Abstract: Cost estimation is crucial for health accounts analyses in developed and develop-
ing countries. This study aims to determine a methodology on the issue of costing systems
and costing methods applicable to all health services carried out on a large scale that by their
nature have a limited variability of resources (time, materials, human resources, etc..). We
use time-driven activity-based costing (TDABC). The average time of health activities has
been estimated within the direct observation of the activities and interviews in a paediatric
radiology service. Direct and indirect costs have been calculated considering the price per
minute for each health service category. TDABC allows calculating the practical expenses
of radiology services. This method reveals a higher expenditure than what is reimbursed by
the national health service. The empirical study shows high costs for CT and Thoracic spine
radiology under sedation, which the national health system does not consider. TDABC can
be used by health managers to evaluate the level of costs and to compare the internal results
with the reimbursement tariffs from the national health service. This method should be in-
cluded gradually as a tool of costs management and considered by policymakers and health
managers.
<a href="https://dx.doi.org/10.15611/fins.2021.2.05">DOI: 10.15611/fins.2021.2.05</a>
<p>JEL Classification: H </p>
<p><span>Keywords:</span> radiology, costs, drivers, TDABC, healthcare management. </p>
<h2>1. Introduction</h2>
<p>The use of diagnostic imaging services has increased due to its essential role in identifying diseases in patients
(Jayawardhana & Welton, 2015). Moreover, Smith-Bindman, Miglioretti, and Larson (2008) stated that the speed and
resolution for detecting diseases increase the number of computed tomography (CT). However, this is also related to
the increase in patient demand and the need for medical surveillance for specific groups of patients with cancer.</p>
<p>For these reasons, the analysis of costs and healthcare accounting are essential factors to consider for healthcare
goods and services to increase their acknowledgement between health providers (Kaplan & Porter, 2011; Organisation
for Economic Co-operation and Development..., 2011). At the same time, cost estimations require standardised
methodologies that allow for comparative analysis between different levels (from the government level to the
individual hospital department) (Organisation for Economic Co-operation and Development, 2010). However, there is a
limited awareness of the costs and information potential in the various healthcare sectors (Biancone, Secinaro,
Brescia, & Calandra, 2019; Okike et al., 2014; Vijayasarathi, Duszak, Gelbard, & Mullins, 2016). </p>
<p>The introduction of the Diagnosis-Related Group (DRGs) as a tool to describe hospital productivity, requires accurate
information on the costs of treatments (Fetter & Freeman, 1986). Therefore, the DRG is a system that classifies
patients and is introduced as a more efficient cost management system. In particular, all groups of physicians are
responsible for determining the number of resources needed to treat and perform all the clinical care of patients
(Messori Trippoli, & Marinai, 2020). This information is functional for reimbursements that governments at the
central level provide to healthcare facilities for the care they provided. Furthermore, each health service is linked
with predetermined rates (divided by homogeneous diagnostic grouping) that are allocated for healthcare, and each
hospital will have to assess whether its expenditure is higher or lower than the rate recognised by their health
systems (Bellavia et al., 2012; Cinquini, Vitali, Pitzalis, & Campanale, 2009). </p>
<p>Different activities are carried out within a healthcare facility in its management (inpatients, outpatient),
specialisation, actual times and complexity, thus generating difficulty in determining the cost of specific tasks
(Sturmberg & Martin, 2013). </p>
<p>According to the literature, different categories of costs are considered crucial to building a precise analysis of
any product or service (Finkler, 1994; Lo Martire, 2017; Suyer, Neumann, & Boles, 1992). For example, direct and
indirect costs in hospitals are varied and correspond to the healthcare activities carried out to treat patients.</p>
<p>However, despite the theoretical premise, calculating costs in healthcare is still a critical issue, creating
disagreements and problems between doctors and the healthcare personnel in charge of management control (Chapko et
al., 2009; Ryan, Watson, & Amaya-Amaya, 2003). Although several researchers have defined specific methodologies
over time, such as Activity-Based Costing (ABC) and Time-Driven Activity-Based Costing (TDABC), the opportunities for
strict empirical application have proved very difficult over time (Oklu et al., 2015). The problems are even more
prevalent in specialisations such as radiology that require constant investment in new equipment, as well as the
obsolescence and the number of examinations carried out over time (Jakovljević et al., 2013). Additionally, as Parikh
et al. (2021) suggested, staff dealing with radiology should be included in financial education programmes as an
extra-clinical competence essential for the management of radiology departments. </p>
<p>Therefore, drawing on the need to spread more expertise in terms of costs, this study will have three primary
objectives: </p>
<ol>
<li>to map the most commonly used methods for calculating costs in radiology healthcare departments;</li>
<li>to propose the use of the time-driven activity-based costing (TDABC) method through empirical analysis and an
interventional case study at the Department of Radiology of the Bambino Gesù Children’s Hospital (OPBG) in Rome
(Italy);</li>
<li>to compare the reimbursement rates (Campra, Orlandini, Amelio, & Brescia, 2021; Demeere, Stouthuysen, &
Roodhooft, 2009; Keel, Savage, Rafiq, & Mazzocato, 2017) of the Ministry of Health with the costs incurred by the
hospital.</li>
</ol>
<p>This research aimed to contribute empirically to the current debate on costing methodologies in radiology
departments. Finally, the results demonstrated the inadequate reimbursement by the National Health Service of those
added-value services that are also performed to safeguard patients. </p>
<p>The remainder of the paper is structured as follows. Section 2 describes the current literature on cost methodologies
such as ABC and TDABC. Section 3 defines the standard workflow and tools used. Section 4 presents the results obtained
from the interventionist case study. Moreover, Section 5 provides an in-depth data interpretation, comments, and
critique on the main findings, and Section 6 concludes with a summary of the main results obtained. </p>
<h2>2. Literature review</h2>
<h3>2.1. Healthcare cost-accounting methods</h3>
<p>The last few years have seen a gradual increase in the population’s average age. Economic expansion and access to
better healthcare have gradually improved health conditions in different areas of the world (OECD, 2004). This has
also been the case in these extraordinary times; for example, during the COVID-19 pandemic, healthcare systems
increased the average public spending on emergency health services by adopting hybrid management approaches (Haldane
et al., 2021; Secinaro, Calandra, & Biancone, 2020). Therefore, the new reality required new procedures and
increased health care costs (Cobianchi, Pugliese, Peloso, Dal Mas, & Angelos, 2020). </p>
<p>In general, costs can be fixed or variable. The former do not vary with the production level, and the latter change
linearly with the production level (Finkler, 1994). Both fixed and variable costs can be classified as direct or
indirect. In the first case, these values are directly attributable to the execution of an activity. At the same time,
indirect costs do not relate to the event but to the structure where it is carried out and to the support functions
that make it possible to carry out the activity in terms of administration, safety, quality, etc. (Lo Martire, 2017;
Suyer, Neumann, & Boles, 1992). </p>
<p>Accurately quantifying fixed and variable costs is not easy, and there are several methods to be adopted. According
to Chapko et al. (2009), two approaches can be used in cost estimation: top-down and bottom-up. These two
classifications differ in the units adopted. For example, while top-down approaches use variables such as the number
of days patients spend in a hospital, bottom-up approaches generally break down costs by individual health and
administrative services used in patient care (Bellavia et al., 2012; Goldberg & Kosinski, 2011). This calculation
method goes under the generic name of Activity-Based Costing (ABC), related to efficiency and adopted in laboratories
(Niñerola, Hernández-Lara, & Sánchez-Rebull, 2021a). </p>
<p>However, researchers have studied and validated different methodologies over time. For example, ABC has been modified
into a time-driven version by monitoring the costs of healthcare services throughout the period of care (Keel et al.,
2017). Other statistical methodologies have been spread by allocating costs from top to bottom according to drivers
and key performance indicators decided by healthcare managers. </p>
<p>Despite the spread of countless generic methods, as stated by Parikh et al. (2021), cost management in the radiology
sector is more complex and relies solely on reporting. Therefore, radiology healthcare managers should consider
strategic methodologies to validate the national health service or insurance revenue streams with departmental costs.
