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Activity-Based Costing and Time-Driven Activity-Based Costing for Assessing the Costs of Cancer Prevention, Diagnosis, and Treatment: A Systematic Review of the Literature

  • Rafael J. Vargas Alves
    Correspondence
    Address correspondence to: Rafael J. Vargas Alves, Graduate Program of Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil.
    Affiliations
    Graduate Program of Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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  • Ana P. Beck da Silva Etges
    Affiliations
    Department of Industrial Engineering, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil

    National Institute for Health Technology Assessment - IATS/CNPq, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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  • Giácomo Balbinotto Neto
    Affiliations
    Graduate Program of Economy, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil

    National Institute for Health Technology Assessment - IATS/CNPq, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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  • Carisi Anne Polanczyk
    Affiliations
    National Institute for Health Technology Assessment - IATS/CNPq, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Open ArchivePublished:August 24, 2018DOI:https://doi.org/10.1016/j.vhri.2018.06.001

      ABSTRACT

      Background

      A review of the literature on economic analyses in cancer (prevention, diagnosis, and treatment) using activity-based costing (ABC) or time-driven activity-based costing (TDABC) for measuring costs and to examine how these approaches have been applied to assess and manage cancer costs.

      Methods

      This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We conducted a search for studies that used ABC or TDABC to calculate the cost of cancer in prevention, diagnosis, and treatment. Only English- and Portuguese-language articles were retrieved from Medline, Lilacs, ScieLO, and Embase (January 1990 to August 2016).

      Results

      In total, 421 studies were evaluated. However, only 27 papers were included. The first publications were from the early 2000s, but most of the studies were published in 2016 (n = 10). Most of the studies were carried out in the United States (n = 6) and Belgium (n = 6). Cancer treatment was the major focus of all studies (n = 20), followed by screening programs evaluations (n = 4) and diagnosis (n = 3). Among treatment modalities, economic analysis of radiotherapy was the most common topic of study. Retrospective clinical data represented 57.6% of the studies. More than 50% of the studies presented unspecified economic analysis. The hospital perspective was the most prevalent perspective among the studies (46.1%).

      Conclusions

      ABC and TDABC economic analyses are a promising area of studies in oncology costs.

