation of the platform. In Step 3, we must estimate the time, in minutes, required to complete the activities. Times are indicated at the bottom right of each sub-activity for the care pathway. Two methods can be used to determine the time required to complete tasks: monitoring staff while they perform tasks and interviewing the resources who perform the tasks . For the purposes of this study, we decided to conduct interviews to determine the activities and sub-activities included in the care pathway as well as the time required for each of the sub-activities. Although time monitoring may be more accurate in terms of the actual duration of the sub-activity when performed in a particular context, it is important that the person responsible for taking the measurements is familiar with the medical procedures and does not disturb the worker by asking questions regarding the actions being performed. This is particularly important because frequent interruptions or intrusive questions can influence the flow of care and disrupt the natural execution of medical tasks. Consequently, data collected under such circumstances may not accurately reflect the actual time required to provide care. As interviews make it possible to deduce the average time for each sub-activity and because the impact of a slight variation between the estimated and actual average durations on the determination of costs is marginal, we used the interview method to determine care pathway times.

Fig. 1.

Care pathway for oncology patients undergoing thoracic surgery prior to the implementation of the platform

Once the sub-activities and times have been determined, Step 4 enables us to validate the group of resources carrying out each of these sub-activities through interviews with care staff and managers. These groups of resources are listed in the boxes to the right, see Fig. 1. In addition, a colour code enables rapid identification of the groups of resources involved in the care pathway.

Determining the cost in minutes of human resources

Table 1 enables us to carry out steps 5, 6 and 7 of the TDABC method by first estimating the total cost of the different groups of human resources, then by determining the practical capacity of each group and finally, by identifying the per-minute cost of all resources.

Table 1.

Cost per minute of identified groups of human resources

Staff	Salaries, benefits and payroll taxes in dollars	Practical capacity of resources in minutes	Cost/Practical capacity = Cost per minute
Assistant to immediate superior or nurse	$187,316.19	184,268	$1.02
Medical secretary -Central operating room booking (CORB)	$49,920.40	90,731	$0.55
Clinic medical secretary	$50,378.81	88,084	$0.57
Preoperative clinic nurse /Care unit nurse	$284,056.85	250,771	$1.13
Preoperative clinic administrative officer	$40,581.70	79,215	$0.51
Care unit administrative officer	$116,695.58	201,932	$0.58
Admissions secretary	$45,663.80	87,471	$0.52
Bed manager	$115,910.47	77,916	$1.49
Preoperative liaison nurse	$398,219.60	364,617	$1.09
Assistant head nurse	$114,461.41	97,563	$1.17
Clinic nurse coordinator	$97,212.64	91,692	$1.06

Total human resources costs for all activities

Finally, by multiplying the per-minute cost of resources by the time required for the different activities, we can determine a cost for each of the human resources across all activities in the care pathway, as shown in Table 2.

Table 2.

Cost of human resources prior to and following optimization

	Pre-implementation care pathway	Post-implementation care pathway	Cost savings after optimization
Activities	Human resources ($)
Reception of files	21.35	21.35	0.00
Consultation day	31.45	26.37	5.08
Post-consultation preparation	92.08	24.45	67.63
Preoperative	99.38	99.38	0.00
Surgery and hospitalization	3,283.31	3,270.96	12.35
Patient discharge	148.18	127.39	20.79
Postoperative appointment preparation	9.85	7.12	2.73
Postoperative appointment	5.08	5.08	0.00
Total	$3,690.68	$3,582.10	$108.58

Based on the findings from Table 2, the cost of human resources for oncology patients amounts to $3,690.68.

Total cost of the care pathway.

Following the human resources cost analysis, we extracted the data from the PPM system.This enabled us to obtain information on patient costs for the oncology thoracic surgery care pathway. Table 3 presents the mean, median, minimum, and maximum cost for the 377 oncology patients for the thoracic surgery prior to optimization.

Table 3.

Total cost and duration of the oncology thoracic surgery care pathway

Measures	Cost	Duration
Mean	$7,429	3.84 days
Median	$6,714	3.14 days
Minimum	$1,383	0.14 days
Maximum	$22,005	19.25 days

The care pathway is also illustrated in Fig. 1. Finally, Fig. 2 presents the distribution of the care pathway costs for the oncology patients (n = 377).

Fig. 2.

Distribution of the 377 oncology patients

Information on the duration of the care pathway

The data extracted from the PPM system, as shown in Table 3, enable us to assess the mean, median, minimum, and maximum duration of the care pathway for the 377 oncology patients. The care pathway is illustrated in Fig. 1.

Optimized care pathways

The new digital health solution has made it possible to optimize the oncology thoracic surgery care pathway. To measure this optimization, we analysed the new care pathway by creating a second map (see Fig. 3).