The remainder of this section aims to describe specific methods applied in radiology departments. </p>
<h3>2.2. Healthcare cost-accounting methods: a radiology perspective</h3>
<p>The results of costing studies in radiology are various and related to different approaches. Cost-effectiveness
studies (CEA) and cost-benefit analyses of radiology treatment are the most performed (Blackmore & Magid, 1997;
Brown, Bryan, & Warren, 1996; Darlington et al., 2015). This method allows for comparing the costs of two
treatments or examinations and has clinical implications. In other cases, the authors explained why radiologists
should know and understand costs in their direct field (Rubin, 2017) or ways to increase transparency in cost
methodology (Durand et al., 2015). The value of these studies is related to the calculation methodologies implemented.
For this reason, top-down costing and bottom-up approaches are also implemented in radiology (Darlington et al., 2015;
Hollingworth, 2005). </p>
<p>Firstly, the top-down approach demonstrates total expenditure by department (Finkler, 1994), however it could be
challenging to calculate the cost of a procedure. Two methods are used: the expenses to charges (RCC) or relative
value units (RVUs). RCC is strictly connected with charges – the total costs are considered at departmental level and
divided by the total expenses for the observation period. </p>
<p>RVUs consider costs usually deriving from national databases, and the rates are created on average values, thus
losing precision in the calculation (Rubin, 2017). </p>
<p>As demonstrated by Rubin (2017), in a simulation for two radiology departments, the results of the two methods are
very different, because RCC is related to the real costs at departmental level, whilst RVU derives from the national
benchmark. Thus, the two methods are not considered reliable if available individually. </p>
<p>Secondly, the bottom-up approach estimates resource utilisation costs involving many healthcare personnel and
managers (Rubin, 2017). The method used is Activity-Based Costing, also called micro-costing, which identifies the
cost driver and single-driver rate for each activity and considers the volume of units consumed or used (Frick, 2009;
Goldberg & Kosinski, 2011; Hollingworth, 2005; Lanen, Anderson, Maher, & Dearman, 2010). An in-depth analysis
of the intervention’s cost is essential at departmental level for maximising the effectiveness of care and cost, but
this method does not consider multiple costs within a single operation (Demeere et al., 2009; Rubin, 2017).
Additionally, other authors stated that this method is deemed time-consuming and resource-intensive (Demeere et al.,
2009; Kaplan & Anderson, 2003). </p>
<p>For these reasons, some costing studies used time-driven ABC (TDABC), which estimates the costs of each resource used
for treatments when considering the activities over time. This method is also accurate because it focuses on the
real-time activities carried out by healthcare personnel (Kaplan & Anderson, 2003; Keel et al., 2017; McLaughlin
et al., 2014; Rubin, 2017). Moreover, the method allows building a process map under the patient care cycle (Kaplan
& Porter, 2011) or single or multiple departments to describe costs and practical capacity (Chen, 2016; Demeere et
al., 2009; Laviana et al., 2016) within hospital departments (Kaplan, 2014; Shankar, Hayatghaibi, & Anzai, 2020).
As suggested by the results of Niñerola et al. (2021), the difference in the use of the two methods stems from the
simplicity of application and the number of publications in recent years. Furthermore, TDABC as a cost-accounting
method, could provide a clearer idea of costs, help healthcare managers to allocate resources and reduce waste of
resources (Kaplan et al., 2014). In addition, the approach is more practical, valid, and scalable than ABC. Finally,
academic indices regarding the number of publications and journals also indicate an increased interest in TDABC.</p>
<p>Despite the widespread interest in this methodology (Keel et al., 2017), few approaches and calculation methodologies
consider the time and effectiveness of the activities performed in specific radiology departments, especially in Italy
(Keel et al., 2017; Terje Geitung, 2016). Therefore, this study presents the application of the TDABC method in a
specific radiological department of the Bambino Gesù Hospital in Rome. The following section illustrates in six steps
the technique used to study and analyse the information. </p>
<h2>3. Methodology</h2>
<p>This section describes the six working steps that allowed the research team to collect and subsequently analyse costs
according to the TDABC method. Figure 1 summarises the followed process. </p>
<p><span><img src="/articles/2021/05-Secinaro-i-in.-web-resources/image/Calandra_r1_fmt.png" /></span></p>
<p><span>Fig. 1.</span> TDABC steps</p>
<p>Source: authors’ elaboration based on (Kaplan & Porter, 2011).</p>
<h3>3.1. Selecting the hospital department</h3>
<p>The clinical activities regarding patients in Italy are presented based on the tertiary care academic hospital OPBG,
which, with its 607 beds, is the largest children’s hospital in Italy. Since 1985 it has been known as an Institute
for Scientific Hospitalisation and Care (IRCCS) and, additionally, in 2006 it was accredited by the Joint Commission
International (JCI), the international body that certifies excellence in reception and quality of care offered
(Biancone, Tradori, De Bernardi, & Brescia, 2018; Ciofi degli Atti et al., 2011). For this study, the department
was chosen for multiple criteria. </p>
<p>First, the Imaging Department is considered an area characterised by large-scale and repeated healthcare activities.