      Keywords

      Introduction

      Cancer is a major public health problem worldwide. In 2012, for 27 countries of the European Union, 3.45 million new cases of cancer were estimated and 1.75 million people died of cancer in these countries [
      • Ferlay J
      • Steliarova-foucher E
      • Lortet-tieulent J
      • Rosso S
      Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012.
      ]. In 2016, in the United States of America, 1.7 million new cases of cancer were expected [
      • Siegel RL
      • Miller KD
      • Jemal A
      Cancer statistics, 2016.
      ].
      Despite an increase in cancer incidence, deaths from cancer have declined in the last years. Death rates from cancer declined by 23% in the United States over the last 20 years [
      • Siegel RL
      • Miller KD
      • Jemal A
      Cancer statistics, 2016.
      ]. In developing countries, cancer deaths have also declined due to several factors, including early diagnosis, improved diagnostic approaches, new cancer treatments, and lifestyle changes [
      • Kohler BA
      • Ward E
      • Mccarthy BJ
      • et al.
      Annual report to the nation on the status of cancer, 1975-2007, featuring tumors of the brain and other nervous system.
      ,
      • Tiwari AK
      • Roy HK
      Progress against cancer (1971-2011): how far have we come?.
      ].
      These advances in cancer diagnosis and treatment through new technologies and innovations have resulted from continued investments in health care. Cancer patient care demands use of new technologies, which are key to add value and to allow health organizations to provide qualified and reliable care services [
      • Porter ME
      What is value in health care?.
      ].
      Improving financial management of health care organizations poses a significant challenge as they operate within a complex system composed of many devices, including health care, social factors, multiple clients, research, and teaching [
      • Kiviniemi A
      • Fischer M
      • Bazjanac V
      • Paulson B
      Premiss—requirements management interface to building product models: problem definition and research issues.
      ]. The multiplicity of stakeholders comprising patients, family members, and health care providers, among others, demands organizational systems that can effectively gather useful information for decision making [
      • Souza AA
      Gestão Financeira e de custos em hospitais.
      ]. It is thus of paramount importance to improve financial management performance of hospitals and to define approaches to better handle this complex environment in the current economic scenario guided by cost restraints and high standards of quality of care [
      • Troyer GT
      • Brashear AD
      • Green KJ
      Managing corporate governance risks in a nonprofit health care organization.
      ,
      • Gallagher TH
      • Brundage G
      • Summy EA
      • et al.
      National survey: risk managers attitudes and experiences regarding patient safety and error disclosure.
      ].
      Economic analyses are required as part of the process for incorporating new health technologies [
      • Rascati KL
      Introdução à Farmacoeconomia.
      ]. These assessments entail identifying direct and indirect costs of a new technology. An accurate estimate of costs is central to determine the validity of an economic analysis in the decision-making process. This field of research employs economic assessment methods to estimate the value of health care products and services by comparing costs and outcomes [
      • Rascati KL
      Introdução à Farmacoeconomia.
      ].
      Although the importance of precise cost assessment of health care services [
      • Souza AA
      Gestão Financeira e de custos em hospitais.
      ] has been tremendously recognized, its implementation has been a challenge in practice due to a lack of standard of cost calculation. In the last years, researchers have explored systems that can help determining health care costs based on specific activities or products, such as activity-based costing (ABC) and time-driven activity-based costing (TDABC).
      ABC is a costing methodology proposed by Cooper and Kaplan [
      • Cooper R
      • Kaplan RS
      Profit priorities from activity-based costing.
      ] that assumes that multiple products consume the same activities and these activities require health care resources in different proportions. ABC methodology provides a more accurate estimative of the cost of a product or service, especially when it is composed of a portion of people-oriented activities and activities in a hospital setting. ABC methodology consists of mapping processes and identifying activities that add value to the process, the analysis of cost allocation to these activities, and the use of first-stage cost drivers [
      • Pamplona E.
      Contribuição para a análise crítica do sistema de custos ABC através da avaliação de direcionadores de custos [dissertation].
      ]. This approach entails first an accurate process mapping, that is, a business process analysis (BPA) of the organization [
      • Pamplona E.
      Contribuição para a análise crítica do sistema de custos ABC através da avaliação de direcionadores de custos [dissertation].
      ,
      • Raffish N
      How much does that product really cost?.
      ], and its application is quite relevant in settings where the largest portion of costs is allocated to skilled work force as in health care organizations. ABC is an appropriate methodology to understand the costs in high-complexity systems, but because it entails process mapping and identification of people-oriented drivers, it is slow to implement and difficult to update [
      • Kaplan RS
      • Anderson SR
      Time-driven activity-based costing.
      ].
      On the other hand, TDABC is a modified version of ABC that does not require interviews with employees of organizations for allocating costs to activities because it directly assigns the costs of resources from cost objects through a simple formula: hourly cost rate. The basic principle of this methodology is that it converts cost drivers into time equations, which represent time required to perform a given activity. Both ABC and TDABC can accurately correlate cost and activity, as both provide actual cost estimates, especially when microcosting approach is used.
      In the light of increasing cancer spending and weak costing methodologies compared to more robust approaches for pharmacoeconomic analyses, the present study aimed to conduct a systematic review of the literature on economic analyses in cancer (prevention, diagnosis, and treatment) using ABC or TDABC for measuring costs and to examine how these approaches have been applied to assess and manage cancer costs.

      Methods

      We conducted a systematic literature review of health-related databases. This review study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [
      • Moher D
      • Liberati A
      • Tetzlaff J
      • Altman DG
      The PRISMA Group
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      ]. We conducted comprehensive search of full-text publications in the PubMed/MEDLINE, LILACS, SciELO, and EMBASE databases using the following descriptors in English and Portuguese: “cancer,” “activity-based costing,” and “time-driven activity-based costing.” Our search strategy is detailed in the Appendix A (see Appendix A in Supplemental Materials found at 10.1016/j.vhri.2018.06.001). All search strategies were run on July 19, 2016, and updated on June 7, 2017.

       Eligibility Criteria and Study Selection

      The eligibility criteria for study selection included studies using ABC or TDABC methodology to estimate the costs of cancer prevention, diagnosis, or treatment. There was no year of publication limits and only articles in Portuguese and/or English were eligible for inclusion.