Fig. 3.

Care pathway for oncology patients undergoing thoracic surgery following the implementation of the platform

We calculated the cost of the new care pathway using the per-minute cost of human resources identified in Table 1. Table 2 presents the costs of optimized care pathway. According to the results, the cost of human resources for oncology patients is $3,582.10.

Analysis of cost savings in the care pathway

By analysing the optimized care pathways, we can identify certain cost savings. Table 2 shows the cost savings by activity.

Using the TDABC method, we determined that the preliminary savings for oncology patients amount to $108.58. It should be noted that for the purposes of this second calculation, we used the hospitalization times of the patients followed during the initial phase of the study. In order to have sufficient conclusive data on the new pathway’s hospitalization times, a longitudinal study would have been necessary, which was not possible in the context of this study. However, we noted faster care management times when using the digital health solution. Thus, we believe that the duration of hospitalization should also be reduced and if this is the case, a more substantial saving will be observed.

Discussion

The implementation of the TDABC method provided a structured approach to understanding and optimizing the care pathway for oncology patients undergoing thoracic surgery. By mapping out the care pathway before the digital health solution’s implementation, we were able to identify specific activities and their associated costs, providing a comprehensive overview of resource utilization and potential areas for improvement.

The initial analysis, as presented in Fig. 1; Table 2, highlighted the existing cost structure and the significative differences in costs between post-consultation and preoperative activities. This granularity allowed for targeted interventions to optimize resource allocation and streamline the care process.

Upon implementing the digital health solution, significant improvements were observed in the optimized care pathway, as illustrated in Fig. 3 and corroborated by Table 2. The per-minute cost of human resources decreased from $3,690.68 to $3,582.10, reflecting the positive impact of the digital solution on resource efficiency.

We are satisfied with the validity of the data obtained, which revealed that oncology patients stay an average of 3.84 days. Extended hospital stays necessitate additional resources, leading to increased costs. This was indeed confirmed by the data, with the median cost of the care pathway amounting to $6,714. Similarly, an analysis focusing solely on human resources costs confirmed this trend.

To facilitate our analysis and understanding of the cost savings, we segmented the milestones of the oncology thoracic surgery care pathway into different steps. Figure 4 illustrated the three steps of the patient’s journey: Step 1 – Preoperative activities, Step 2 – Surgery-related activities and Step 3 – Postoperative activities.

Fig. 4.

Steps of the care pathway

The greatest savings were observed in the post-consultation preparation activity (Step 1 - Preoperative activities), where there was a reduction of $67,73 or 73% per patient for care pathways where preoperative activities (see Table 2). Other notable savings were related to the transmission and exchange of clinical information between the two establishments.

Subsequent savings were observed for activities related to patient discharge, amounting to $20,79 or 14% per patient for the care pathway (see Table 2). The digital health solution facilitated easier scheduling of postoperative appointments and streamlined the sharing and transmission of discharge documents.

By implementing care pathways, organizations seek to improve patient care management, clinical outcomes and patient satisfaction without compromising the quality of care provided, while limiting the costs associated with these pathways [42]. Various studies have demonstrated the benefits of managing and standardizing care pathways in terms of organizational efficiency, employee satisfaction, average time required per patient and the costs associated with these pathways [16, 43, 44].

The TDABC method proved to be an effective tool for analysing and optimizing the care pathway for oncology patients undergoing thoracic surgery. The implementation of a digital health solution demonstrated tangible benefits in improving resource efficiency and potentially reducing hospitalization times. While the initial findings indicate promising cost savings further studies are warranted to validate these results and explore additional opportunities for optimization. The segmentation of the care pathway into distinct steps further highlighted significant savings, particularly in preoperative activities and patient discharge, underscoring the potential of standardized care pathways in enhancing both clinical and economic outcomes.

Limitations and future research

While this study provides valuable insights into the costs associated with the oncology care pathway for thoracic surgery patients in two specific healthcare establishments, there are inherent limitations that need to be acknowledged.

Firstly, the research primarily focuses on a limited scope, examining the costs of the care pathway in only two healthcare establishments. This narrow focus may constrain the generalizability of the findings to broader healthcare settings and diverse patient populations. Future research endeavors should aim to expand the scope to include a more extensive range of healthcare settings and patient populations. Such an approach would enable a more comprehensive assessment of the generalizability of the findings across different contexts and care pathways.

Secondly, the study evaluates the impact of the digital health solution and the VBHC model on costs and processes over a relatively limited time-period. While the initial findings are promising, there is a need for conducting longitudinal studies to evaluate the sustainability and long-term effects of implementing the digital health solution and the VBHC model. Such studies could provide insights into the enduring impacts on costs, processes, clinical outcomes, and patient satisfaction, offering a more robust assessment of the value and effectiveness of these interventions.