</p>
<p>Second, the performed activities have a limited variability of resources such as time, materials, and human
resources. Consequently, the time associated with each health examination is easily standardised, which allows greater
rigor and precision. </p>
<h3>3.2. Defining the care delivery value chain</h3>
<p>The care delivery value chain of the Imaging Department is implemented according to the typical path of patient care
(Dal Mas, Piccolo, Edvinsson, Skrap, & D’Auria, 2020; Kaplan & Porter, 2011). Essential elements are the
activities of monitoring and prevention. Moreover, diagnosis, preparation and intervention help in the recovery of
patients by the medical and technical personnel (doctors, nurses, radiologists) attending to the patient. These tasks
include administering the contrast medium, using the medical equipment and carrying out the follow-up visits of the
patients. In particular, the healthcare activities carried out are Diagnostic Radiology, Conventional X-ray
Fluoroscopy, Ultrasound, Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Nuclear Medicine.</p>
<p>Additionally, other essential activities are performed by administrative staff who manage patient reservations and
delivery of medical examinations. </p>
<h3>3.3. Developing process maps for each activity in delivery of patient care </h3>
<p>Patients accessing the Imaging Department may be outpatients or inpatients (in agreement with the public health
service). In the first case, this means the patients admitted to the departments of the teaching hospital. In
addition, patients not yet treated can also access healthcare services. </p>
<p>The activities can be divided into two groups (Maffioli, Mazzuca, Rota, Salvo, & Silvestri, 2004):</p>
<ol>
<li>diagnostics</li>
<li>therapy</li>
</ol>
<p>For diagnostics, outpatients approach the hospital by booking a medical examination (which is associated with the
daily schedule and the specific order of the radiopharmaceutical or radioisotope), there is the subsequent
administrative acceptance with the assessment of appropriateness and justification of the request (Jarritt, Perkins,
Woods, 2004). The hospital administrative activities continue informing the patient prescribing the type of
radiopharmaceutical. All these activities are ex-ante administrative activities. </p>
<p>Furthermore, after the quality control of the radiopharmaceutical and the administration, it is possible to carry out
the prescribed examination. After this, ex-post administrative activities are carried out by processing the data
acquired by the laboratory technicians and the preparation of the iconography end in the report. Finally, the delivery
of the report regarding the patient is followed by the administrative filing of the document (Figure 2).</p>
<p>The second group, therapy, starts with the ‘therapeutic proposal’ to the patient that takes place with the collection
of informed consent and the prescription of preliminary examinations (Monge, Perez, & Rein, 2013). Next, ex-ante
administrative activities are carried on with the treatment planning, and the administrative order</p>
<p><span><img src="/articles/2021/05-Secinaro-i-in.-web-resources/image/Calandra_r2_fmt.png" /></span></p>
<p><span>Fig. 2.</span> The main activities for in vitro diagnostics</p>
<p>Source: authors’ elaboration.</p>
<p><span><img src="/articles/2021/05-Secinaro-i-in.-web-resources/image/Calandra_r3_fmt.png" /></span></p>
<p><span>Fig. 3.</span> The main activities for therapy</p>
<p>Source: authors’ elaboration.</p>
<p>of the radiopharmaceutical takes place. After the acceptance, the medication and the radiopharmaceutical preparation,
it is possible to administer to the patient. During the examination, the recording of diagnostic images is possible.
With ex-post administrative activities, the delivery of the findings to the patient, the report is archived with the
consequent discharge of the patient and the therapeutic prescriptions. Finally, follow-up is provided for those who
have to repeat their exam or come back for another visit (Figure 3). </p>
<h3>3.4. Obtaining time estimates of each process</h3>
<p>This part concerns the estimation method of time spent with patients. Researchers implemented interviews and direct
observations to determine the average time of health activities (Demeere et al., 2009; Keel et al., 2017; Secinaro,
Calandra, Cappa, & Bignamini, 2020). In particular, interviews were conducted repeatedly while asking doctors and
nurses to account for minutes spent on radiological examinations (DiCicco‐Bloom & Crabtree, 2006). Special
treatment was used for extraordinary examinations, which made it possible to keep track of even non-routine
inspections that substantially impact the activities of the health personnel.</p>
<p>The following are the steps for determining the cost per minute:</p>
<ol>
<li>survey of the services performed in one year by a single technique (conventional radiology, ultrasound, etc.);
</li>
<li>survey of the average times of the different professional figures involved (radiologists, nurses, radiographers,
administrative staff) for each type of examination;</li>
<li>calculation of the overall annual minutes for each performance obtained as a product between time per activity and
the number of yearly events<a href="#footnote-10400-1">1</a>;</li>
<li>evaluation of the total worked time of the structure (Department of Diagnostic Imaging) that carries out the
performances in question as to the sum of the annual minutes of each activity, see pt. 3;</li>
<li>assessment of the cost/minute (chosen as a unit of time) for each cost category as the ratio between the total
cost of that category (depreciation, overheads, labour costs, etc.) and the whole minutes of activity of the
structure that carries out the services in question. An exception is the direct material costs, which are punctually
evaluated and not based on the time taken to perform the examination.</li>
</ol>
<h3>3.5. Estimating the cost of supplying patient care resources</h3>
<p>The next step identifies the cost of a single service by determining the rate of a unit of time in a given
operational structure which is then multiplied by the average time necessary to perform the whole service itself
(Frasquilho et al., 2016; Kaplan & Anderson, 2003). </p>
<p>The direct costs, directly attributable to the performance of the examinations, were calculated as follows: the rate
per minute of personnel (for each level) and the depreciation of the equipment used to perform the examinations was
multiplied by the minutes of the examination. The material cost was recorded on a case-by-case basis for analysis.