       Search, Data Extraction, and Analysis

      Pairs of reviewers (Vargas and Etges) conducted the search of studies and data extraction. Duplicates were excluded using the Mendeley Desktop Software (version 1.16.1). The reviewers screened titles and abstracts and reviewed the full text of the studies selected. Any disagreements between the pair of reviewers on the selection status were settled by a third reviewer (Balbinoto).
      After selecting studies for review, data were extracted and classified in a standardized manner according to general and specific characteristics of studies. The following data were arranged in tables: the authors, year of publication, study population, factor under study, type of economic analysis, source of medical data, country of origin, main study objective, study site, and comments. Data were stored in Microsoft Excel 2010.

       Methodological Limitations and Statistical Analysis

      The scientific quality of the articles was not fully explored, because the aim of this study was to investigate how ABC or TDABC has been applied in the oncology field, and not the quantitative estimates of their results. Hence, there is a probability of inclusion of studies with methodological limitations and/or imprecise results.

      Results and Discussion

      A total of 421 studies were identified and evaluated, and 27 studies met the eligibility criteria and were included in this review. Figure 1 summarizes the study selection process, excluded studies, and criteria for excluding them. Table 1 presents consolidated results from the studies selected [
      • Ilg AM
      • Laviana AA
      • Kamrava M
      • et al.
      Time-driven activity-based costing of low-dose-rate and high-dose-rate brachytherapy for low-risk prostate cancer.
      ,
      • Govaert JA
      • Lijftogt N
      • Van Dijkt W
      • et al.
      Colorectal cancer surgery for obese patients: financial and clinical outcomes of a Dutch population‐based registry.
      ,
      • Govaert JA
      • Van Dijkt W
      • Fiocco M
      • et al.
      Nationwide outcomes measurement in colorectal cancer surgery: improving quality and reducing costs.
      ,
      • Han K
      • Yap ML
      • Yong JHE
      • et al.
      Omission of breast radiotherapy in low-risk luminal A breast cancer: impact on health care costs.
      ,
      • Herling SF.
      Robotic-assisted laparoscopic hysterectomy for women with endometrial cancer-complications, women's experiences, quality of life and a health economic evaluation [dissertation].
      ,
      • Laviana AA
      • Ilq AM
      • Veruttipong D
      • et al.
      Utilizing time‐driven activity‐based costing to understand the short‐and long‐term costs of treating localized, low‐risk prostate cancer.
      ,
      • Crott R
      • Lawson G
      • Nollevaux MC
      • et al.
      Comprehensive cost analysis of sentinel node biopsy in solid head and neck tumors using a time-driven activity-based costing approach.
      ,
      • Tan RYC
      • Met-Domestici M
      • Zhou K
      • et al.
      Using quality improvement methods and time-driven activity-based costing to improve value-based cancer care delivery at a cancer genetics clinic.
      ,
      • Thaker NG
      • Phug TJ
      • Mahmood U
      • et al.
      Defining the value framework for prostate brachytherapy using patient-centered outcome metrics and time-driven activity-based costing.
      ,
      • Yong JHE
      • McGowan T
      • Redmond-Misner R
      • et al.
      Estimating the costs of intensity-modulated and 3-dimensional conformal radiotherapy in Ontario.
      ,
      • Dalley C
      • Basarir H
      • Wright JG
      • et al.
      Specialist integrated haematological malignancy diagnostic services: an Activity Based Cost (ABC) analysis of a networked laboratory service model.
      ,
      • Lievens Y
      • Obyn C
      • Mertens AS
      • Hulstaert DVHF
      Stereotactic body radiotherapy for lung cancer: how much does it really cost?.
      ,
      • Aguilar-Bernier M
      • González-Carrascosa M
      • Padilla-España L
      • et al.
      Five-year economic evaluation of non-melanoma skin cancer surgery at the Costa del Sol Hospital (2006–2010).
      ,
      • Pryor DI
      • Porceddu SV
      • Scuffham PA
      • et al.
      Economic analysis of FDG-PET–guided management of the neck after primary chemoradiotherapy for node-positive head and neck squamous cell carcinoma.
      ,
      • Rezapour A
      • Larijani B
      • Azar FE
      • Sofia AS
      Microeconomic analysis of health care services delivered to patients under urologic tumor surgeries.
      ,
      • Subramanian S
      • Tangka FKL