Thirdly, this study focuses on evaluating only one specific care pathway. The research could benefit from exploring the potential impact of the digital health solution across various care pathways. Investigating the potential impact of technology-driven interventions across a diverse range of care pathways would provide a more comprehensive view of waste reduction, care optimization, and value creation in healthcare. Such an approach would allow for the identification of common themes, best practices, and opportunities for improvement, facilitating the development of more effective and efficient healthcare delivery models.

While this study contributes valuable insights into the costs and potential benefits of implementing a digital health solution and the VBHC model in the oncology care pathway for thoracic surgery patients, it is essential to recognize the limitations. Addressing these limitations through future research endeavors will be crucial in advancing our understanding of the broader applicability, sustainability, and impact of these interventions in healthcare settings.

Conclusions

The implementation of the digital health solution for the oncology thoracic surgery patient care pathway shared between the CISSSO and the MUHC, has made it possible to optimize both the care pathway and the associated costs. Aligned with the VBHC model [45], this approach aims to improve the quality of care while effectively managing and controlling costs. Using the TDABC method within the VBHC model enables care pathway stakeholders to gain a better understanding of the activities involved and cost allocation. This promotes a more efficient allocation of resources and facilitates the identification of optimization opportunities that are less costly to the healthcare system [46, 47].

The implementation of the digital health solution and application of VBHC model principles have led to improvements in the optimization of the oncology thoracic surgery care pathway. Specifically, this approach has enabled a thorough review and clarification of processes and roles of various stakeholders, identification and elimination of unnecessary or redundant activities, automation of specific tasks within the care pathway, and enhancement of care coordination and service corridors between CISSSO and MUHC. Consequently, this has contributed to improved care for CISSSO patients and an overall improvement in the quality of care.

Akinox’s web platform, implemented in January 2021, has played a pivotal role in enhancing connectivity among service providers and within clinical teams, facilitating seamless information exchange and traceability, and ensuring a comprehensive understanding of the patient care process at both MUHC and CISSSO.

In view of the success of this pilot project, decision-makers chose to continue using this digital health solution for targeted care pathways in the long term, and to continue developing the platform in order to meet the expectations of healthcare professionals as effectively as possible, thereby ensuring that resources are used optimally to provide the best care to patients.

In conclusion, going forward, both MUHC and CISSSO are planned to scale up, adding other care pathways to extend the benefits of the digital health solution to a broader patient base across various medical specialities. This expansion strategy aims to replication the observed success in other clinical areas, offering continuous improvement in care throughout the organization.

Abbreviations

ABC

Activity-based costing

ABF

Activity-based funding

CMG

Case mix group

CISSSO

Centre intégré de santé et des services sociaux de l’Outaouais

DRGs

Developed diagnosis-related groups

MUCH

McGill University Health Centre

PFF

Patient-focused funding

PPM

PowerPerformance Manager

RAMQ

Régie de l’assurance maladie du Québec

TDABC

Time-driven activity-based costing

VBHC

Value-based healthcare

Authors’ contributions

All authors have seen and approved the submission of this paper to your journal. V.N. is the Principal Investigator; she conceived the study and secured funding, and led all aspects of this study. V.N. and V.P. were involved in the concept and design, and wrote the first draught of the manuscript. V.P. was responsible for data collection and, V.P. and V.N. conducted the data analysis. Both authors contributed to the manuscript revisions, and approved the final manuscript.

Authors’ information

Véronique Nabelsi is a Full Professor in the Department of Administrative Sciences at the University of Quebec in Outaouais. Her current research focuses on health care to better understanding promising technological and organizational innovations to improve accessibility and continuity of the health system, with a view to improving its performance.

Véronique Plouffe, M.Sc., CPA auditor, is an Adjunct Professor in the Department of Accounting at the University of Quebec in Outaouais. Her research interests include project management and the use of performance management methods in healthcare organizations, including Time-driven activity-based costing and Activity-based costing.

Funding

This research was supported by a grant from the Fonds de soutien à l’innovation en santé et en services sociaux (FSISSS) (#2-2-21).

Data availability

The tables presented along the entire article contains most data used to develop the article analysis. Additional datasets used during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval has been obtained from the Research Ethics Committee of the Centre intégré de santé et des services sociaux de l’Outaouais (ref. number 2019 − 258_141_MP) in Quebec, Canada. All methods were carried out in accordance with the relevant institutional guidelines and regulations. The Research Ethical Committee is affiliated with Université du Québec en Outaouais. All participants gave informed, written consent to participate, and interviewees were sent the interview questions in advance, allowing them time to consider their viewpoints.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.