</p>
<p>Indirect costs were attributed to the structure using the percentage ratio between the cost of staff of the
Department of Imaging Diagnostics and the total cost of personnel of the hospital. The cost shares thus obtained were
divided by the whole minutes worked, thus obtaining the price per minute for each indirect cost category allocated to
each service. </p>
<p>For a detailed calculation of direct and indirect costs, see Table 1 and Figure 4 below. </p>
<p><span>Table 1. </span>Type and method of calculation of direct and indirect costs </p>
<table class="table table-bordered">
<colgroup>
<col></col>
<col></col>
</colgroup>
<tr>
<td>
<p>Direct costs</p>
<p>(Costs directly attributable to the performance of examinations)</p>
</td>
<td>
<p>Personnel costs</p>
<p>Cost of work/minute of the Department of Imaging for the minutes of the execution of the single examinations
(not including supplementing and requires counting labour time)</p>
</td>
</tr>
<tr>
<td>
<p>Consumables the sum of the costs of the material used per single examination</p>
</td>
</tr>
<tr>
<td>
<p>Depreciation of equipment in the Department of Imaging Diagnostics</p>
<p>Administration / minute of the equipment of the Imaging Department for the processing minutes of the single
examination</p>
</td>
</tr>
<tr>
<td>
<p>Costs of Health Physics activities</p>
<p>Value of Health Physics activities/minute of the Diagnostic Imaging Department for the minutes of processing
of the individual examination. Cost of the Physicians/minute per performance of Nuclear Medicine</p>
</td>
</tr>
<tr>
<td>
<p>Indirect costs</p>
<p>(all costs related to the structure)</p>
</td>
<td>
<p>Other materials, Diagnostic Imaging Dept.</p>
<p>Cost/minute of material consumption for the processing minutes of the individual examination</p>
</td>
</tr>
<tr>
<td>
<p>General expenses</p>
<p>Cost per minute of General Expenses charged through drivers to the Imaging Diagnostics Department for the
processing minutes of the single exam.</p>
</td>
</tr>
<tr>
<td>
<p>Infrastructure depreciation</p>
<p>Cost per minute of infrastructure administration for processing minutes of a single examination</p>
</td>
</tr>
<tr>
<td>
<p>Personnel costs</p>
<p>Cost per minute of non-health personnel for the minutes of processing of the single examinations</p>
</td>
</tr>
<tr>
<td>
<p>Quality Certification Costs </p>
<p>Cost per minute of quality certification procedures for the processing minutes of the individual examination
</p>
</td>
</tr>
</table>
<p>Source: authors’ elaboration.</p>
<table class="table table-bordered">
<colgroup>
<col></col>
<col></col>
<col></col>
</colgroup>
<tr>
<td>
<p>Indirect</p>
</td>
<td>
<ul>
<li>Consumables (stationery, disinfectants, etc.)</li>
</ul>
</td>
<td>
<ul>
<li>General expenses</li>
<li>Depreciation of infrastructure</li>
<li>Staff costs</li>
<li>Quality certification</li>
</ul>
</td>
</tr>
<tr>
<td>
<p>Direct</p>
</td>
<td>
<ul>
<li>Personnel costs</li>
<li>Consumables</li>
</ul>
</td>
<td>
<ul>
<li>Direct depreciation of machines</li>
<li>Cost of health physics</li>
</ul>
</td>
</tr>
<tr>
<td>
</td>
<td>
<p>Variables</p>
</td>
<td>
<p>Fixed</p>
</td>
</tr>
</table>
<p><span>Fig. 4.</span> Costs’ matrix</p>
<p>Source: authors’ elaboration.</p>
<h3>3.6. Estimating the capacity of each resource and calculating the capacity cost rate</h3>
<p>The activities of the Department of Diagnostic Imaging were evaluated based on data provided by the Department
itself, by the Health Physics Service and by the Department of Anesthesiology, in terms of:</p>
<ul>
<li>average time of execution per examination per category of staff involved; </li>
<li>average additional time for bedside examinations;</li>
<li>number and type of studies performed with sedation; </li>
<li>average time of activity of the anesthesiologists;</li>
<li>average time of action of the Health Physicist for the Department;</li>
<li>Average time of the Health Physicist for Nuclear Medicine;</li>
<li>Average time of the Health Physicist for mandatory activities for the Department.</li>
</ul>
<p>According to the proposed method, the first step was recording the time spent for examination. A survey of the
services performed in one year was carried out. For each type of examination, the average time spent by the various
professional figures involved was recorded, which, added together, gave the total time worked by the Department
(Demeere et al., 2009; Keel et al., 2017; Rubin, 2017). In particular, the average time of services was measured by
conducting face-to-face interviews with doctors and nurses after a radiological service had been provided (Brescia et
al., 2019; Secinaro, et al., 2020). In addition, a dedicated register was created to track the time and number of
extraordinary examinations given to patients. </p>
<p>Concerning the radiographers, the following calculation did not includ the dead times in which the radiographers are
present ‘at the disposal’, such as those in the operating theatre or engaged in other activities.</p>
<p>After analysing the survey and recording the time of each operation, it was possible to determine the cost of each
process by multiplying the time per cost rate (Rubin, 2017).</p>
<p>Given that:</p>
<ul>
<li>Ci = Cost per minute of a given cost category (personnel, depreciation, overheads, etc.)</li>
<li>Tp = Average performance time </li>
<li>Md = Direct material </li>
</ul>
<p>the Cost of Service (Cp) is: </p>
<p><span><img src="/articles/2021/05-Secinaro-i-in.-web-resources/image/14953.png" /></span></p>
<h2>4. Results</h2>
<h3>4.1. Obtaining time estimates for each process </h3>
<p>The observation of the activities carried out in the Department of Diagnostic Imaging allowed to obtain the number of
staff and hence the time required for each process. The staff consists of 144 persons:</p>
<ul>
<li>40 radiologists (of which seven freelancers);</li>
<li>12 administrative staff;</li>
<li>42 nurses (including six freelancers);</li>
<li>47 radiographers;</li>
<li> 2 auxiliary staff.</li>
</ul>
<p>The anesthesiologists of the Department of Anesthesiology, Critical Care and Pain Medicine support the activity of
Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Nuclear Medicine (NM) for non-cooperative patients.
</p>
<p>In this part, it is necessary to identify how much time is required for each exam. This is an essential functional
step to calculate in the second part the cost per minute.</p>
<p>The number of examinations carried out in the Department in 2016 was equal to 155,738 for 9,494,912 minutes. The
highest number related to “Standard chest X-Ray” with 23,971 examinations linked to a commitment of 841,596 minutes.