      • Hoover S
      • et al.
      Clinical and programmatic costs of implementing colorectal cancer screening: evaluation of five programs.
      ,
      • Accetta G
      • Biggeri A
      • Carreras G
      • et al.
      Is human papillomavirus screening preferable to current policies in vaccinated and unvaccinated women? A cost-effectiveness analysis.
      ,
      • Baratti D
      • Scivales A
      • Balestra MR
      • et al.
      Cost analysis of the combined procedure of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).
      ,
      • Ploquin N
      • Dunscombe P
      A cost-outcome analysis of image-guided patient repositioning in the radiation treatment of cancer of the prostate.
      ,
      • Bermúdez-tamayo C
      • Martin Martin J
      • Gonzalez MP
      • Perez Romero C
      Cost-effectiveness of percent free PSA for prostate cancer detection in men with a total PSA of 4–10 ng/ml.
      ,
      • Annemans L
      • Van Overbeke N
      • Santadaert B
      • Van Belle S
      Estimating resource use and cost of prophylactic management of neutropenia with filgrastim.
      ,
      • Lievens Y
      • Kesteloot K
      • Van den bogaert W
      Economic consequence of local control with radiotherapy: cost analysis of internal mammary and medial supraclavicular lymph node radiotherapy in breast cancer.
      ,
      • Lievens Y
      • Kesteloot K
      • Van den bogaert W
      Chart in lung cancer: economic evaluation and incentives for implementation.
      ,
      • Hollingworth W
      • Gray DT
      • Martin BI
      • et al.
      Rapid magnetic resonance imaging for diagnosing cancer-related low back pain: a cost-effectiveness analysis.
      ,
      • Bech M
      • Gyrd-hansen D
      Cost implications of routine mammography screening of women 50–69 years in the county of Funen, Denmark.
      ,
      • Grant CM.
      Cervical screening interval: costing the options in one health authority.
      ,
      • Holschneider CH
      • Ghosh K
      • Montz FJ
      See‐and‐treat in the management of high‐grade squamous intraepithelial lesions of the cervix: a resource utilization analysis.
      ].
      Table 1Studies selected for review
      Year of publicationAuthor [Ref.]Method usedStudy population or type of cancer studiedTechnology assessedEconomic analysisSource of dataCountry of originPerspective
      2016Ilg et al.
      • Ilg AM
      • Laviana AA
      • Kamrava M
      • et al.
      Time-driven activity-based costing of low-dose-rate and high-dose-rate brachytherapy for low-risk prostate cancer.
      TDABCProstateBrachytherapyNANAUnited StatesHospital
      2016Govaert et al.
      • Govaert JA
      • Lijftogt N
      • Van Dijkt W
      • et al.
      Colorectal cancer surgery for obese patients: financial and clinical outcomes of a Dutch population‐based registry.
      TDABCColonNANARetrospectiveNetherlandsHospital
      2016Govaert et al.
      • Govaert JA
      • Van Dijkt W
      • Fiocco M
      • et al.
      Nationwide outcomes measurement in colorectal cancer surgery: improving quality and reducing costs.
      TDABCColonNANARetrospectiveNetherlandsHospital
      2016Han et al.
      • Han K
      • Yap ML
      • Yong JHE
      • et al.
      Omission of breast radiotherapy in low-risk luminal A breast cancer: impact on health care costs.
      ABCBreastRadiation therapyNARetrospectiveCanadaPublic system
      2016Herling
      • Herling SF.
      Robotic-assisted laparoscopic hysterectomy for women with endometrial cancer-complications, women's experiences, quality of life and a health economic evaluation [dissertation].
      ABCEndometriumRobotic surgeryNARetrospectiveDenmarkHospital
      2016Laviana et al.
      • Laviana AA
      • Ilq AM
      • Veruttipong D
      • et al.
      Utilizing time‐driven activity‐based costing to understand the short‐and long‐term costs of treating localized, low‐risk prostate cancer.
      TDABCProstateNANARetrospectiveUnited StatesHospital
      2016Crott et al.
      • Crott R
      • Lawson G
      • Nollevaux MC
      • et al.
      Comprehensive cost analysis of sentinel node biopsy in solid head and neck tumors using a time-driven activity-based costing approach.
      TDABCHead and neckSentinel lymph node mappingNANABelgiumHospital
      2016Tan et al.
      • Tan RYC
      • Met-Domestici M
      • Zhou K
      • et al.
      Using quality improvement methods and time-driven activity-based costing to improve value-based cancer care delivery at a cancer genetics clinic.
      TDABCHereditary CancerGenetic testingCUA + CEARetrospectiveSingaporeClinic
      2016Thaker et al.
      • Thaker NG
      • Phug TJ
      • Mahmood U
