Cost Comparison of In-Suite Versus Portable Tunneled Femoral Central Line Placements in Children Using Time-Driven Activity-Based Costing.

OBJECTIVE: Compare the cost of placing tunneled femoral central lines in the interventional radiology suite to portable bedside placement using time-driven activity-based costing. METHODS: Detailed process maps were created using information generated from interviews with frontline staff, direct shadowing of patient procedures (19 patients-8 in-suite, 11 portable; patient age 4 days to 37 months; 6 males, 13 females), and electronic medical record review (80 patients-44 in-suite, 36 portable; patient age 1 day to 20 months; 42 males, 38 females) who underwent a tunneled femoral central line placement at a tertiary care pediatric hospital from January 1, 2018, to June 30, 2018. Procedures were conducted in-suite using fluoroscopy guidance or portably at the patient's bedside using ultrasound. Capacity cost rates for each resource in the process maps were calculated for personnel, equipment, facilities, and supply costs. Costs for each process step were then calculated by multiplying the capacity cost rate by the mean duration of each step. Stepwise costs were summed for the entire process to generate a cost for each tunneled femoral central line placement pathway. RESULTS: Total pathway time for tunneled femoral central lines placement in-suite was 123 to 134 min (nonsedated) and 120 to 131 min (sedated) for a cost of $923 to $990 and $1,262 to $1,386, respectively. Total pathway time for tunneled femoral central lines placed portably were 117 to 119 min (nonsedated) and 115 to 147 min (sedated) for a cost of $1,060 to $1,066 and $1,379 to $1,393, respectively. CONCLUSION: Total costs of tunneled femoral central lines placed in-suite were similar to total costs for lines placed portably. Cost should not be a primary consideration when deciding upon tunneled femoral central line approach in these patients.

Cost Comparison of Ultrasound Versus MRI to Diagnose Adolescent Female Patients Presenting with Acute Abdominal/Pelvic Pain Using Time-Driven Activity-Based Costing.

RATIONALE AND OBJECTIVES: To compare the cost of ultrasound (US) versus magnetic resonance imaging (MRI) using time-driven activity-based costing in adolescent female patients with suspected appendicitis. MATERIALS AND METHODS: Process maps were created using data from electronic medical record review and patient shadowing for adolescent female patients undergoing US or noncontrast MRI exams of the abdomen and pelvis for suspected appendicitis. Capacity cost rates for all personnel, equipment, facilities, and supplies in each exam pathway were established from institutional accounting data. The cost of each process step was determined by multiplying step-specific capacity cost rates by the mean time required to complete the step. Total pathway costs for US and MRI were computed by summing the costs of all steps through each pathway, and a direct cost comparison was made between the two modalities. RESULTS: Process maps for US and MRI pathways were generated from 231 and 52 patient encounters, respectively. Patients undergoing US exams followed one of six pathways depending on exam order (abdomen versus pelvis performed first) and whether additional time was needed for bladder filling. Mean total US pathway time was 91 minutes longer than for MRI (US = 166 minutes; MRI = 75 minutes). Total MRI pathway cost was $209.97 compared to a mean US cost of $258.33 (range = $163.21-$293.24). CONCLUSION: MRI can be a faster and less costly alternative to US for evaluating suspected appendicitis in adolescent female patients. While precise costs will vary by institution, MRI may be a viable and at times preferable alternative to US in this patient population.

Kidney transplantation at the University of Pennsylvania: 1998-2008.

Kidney transplantation at the University of Pennsylvania has grown substantially over the past 11 years. Although our transplant volume has increased primarily as a consequence of multiorgan transplants as well as the utilization of historically "marginal" allografts, our post-transplantation outcomes remain excellent in both children and adults. We attribute these outcomes to technical improvements in tissue typing and donor-recipient crossmatching, modification of immunosuppression protocols, and rigorous donor and recipient selection. In the next decade, we hope to substantially expand our living donor program and refine our overall donor and recipient selection process such that we maintain excellent post-transplant outcomes in the face of aging and increasingly comorbid donors and recipients. We further predict significant changes in post-transplant management of kidney recipients with respect to immunosuppression regimens. In particular, we anticipate the modulation of immunosuppression regimens in recipients with high titers of donor-specific antibody and the integration of B-cell specific immunosuppression into post-transplant patient care. Only time will tell whether such therapies will 1) improve long-term outcomes, 2) allow us to diminish the degree of non-specific pharmacologic immunosuppression currently in use, 3) or even promote donor-specific tolerance in kidney transplant recipients.