Next, an MRI of the brain and brainstem amounted to 2,343 examinations for 390,838 minutes and an US of the lower
abdomen with 4,332 examinations for 21,449 minutes, followed by CT of the thorax with 1,618 times for a total of
158,258 minutes. In addition, live dosimetry was performed 40 times for 35,672 minutes. Musculoskeletal ultrasound
examinations were performed 539 times for a total of 28,532 minutes. Finally, for a segmented scintigraphy, followed
by a total body scintigraphy, was completed 244 times for 22,402 minutes, radiography of the thoracic spine was
performed 569 times for 20,945 minutes. Lastly, an Abdomen CT was carried out 49 times for 4,131 minutes and physical
dosimetric study 25 times for 2,725 minutes. For more details see Table 2.</p>
<p>Table 2. The timescale for each examination and category of health operator </p>
<table class="table table-bordered">
<colgroup>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
</colgroup>
<tr>
<td>
<p>Examinations</p>
</td>
<td>
<p>Number per year</p>
</td>
<td>
<p>Number of radio-logists</p>
</td>
<td>
<p>Number of admini-strative staff </p>
</td>
<td>
<p>Number of nurses</p>
</td>
<td>
<p>Number of radio-graphers</p>
</td>
<td>
<p>Total</p>
</td>
<td>
<p>Total minutes per year</p>
</td>
</tr>
<tr>
<td>
<p>1</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>4</p>
</td>
<td>
<p>5</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>7</p>
</td>
<td>
<p>8</p>
</td>
</tr>
<tr>
<td>
<p>Abdomen CT </p>
</td>
<td>
<p>49</p>
</td>
<td>
<p>33</p>
</td>
<td>
<p>9</p>
</td>
<td>
<p>21</p>
</td>
<td>
<p>22</p>
</td>
<td>
<p>84</p>
</td>
<td>
<p>4,131</p>
</td>
</tr>
<tr>
<td>
<p>Thorax CT</p>
</td>
<td>
<p>1,618</p>
</td>
<td>
<p>36</p>
</td>
<td>
<p>9</p>
</td>
<td>
<p>31</p>
</td>
<td>
<p>22</p>
</td>
<td>
<p>98</p>
</td>
<td>
<p>158,258</p>
</td>
</tr>
<tr>
<td>
<p>Thoracic spine radiography</p>
</td>
<td>
<p>569</p>
</td>
<td>
<p>10</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>4</p>
</td>
<td>
<p>17</p>
</td>
<td>
<p>37</p>
</td>
<td>
<p>20,945</p>
</td>
</tr>
<tr>
<td>
<p>Standard chest X-RAY</p>
</td>
<td>
<p>23.971</p>
</td>
<td>
<p>7</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>4</p>
</td>
<td>
<p>18</p>
</td>
<td>
<p>35</p>
</td>
<td>
<p>841,596</p>
</td>
</tr>
<tr>
<td>
<p>Skeletal Survey </p>
</td>
<td>
<p>118</p>
</td>
<td>
<p>30</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>4</p>
</td>
<td>
<p>32</p>
</td>
<td>
<p>72</p>
</td>
<td>
<p>8,474</p>
</td>
</tr>
<tr>
<td>
<p>1</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>4</p>
</td>
<td>
<p>5</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>7</p>
</td>
<td>
<p>8</p>
</td>
</tr>
<tr>
<td>
<p>US of the lower abdomen</p>
</td>
<td>
<p>4,332</p>
</td>
<td>
<p>20</p>
</td>
<td>
<p>9</p>
</td>
<td>
<p>18</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>49</p>
</td>
<td>
<p>211,449</p>
</td>
</tr>
<tr>
<td>
<p>Musculoskeletal Ultrasound</p>
</td>
<td>
<p>539</p>
</td>
<td>
<p>21</p>
</td>
<td>
<p>9</p>
</td>
<td>
<p>21</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>53</p>
</td>
<td>
<p>28,532</p>
</td>
</tr>
<tr>
<td>
<p>MRI of the srain and brainstem</p>
</td>
<td>
<p>2,343</p>
</td>
<td>
<p>75</p>
</td>
<td>
<p>9</p>
</td>
<td>
<p>36</p>
</td>
<td>
<p>47</p>
</td>
<td>
<p>167</p>
</td>
<td>
<p>390,838</p>
</td>
</tr>
<tr>
<td>
<p>Segmentary scintigraphy after total body scintigraphy</p>
</td>
<td>
<p>244</p>
</td>
<td>
<p>30</p>
</td>
<td>
<p>30</p>
</td>
<td>
<p>15</p>
</td>
<td>
<p>17</p>
</td>
<td>
<p>92</p>
</td>
<td>
<p>22,402</p>
</td>
</tr>
<tr>
<td>
<p>Physical-dosimetric study</p>
</td>
<td>
<p>25</p>
</td>
<td>
<p>90</p>
</td>
<td>
<p>30</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>122</p>
</td>
<td>
<p>2,725</p>
</td>
</tr>
<tr>
<td>
<p>Live dosimetry</p>
</td>
<td>
<p>40</p>
</td>
<td>
<p>90</p>
</td>
<td>
<p>30</p>
</td>
<td>
<p>140</p>
</td>
<td>
<p>632</p>
</td>
<td>
<p>892</p>
</td>
<td>
<p>35,672</p>
</td>
</tr>
</table>
<p>Source: authors’ elaboration.</p>
<h3>4.2. Estimating the cost of supplying patient care resources: direct costs</h3>
<p>In the second part of the TDABC method, the study estimated the cost per minute for both direct and indirect costs.
</p>
<p>Firstly, direct costs include labour costs per minute which include the total annual cost per each year and the total
minutes of activities per year; this is repeated for the four categories of health operators: radiologists,
administrative staff, nurses, and radiographers. For radiologists, the annual labour cost was €3,398,974, the capacity
in terms of minutes was 3,303,237; the radiologists’ cost was 1.03 €/min. The annual labour cost of administrative
staff amounted to €331,910, the capacity in terms of minutes of activities – €1,205,548; the administrative cost was
0.28 €/min. For nurses, the value of annual labour was €1,410,255, the capacity in terms of minutes of activities was
€3,003,122; the nurses’ cost was 0.47 €/min. Finally, the radiographers’ annual cost was €2,123,556, the capacity for
minutes of activities – €2,395,650; the radiographers’ cost was 0.89 €/min. See Table 7 in Appendix 1 for a holistic
view of the direct costs per examination. </p>
<p>Secondly, direct costs also include all healthcare consumption used by the Department to execute examinations,
excluding drugs, contrast media and radiopharmaceuticals. The total amount of consumables was €186,667, while the
capacity for minutes of activities – €10,092,218; the cost of consumables was 0.02 €/min. </p>
<p>Thirdly, the authors also considered also contrast media and radiopharmaceuticals, which are essential for
computerised axial tomography (n = 4,835 examinations in 2016), magnetic resonance (n = 7,145), radiography (n =
1,930), and scintigraphy and nuclear medicine (n = 2,381). For computerised axial tomography, total costs are €62,407,
the full capacity per year was 614,393 minutes, the cost per minute – 0.10 €/min. The total costs for magnetic
resonance were €50,212, the capacity in terms of minutes was 1,092,301; the cost per minute was 0.05 €/min. For
radiography, the total costs were €49,358. The minute capacity was 69,343, while the cost per minute 0.71 €/min.