      • et al.
      Defining the value framework for prostate brachytherapy using patient-centered outcome metrics and time-driven activity-based costing.
      TDABCProstateBrachytherapyNARetrospectiveUnited StatesNA
      2016Yong et al.
      • Yong JHE
      • McGowan T
      • Redmond-Misner R
      • et al.
      Estimating the costs of intensity-modulated and 3-dimensional conformal radiotherapy in Ontario.
      ABCProstateRadiation therapyNARetrospectiveCanadaHospital
      2015Dalley et al.
      • Dalley C
      • Basarir H
      • Wright JG
      • et al.
      Specialist integrated haematological malignancy diagnostic services: an Activity Based Cost (ABC) analysis of a networked laboratory service model.
      ABCBloodNANARetrospectiveUnited KingdomNA
      2015Lievens et al.
      • Lievens Y
      • Obyn C
      • Mertens AS
      • Hulstaert DVHF
      Stereotactic body radiotherapy for lung cancer: how much does it really cost?.
      TDABCLungStereotactic radiation therapyNANABelgiumInsurance
      2014Aguilar-Bernier et al.
      • Aguilar-Bernier M
      • González-Carrascosa M
      • Padilla-España L
      • et al.
      Five-year economic evaluation of non-melanoma skin cancer surgery at the Costa del Sol Hospital (2006–2010).
      ABCSkinSurgeryCEARetrospectiveSpainHospital
      2013Pryor et al.
      • Pryor DI
      • Porceddu SV
      • Scuffham PA
      • et al.
      Economic analysis of FDG-PET–guided management of the neck after primary chemoradiotherapy for node-positive head and neck squamous cell carcinoma.
      ABCHead and neckPET-CT imagingCEAProspectiveAustraliaPublic system
      2012Rezapour et al.
      • Rezapour A
      • Larijani B
      • Azar FE
      • Sofia AS
      Microeconomic analysis of health care services delivered to patients under urologic tumor surgeries.
      ABCGenitourinaryGenitourinary surgeryNARetrospectiveIranHospital
      2011Subramanian et al.
      • Subramanian S
      • Tangka FKL
      • Hoover S
      • et al.
      Clinical and programmatic costs of implementing colorectal cancer screening: evaluation of five programs.
      ABCColonScreening testingNAProspectiveUnited StatesPublic system
      2010Accetta et al.
      • Accetta G
      • Biggeri A
      • Carreras G
      • et al.
      Is human papillomavirus screening preferable to current policies in vaccinated and unvaccinated women? A cost-effectiveness analysis.
      ABCCervixScreening testingCUA + CEAProspectiveItalyPublic system
      2010Baratti et al.
      • Baratti D
      • Scivales A
      • Balestra MR
      • et al.
      Cost analysis of the combined procedure of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).
      ABCPeritoneumSurgery + hyperthermic intraperitoneal chemotherapyNARetrospectiveItalyHospital
      2009Ploquin and Dunscombe
      • Ploquin N
      • Dunscombe P
      A cost-outcome analysis of image-guided patient repositioning in the radiation treatment of cancer of the prostate.
      ABCProstateRadiation therapyCUA + CEAProspectiveCanadaHospital
      2007Bermúdez et al.
      • Bermúdez-tamayo C
      • Martin Martin J
      • Gonzalez MP
      • Perez Romero C
      Cost-effectiveness of percent free PSA for prostate cancer detection in men with a total PSA of 4–10 ng/ml.
      ABCProstateScreening programCEARetrospectiveSpainHospital
      2005Annemans et al.
      • Annemans L
      • Van Overbeke N
      • Santadaert B
      • Van Belle S
      Estimating resource use and cost of prophylactic management of neutropenia with filgrastim.
      ABCRisk of neutropeniaProphylactic filgrastimCEANABelgiumHospital
      2005Lievens et al.
      • Lievens Y
      • Kesteloot K
      • Van den bogaert W
      Economic consequence of local control with radiotherapy: cost analysis of internal mammary and medial supraclavicular lymph node radiotherapy in breast cancer.
      ABCBreastRadiation therapyCUA + CEAProspectiveBelgiumSocietal
      2005Lievens et al.
      • Lievens Y
      • Kesteloot K
      • Van den bogaert W
      Chart in lung cancer: economic evaluation and incentives for implementation.
      ABCLungRadiation therapyCEAProspectiveBelgiumSocietal
      2003Hollingworth et al.
      • Hollingworth W
      • Gray DT
      • Martin BI
      • et al.
      Rapid magnetic resonance imaging for diagnosing cancer-related low back pain: a cost-effectiveness analysis.
      ABCBack painMRICUA + CEAProspectiveUSANA
      2000Bech and Gyrd-hansen
      • Cherny NI
      • Sullivan R
      • Dafini U
      • et al.
      A standardised, generic, validated approach to stratify the magnitude of clinical benefit that can be anticipated from anti-cancer therapies: the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS).
      ABCRisk of breast cancerMammographyCCARetrospectiveDenmarkSocietal
      1999Grant
      • Grant CM.
      Cervical screening interval: costing the options in one health authority.
      ABCRisk of cervical cancerScreening testingNARetrospectiveEnglandNA
      1999Holschneider et al.
      • Holschneider CH
      • Ghosh K
      • Montz FJ
      See‐and‐treat in the management of high‐grade squamous intraepithelial lesions of the cervix: a resource utilization analysis.
      ABCCervical intraepithelial neoplasiaTreatment programsNANAUSANA
      ABC, activity-based costing; CCA, cost-consequence analysis; CEA, cost-effectiveness analysis; CUA, cost-utility analysis; MRI, magnetic resonance imaging; NA, not available or not applicable; PET-CT, positron-emission tomography and computed tomography; TDABC, time-driven activity-based costing.
      Over the years, the number of studies published on microcosting and cancer has increased. The number of publications by year using ABC and TDABC methodology for measuring cancer costs was 19 and 8, respectively. The first studies were published in 1999 (n = 2), but most of them were published in 2016 (n = 10). TDABC was developed in 2004; therefore, it has been used in research and put in practice in other markets only recently (2015) [
      • Keel G
      • Savage C
      • Rafiq M
      • Mazzocato P
      Time-driven activity-based costing in health care: a systematic review of the literature.
      ].
      A larger number of publications were from the United States and Belgium (n = 6 each) and three were from Canada. Most of the studies were conducted in developed countries mainly because they had high-capacity data-processing systems and could apply advanced costing methodologies. As for the large number of studies from the United States, it is worth noting that ABC and TDABC were developed at Harvard University. In developing countries, given the scarcity of health care resources and low investments in health information systems, there is a need to bridge this gap in order to improve several areas of management, especially financial management.
      The studies reviewed here mainly focused on cancer treatment (n = 20), followed by evaluation of screening/prevention programs (n = 4) and diagnostic approaches (n = 3). Concerning cancer treatment, radiation therapy and related treatment modalities stood out as the most common factor under study. It can thus be inferred that radiotherapy is part of a process with fewer variances because it is a machine-based treatment. Considering that the ABC method requires mapping processes to implement ABC, its application in health care services with well-shaped processes is easier and provides results that are more accurate. In addition, machine-based procedures enable the collection and analysis of information about patient flow and treatment time, thus minimizing the time required for planning and implementing ABC.
      Most studies presented results from hospitals perspective (46.1%). Hospitals are expected to profit while undertaking their routine operations–either by adhering to a public budget (public sector) or by generating earnings (private sector). In a competitive market, organizations aim at a high-efficiency performance to reduce costs and become more competitive regardless of their market [
      • Holschneider CH
      • Ghosh K
      • Montz FJ
      See‐and‐treat in the management of high‐grade squamous intraepithelial lesions of the cervix: a resource utilization analysis.
      ].
      The pursuit of improved cost management is focused on becoming more competitive in flexible markets in the current global economy. Thus, the fact that hospital perspective prevailed in most studies may point to a need to increase profitability by reducing costs [
      • Souza AA
      Gestão Financeira e de custos em hospitais.
      ] through value added by improving cost management using costing methodologies such as ABC and TDABC [
      • Lievens Y
      • Van den bogaert W
      • Kesteloot K
      Activity-based costing: a practical model for cost calculation in radiotherapy.
      ]. It is clear how these methodologies are related with the health organization capability to prospect value and to be more efficient. However, some difficulties are present and need to be improved using different case studies [
      • Lievens Y
      • Van den bogaert W
      • Kesteloot K
      Activity-based costing: a practical model for cost calculation in radiotherapy.
      ,
      • Cao P
      • Toyabe SI
      • Akazawa K
      Development of a practical costing method for hospitals.