Finally, the whole scintigraphy and nuclear medicine costs were €93,757, the capacity per minute was 710,024, and the
cost per minute 0.13 €/min. </p>
<p>Additionally, the annual depreciation of the machines was considered. Annual amortisation of the equipment was
€1,232,028, the total minutes per year was 10,092,218; the machine depreciation was 0.12 €/min.</p>
<p>Moreover, annual costs of service for machinery contracts and interventions were considered. The total fees for
equipment maintenance were €919,778, the total minutes per year was 10,092,218; the equipment maintenance was 0.09
€/min.</p>
<p>Furthermore, the labour costs of the health physicist were calculated separately due to external contracts. The price
for health physics was €127,416, and the total number of minutes per year of activities was 10,092,218; health physics
cost was 0.01 €/min.</p>
<p>To conclude, additional costs for examinations under sedation, or not included in the price list, were considered.
The total cost for the consumption of materials for anaesthesia which allows the execution of MRIs and CT scans on
non-cooperative patients, was €145,146, total minutes per year of activities was 142,738; the additional costs were
0.74 €/min (Table 3). </p>
<p>Table 3. Direct costs</p>
<table class="table table-bordered">
<colgroup>
<col></col>
<col></col>
<col></col>
</colgroup>
<tr>
<td>
<p>Direct costs</p>
</td>
<td>
<p>Specifications</p>
</td>
<td>
<p>€/min</p>
</td>
</tr>
<tr>
<td>
<p>Labour costs</p>
</td>
<td>
<p>Radiologists</p>
</td>
<td>
<p>1.03</p>
</td>
</tr>
<tr>
<td>
<p>Administrative</p>
</td>
<td>
<p>0.28</p>
</td>
</tr>
<tr>
<td>
<p>Nurses</p>
</td>
<td>
<p>0.47</p>
</td>
</tr>
<tr>
<td>
<p>Radiographers</p>
</td>
<td>
<p>0.89</p>
</td>
</tr>
<tr>
<td>
<p>Cost of consumables</p>
</td>
<td>
<p>–</p>
</td>
<td>
<p>0.02</p>
</td>
</tr>
<tr>
<td>
<p>Contrast media/Radiopharmaceutical</p>
</td>
<td>
<p>Computerised axial tomography</p>
</td>
<td>
<p>0.10</p>
</td>
</tr>
<tr>
<td>
<p>Magnetic resonance</p>
</td>
<td>
<p>0.05</p>
</td>
</tr>
<tr>
<td>
<p>Radiography</p>
</td>
<td>
<p>0.71</p>
</td>
</tr>
<tr>
<td>
<p>Scintigraphy and nuclear medicine</p>
</td>
<td>
<p>0.13</p>
</td>
</tr>
<tr>
<td>
<p>Machines depreciation</p>
</td>
<td>
<p>–</p>
</td>
<td>
<p>0.12</p>
</td>
</tr>
<tr>
<td>
<p>Equipment maintenance</p>
</td>
<td>
<p>–</p>
</td>
<td>
<p>0.09</p>
</td>
</tr>
<tr>
<td>
<p>Health Physics</p>
</td>
<td>
<p>External service</p>
</td>
<td>
<p>0.01</p>
</td>
</tr>
<tr>
<td>
<p>Additional costs</p>
</td>
<td>
<p>Sedation for non-cooperative patients</p>
</td>
<td>
<p>0.74</p>
</td>
</tr>
</table>
<p>Source: authors’ elaboration.</p>
<h3>4.3. Estimating the cost of supplying patient care resources: indirect costs</h3>
<p>Indirect costs were attributed to the unit using as a driver the percentage ratio between the cost of personnel of
the Department of Diagnostic Imaging and the total cost of personnel of the hospital. The cost per minute was obtained
by dividing the shares by the total number of minutes worked to be charged to each service. The department’s
consumables, not directly used for the execution of the examinations, were attributed to each examination by their
cost per minute.</p>
<p>The percentage ratio was calculated as follows: the personnel costs were €7,329,356, annual personnel costs on the
entire hospital amounted to €157,082,655. The share of expenses for the Department of Diagnostic Imaging was 4.7%.
</p>
<p>Indirect costs include the cost of utilities (electricity, telephony, gas, water, heating), contracts (linen hire,
cleaning, waste disposal, medical records management, secretarial services, sterilisation, security), accommodation
for accompanying persons and fuel. Total general expenses for OPBG were €15,224,406 × 4.7% equal €710,359. The total
minutes per year of expenses was 10,092,218, hence the cost per minute was 0.07. </p>
<p>Moreover, infrastructure depreciation includes the depreciation of buildings and plants, office machinery, equipment
not assigned to the Clinic. Total amortisation of the hospital was €13,565,377 × 4,7% equal €632,950. The total
minutes per year was 10,092,218, therefore the cost per minute – €0.06. </p>
<p>Furthermore, staff costs are not assigned to Clinical Departments, but to those who carry out their activities in
support of their management, i.e. the staff not working in the health services were considered. The total staff costs
of the hospital were €30,695,037 × 4.7% equal €1,432,207 for the Diagnostic Imaging Department. The total minutes per
year was 10,092,218, thus the cost per minute was €0.14. </p>
<p>To conclude, costs for quality certification (ISO9000) were considered. The total cost was €15,333 × 4.7% equals
€715. The total minutes per year was 10,092,218, thus the cost per minute was €0.0001 (Table 4). </p>
<p><span>Table 4. </span>Indirect costs</p>
<table class="table table-bordered">
<colgroup>
<col></col>
<col></col>
</colgroup>
<tr>
<td>
<p>Indirect costs</p>
</td>
<td>
<p>€/min</p>
</td>
</tr>
<tr>
<td>
<p>Cost of utilities</p>
</td>
<td>
<p>0.07</p>
</td>
</tr>
<tr>
<td>
<p>Infrastructure depreciation</p>
</td>
<td>
<p>0.06</p>
</td>
</tr>
<tr>
<td>
<p>External staff</p>
</td>
<td>
<p>0.14</p>
</td>
</tr>
<tr>
<td>
<p>Quality certification</p>
</td>
<td>
<p>0.001</p>
</td>
</tr>
</table>
<p>Source: authors’ elaboration.</p>
<h3>4.4. Calculating the total cost of patient care</h3>
<p>After estimating the cost per minute for direct and indirect costs, it was possible to calculate the total costs for
each examination performed in the Department of Diagnostic Imaging of OPBG. Total costs were calculated in two steps.