      ]. The prospective value of a health organization is determined by quality and safety of medical services delivered to patient [
      • Kohn LT
      • Corrigan JM
      • Donaldson MS
      To err is human: building a safer health system.
      ,
      • Wolf JA
      • Niederhauser V
      • Marshburn D
      • Lavela SL
      Defining patient experience.
      ]. Porter et al. [
      • Baratti D
      • Scivales A
      • Balestra MR
      • et al.
      Cost analysis of the combined procedure of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).
      ] stated that achieving a high value of health care delivery for patients must become the overachieving goal of health organizations. The authors measured value as the health outcomes achieved per dollar spent [
      • Porter ME
      • Larsson S
      • Lee TH
      Standardizing patient outcomes measurement.
      ]. Processes that contribute to managing an organization in a systemic and proactive way encourage efficient practices among the organization's divisions, resulting in cost reduction and consequent improvement in future value [
      • Kaplan RS
      • Hass DA
      • Warsh J
      Adding value by talking more.
      ].
      The ways to deal with shared structures presents in health care and to identify precisely the activity times are examples of issues that need to be more explored by researchers and hospital financial managers. One suggestion to tackle this problem is to restrict the precise time estimation to activities that are more representative of the process care [
      • Sherrat M
      Editorial.
      ]. To precisely estimate time, chronoanalysis, participant observation, and Delphi methodology are suggested [
      • Cardinaels E
      • Roodhooft F
      • Van Herck G
      Drivers of cost system development in hospitals: results of a survey.
      ].
      Medical data were largely collected using a retrospective design (over half of the studies, 57.6%). The data collected were used for cost estimates of the amounts spent by a hospital with the delivery of care services and procedures. In the studies of Lievens et al. [
      • Annemans L
      • Van Overbeke N
      • Santadaert B
      • Van Belle S
      Estimating resource use and cost of prophylactic management of neutropenia with filgrastim.
      ,
      • Lievens Y
      • Kesteloot K
      • Van den bogaert W
      Chart in lung cancer: economic evaluation and incentives for implementation.
      ] and Bermúdez et al. [
      • Bermúdez-tamayo C
      • Martin Martin J
      • Gonzalez MP
      • Perez Romero C
      Cost-effectiveness of percent free PSA for prostate cancer detection in men with a total PSA of 4–10 ng/ml.
      ], the authors strongly advocated for improving the accuracy of cost information by applying ABC as a costing method. It is noteworthy that there were no studies conducted in middle- and low-income countries. Using retrospective cost data from other countries reduces the accuracy of financial information. Countries have different organizational structures for health care, and their resource allocation, organizational values, ​​and input assignment to patients vary considerably, which stresses the need of individual cost estimates for each country. The use of ABC to determine the cost of a specific treatment represents an advance in improving quality of information available for pharmacoeconomic analyses and consequent improvements in decision making.
      In addition to supporting pharmacoeconomic studies, advanced costing methods such as ABC and TDABC are also effective approaches for cost management studies in health care settings. Lievens et al. [
      • Lievens Y
      • Kesteloot K
      • Van den bogaert W
      Economic consequence of local control with radiotherapy: cost analysis of internal mammary and medial supraclavicular lymph node radiotherapy in breast cancer.
      ,
      • Lievens Y
      • Kesteloot K
      • Van den bogaert W
      Chart in lung cancer: economic evaluation and incentives for implementation.
      ] underlined the importance of using ABC to improve resource allocation planning on prospective demand for health services. The use of advanced costing methods in health offers an opportunity for researchers to fully explore alternatives to improve allocation of public health care resources, especially in developing countries, which are often not capable of meeting the enormous demands from the population.
      Both ABC and TDBAC are methods that can help to analyze the cost of value in health. Value is defined in terms of the value equation—health outcomes achieved per unit cost expended over the entire care delivery value chain (CDVC) [

      Internacional Society for Pharmacoeconomics and Outcomes Research (ISPOR). Value Assessment Framework. Available at: www.ispor.org/USValueAssessmentFrameworks/STF-White-Paper-Section7-DRAFT-for-Member-Review.pdf

      ]. The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) presented a draft policy in 2017 on the appropriate definition and use of value frameworks [

      Internacional Society for Pharmacoeconomics and Outcomes Research (ISPOR). Value Assessment Framework. Available at: www.ispor.org/USValueAssessmentFrameworks/STF-White-Paper-Section7-DRAFT-for-Member-Review.pdf

      ]. The ISPOR identified and defined a series of elements that should be taken into consideration in assessing value of medical technologies, for instance, quality-adjusted life-years gained, labor productivity, fear of contagion, insurance value, and severity of disease. The American Society of Clinical Oncology (ASCO) [
      • Schnipper LE
      • Davidson NE
      • Wollins DS
      • et al.
      Updating the American Society of Clinical Oncology Value Framework: revisions and reflections in response to comments received.
      ] and the European Society for Medical Oncology (ESMO) [
      • Del Paggio JC
      • Sullivan R
      • Schraq D
      • et al.
      Delivery of meaningful cancer care: a retrospective cohort study assessing cost and benefit with the ASCO and ESMO frameworks.
      ] have also released frameworks to offer insight into the relation between treatment benefit and treatment cost. However, the ISPOR policy and ASCO and ESMO frameworks as well as most discussion of value in health are centered in outcomes and not in costs. Little attention is paid to development of cost estimative tools. A recent criticism on ASCO and ESMO frameworks [
      • Cherny NI
      • Sullivan R
      • Dafini U
      • et al.
      A standardised, generic, validated approach to stratify the magnitude of clinical benefit that can be anticipated from anti-cancer therapies: the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS).
      ] highlighted the weak association between their frameworks in terms of quantifying the benefits, but again there was little discussion on cost estimation.
      Neglecting costs in health or adopting inaccurate methodologies for cost estimations can bias interpretations of pharmacoeconomics studies. Valid value-based comparisons are not possible without consensus around how to calculate costs of medical conditions. This consensus can help health care providers to estimate more accurately the cost of care delivery for medical conditions and reduce the variability of costs in different scenarios [
      • McBain RK
      • Jerome G
      • Warsh J
      • et al.
      Rethinking the cost of healthcare in low-resource settings: the value of time-driven activity-based costing.
      ]. These positions contribute with the opportunity that activity-based cost methodologies can represent because have the capability to show: how, when and with what intensity the resources are being used by different patients.
      Kaplan and Porter [
      • Kaplan RS
      • Porter ME
      How to solve the cost crisis in health care.
      ] suggested that TDABC is a cost-accounting solution to be used in health care settings. To follow TDABC, Kaplan and Porter [
      • Kaplan RS
      • Porter ME
      How to solve the cost crisis in health care.
      ] suggested seven steps: 1) select the medical condition; 2) define the care delivery value chain, that is, chart all key activities performed within the entire care cycle; 3) develope process maps that include each activity in patient care delivery and incorporating all direct and indirect capacity-supplying resources; 4) obtain time estimates for each process, that is, obtain time estimates for activities and resources used; 5) estimate the cost of supplying patient care resources, that is, the cost of all direct and indirect resources involved in care delivery; 6) estimate the capacity of each resource and calculating the capacity cost rate; and 7) calculate the total cost of patient care. A recent systematic review on the use of TDABC in general health care also identified that use of capacity cost rate (used in TDABC) simplifies the application of ABC in complex environments such as health care [
      • Keel G
      • Savage C
      • Rafiq M
      • Mazzocato P
      Time-driven activity-based costing in health care: a systematic review of the literature.
      ]. These authors also suggest that the TDABC should be gradually incorporated in health care systems. These findings corroborate the fact that we found a higher number of publications on TDABC between 2015 and 2016 in our review (66% de TDABC). In fact, we believe that the TDABC product is the most accurate denominator to assess value in health for certain medical conditions, such as cancer.

      Conclusions

      Our review included studies on economic analyses using advanced ABC and TDABC methods for measuring cancer costs. These methodologies have the advantage of providing more accurate cost information in complex environments with resources focusing on skills and implicit knowledge. At the same time, the main challenge of these methods is that they require process mapping in different health care services. Mapping processes and identifying the flow of values can be challenging in hospital settings as they demand much effort and consume time in real case scenarios.
      The present review study focused on cancer-related practices and did not investigate other diseases and overall hospital costing analyses. Thus, our findings cannot be generalized to other health settings. Because we reviewed only international studies, further investigations are needed to assess the application of these costing methods in other countries, especially in developing countries.
      Our study pointed to a need to further exploration of the use of ABC and especially TDABC methodologies to support economic health analyses. We also recommend similar reviews on other health conditions and in hospitals as well.

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