</p>
<p>First, all direct costs (personnel, external personnel, contrast or radio drugs, depreciation of machines,
maintenance of machines, Health Physics, and additional costs in case of sedation) were considered. These costs
derived from the methodology formulation, which includes cost per minute of a given cost category × average
performance time. Additionally, the authors included the direct material costs to calculate the service cost. </p>
<p>Second, all indirect costs (consumption of other materials, general expenditure, structure’s amortisation, external
staff, and certification costs were considered. See Tables 5.1 and 5.2 for a detailed picture of total costs. </p>
<p>Table 5.1 Total direct costs</p>
<table class="table table-bordered">
<colgroup>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
</colgroup>
<tr>
<td>
<p>Examinations</p>
</td>
<td>
<p>Direct costs in euro</p>
</td>
<td>
<p>Total direct costs</p>
</td>
</tr>
<tr>
<td>
<p>Personnel</p>
</td>
<td>
<p>External personnel</p>
</td>
<td>
<p>Contrast/radio drugs</p>
</td>
<td>
<p>Depreciation</p>
</td>
<td>
<p>Maintenance</p>
</td>
<td>
<p>Health Physics</p>
</td>
<td>
<p>Additional costs</p>
</td>
</tr>
<tr>
<td>
<p>Abdomen CT </p>
</td>
<td>
<p>65</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>10</p>
</td>
<td>
<p>8</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>86</p>
</td>
</tr>
<tr>
<td>
<p>Abdomen CT under sedation</p>
</td>
<td>
<p>65</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>10</p>
</td>
<td>
<p>8</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>20</p>
</td>
<td>
<p>106</p>
</td>
</tr>
<tr>
<td>
<p>Thorax CT</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>73</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>10</p>
</td>
<td>
<p>12</p>
</td>
<td>
<p>9</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>106</p>
</td>
</tr>
<tr>
<td>
<p>Thorax CT under sedation</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>73</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>10</p>
</td>
<td>
<p>12</p>
</td>
<td>
<p>9</p>
</td>
<td>
<p>20</p>
</td>
<td>
<p>126</p>
</td>
</tr>
<tr>
<td>
<p>Thoracic spine radiography</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>29</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>4</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>37</p>
</td>
</tr>
<tr>
<td>
<p>Standard chest X-RAY</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>27</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>4</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>35</p>
</td>
</tr>
<tr>
<td>
<p>Skeletal survey </p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>63</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>9</p>
</td>
<td>
<p>7</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>79</p>
</td>
</tr>
<tr>
<td>
<p>US of the lower abdomen</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>33</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>4</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>44</p>
</td>
</tr>
<tr>
<td>
<p>Bedside Ultrasound</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>33</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>4</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>44</p>
</td>
</tr>
<tr>
<td>
<p>Musculoskeletal Ultrasound</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>36</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>5</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>48</p>
</td>
</tr>
<tr>
<td>
<p>Bedside Musculoskeletal Ultrasound</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>36</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>5</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>48</p>
</td>
</tr>
<tr>
<td>
<p>MRI of the brain and brainstem</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>138</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>8</p>
</td>
<td>
<p>20</p>
</td>
<td>
<p>15</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>184</p>
</td>
</tr>
<tr>
<td>
<p>MRI of the brain and brainstem under sedation</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>138</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>8</p>
</td>
<td>
<p>20</p>
</td>
<td>
<p>15</p>
</td>
<td>
<p>43</p>
</td>
<td>
<p>228</p>
</td>
</tr>
<tr>
<td>
<p>Segmentary scintigraphy after total body scintigraphy</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>61</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>12</p>
</td>
<td>
<p>11</p>
</td>
<td>
<p>8</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>94</p>
</td>
</tr>
<tr>
<td>
<p>Physical-dosimetric study</p>
</td>
<td>
<p>2,624</p>
</td>
<td>
<p>2,726</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>16</p>
</td>
<td>
<p>15</p>
</td>
<td>
<p>11</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>5,394</p>
</td>
</tr>
<tr>
<td>
<p>Live dosimetry</p>
</td>
<td>
<p>605</p>
</td>
<td>
<p>1,332</p>
</td>
<td>
<p>16</p>
</td>
<td>
<p>118</p>
</td>
<td>
<p>109</p>
</td>
<td>
<p>81</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>2,261</p>
</td>
</tr>
</table>
<p>Source: authors’ elaboration.</p>
<p>Table 5.2 Total indirect costs in euro</p>
<table class="table table-bordered">
<colgroup>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
</colgroup>
<tr>
<td>
<p>Examinations</p>
</td>
<td>
<p>Consumption other materials</p>
</td>
<td>
<p>General expenditure</p>
</td>
<td>
<p>Structure’s amortisation</p>
</td>
<td>
<p>Staff</p>
</td>
<td>
<p>Certification costs</p>
</td>
<td>
<p>Total indirect costs</p>
</td>
<td>
<p>Total costs</p>
</td>
</tr>
<tr>
<td>
<p>Abdomen CT </p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>5</p>
</td>
<td>
<p>12</p>
</td>
<td>
<p>0.01</p>
</td>
<td>
<p>23</p>
</td>
<td>
<p>109</p>
</td>
</tr>
<tr>
<td>
<p>Abdomen CT under sedation</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>5</p>
</td>
<td>
<p>12</p>
</td>
<td>
<p>0.01</p>
</td>
<td>
<p>23</p>
</td>
<td>
<p>129</p>
</td>
</tr>
<tr>
<td>
<p>Thorax CT</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>7</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>13.88</p>
</td>
<td>
<p>28</p>
</td>
<td>
<p>134</p>
</td>
</tr>
<tr>
<td>
<p>Thorax CT under sedation</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>7</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>13.88</p>
</td>
<td>
<p>28</p>
</td>
<td>
<p>155</p>
</td>
</tr>
<tr>
<td>
<p>Thoracic spine radiography</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>5.22</p>
</td>
<td>
<p>11</p>
</td>
<td>
<p>48</p>
</td>
</tr>
<tr>
<td>
<p>Standard chest X-RAY</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>4.98</p>
</td>
<td>
<p>10</p>
</td>
<td>
<p>45</p>
</td>
</tr>
<tr>
<td>
<p>Skeletal survey </p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>5</p>
</td>
<td>
<p>5</p>
</td>
<td>
<p>10.19</p>
</td>
<td>
<p>21</p>
</td>
<td>
<p>100</p>
</td>
</tr>
<tr>
<td>
<p>US of the lower abdomen</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>6.93</p>
</td>
<td>
<p>14</p>
</td>
<td>
<p>59</p>
</td>
</tr>
<tr>
<td>
<p>Bedside Ultrasound</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>6.93</p>
</td>
<td>
<p>14</p>
</td>
<td>
<p>59</p>
</td>
</tr>
<tr>
<td>
<p>Musculoskeletal ultrasound</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>4</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>7.51</p>
</td>
<td>
<p>15</p>
</td>
<td>
<p>63</p>
</td>
</tr>
<tr>
<td>
<p>Bedside Musculoskeletal ultrasound</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>4</p>
</td>
<td>
<p>3</p>
</td>
<td>
<p>7.51</p>
</td>
<td>
<p>15</p>
</td>
<td>
<p>63</p>
</td>
</tr>
<tr>
<td>
<p>MRI of the brain and brainstem</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>12</p>
</td>
<td>
<p>10</p>
</td>
<td>
<p>23.67</p>
</td>
<td>
<p>48</p>
</td>
<td>
<p>233</p>
</td>
</tr>
<tr>
<td>
<p>MRI of the brain and brainstem under sedation</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>12</p>
</td>
<td>
<p>10</p>
</td>
<td>
<p>23.67</p>
</td>
<td>
<p>48</p>
</td>
<td>
<p>276</p>
</td>
</tr>
<tr>
<td>
<p>Segmentary scintigraphy after total body scintigraphy</p>
</td>
<td>
<p>1</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>6</p>
</td>
<td>
<p>13.03</p>
</td>
<td>
<p>27</p>
</td>
<td>
<p>121</p>
</td>
</tr>
<tr>
<td>
<p>Physical-dosimetric study</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>0</p>
</td>
<td>
<p>9</p>
</td>
<td>
<p>8</p>
</td>
<td>
<p>17.29</p>
</td>
<td>
<p>35</p>
</td>
<td>
<p>5,429</p>
</td>
</tr>
<tr>
<td>
<p>Live dosimetry</p>
</td>
<td>
<p>11</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>63</p>
</td>
<td>
<p>56</p>
</td>
<td>
<p>126.56</p>
</td>
<td>
<p>258</p>
</td>
<td>
<p>2,519</p>
</td>
</tr>
</table>
<p>Source: authors’ elaboration.</p>
<h2>5. Discussion</h2>
<p>The presented analysis describes the cost transparency for the Department of Diagnostic Imaging and its services.
TDABC offers the possibility to evaluate the healthcare process and assess the value of patient care. As a result of
the analysis, healthcare management can better organise the future costs for the department, also in light of the
reimbursements of the national health service (Kaplan & Porter, 2011). </p>
<p>According to the rates currently applied for reimbursements provided in the Decree of the Commissioner no. U00313/13
“Approval of the Regional Tariff Nomenclature for Outpatient Specialist Assistance Services”, the current tariff has a
lower level than the real expenditure of the Department (see Table 6). </p>
<p><span>Table </span><span>6.</span><span> </span>Total costs vs national health reimbursements in euro</p>
<table class="table table-bordered">
<colgroup>
<col></col>
<col></col>
<col></col>
<col></col>
</colgroup>
<tr>
<td>
<p>Exams</p>
</td>
<td>
<p>Total costs</p>
</td>
<td>
<p>Reimbursements</p>
</td>
<td>
<p>Δ</p>
</td>
</tr>
<tr>
<td>
<p>Abdomen CT </p>
</td>
<td>
<p>109</p>
</td>
<td>
<p>104</p>
</td>
<td>
<p>(5)</p>
</td>
</tr>
<tr>
<td>
<p>Abdomen CT under sedation</p>
</td>
<td>
<p>129</p>
</td>
<td>
<p>104</p>
</td>
<td>
<p>(25)</p>
</td>
</tr>
<tr>
<td>
<p>Thorax CT</p>
</td>
<td>
<p>134</p>
</td>
<td>
<p>124</p>
</td>
<td>
<p>(10)</p>
</td>
</tr>
<tr>
<td>
<p>Thorax CT under sedation</p>
</td>
<td>
<p>155</p>
</td>
<td>
<p>124</p>
</td>
<td>
<p>(31)</p>
</td>
</tr>
<tr>
<td>
<p>Thoracic spine radiography</p>
</td>
<td>
<p>48</p>
</td>
<td>
<p>17</p>
</td>
<td>
<p>(31)</p>
</td>
</tr>
<tr>
<td>
<p>Standard chest X-RAY</p>
</td>
<td>
<p>45</p>
</td>
<td>
<p>15</p>
</td>
<td>
<p>(30)</p>
</td>
</tr>
<tr>
<td>
<p>Skeletal survey </p>
</td>
<td>
<p>100</p>
</td>
<td>
<p>90</p>
</td>
<td>
<p>(10)</p>
</td>
</tr>
<tr>
<td>
<p>US of the lower abdomen</p>
</td>
<td>
<p>59</p>
</td>
<td>
<p>32</p>
</td>
<td>
<p>(27)</p>
</td>
</tr>
<tr>
<td>
<p>Bedside ultrasound</p>
</td>
<td>
<p>59</p>
</td>
<td>
<p>32</p>
</td>
<td>
<p>(27)</p>
</td>
</tr>
<tr>
<td>
<p>Musculoskeletal ultrasound</p>
</td>
<td>
<p>63</p>
</td>
<td>
<p>28</p>
</td>
<td>
<p>(35)</p>
</td>
</tr>
<tr>
<td>
<p>Bedside Musculoskeletal ultrasound</p>
</td>
<td>
<p>63</p>
</td>
<td>
<p>28</p>
</td>
<td>
<p>(35)</p>
</td>
</tr>
<tr>
<td>
<p>MRI of the brain and brainstem</p>
</td>
<td>
<p>233</p>
</td>
<td>
<p>248</p>
</td>
<td>
<p>15</p>
</td>
</tr>
<tr>
<td>
<p>MRI of the brain and brainstem under sedation</p>
</td>
<td>
<p>276</p>
</td>
<td>
<p>248</p>
</td>
<td>
<p>(28)</p>
</td>
</tr>
<tr>
<td>
<p>Segmentary scintigraphy after total body scintigraphy</p>
</td>
<td>
<p>121</p>
</td>
<td>
<p>25</p>
</td>
<td>
<p>(96)</p>
</td>
</tr>
<tr>
<td>
<p>Physical-dosimetric study</p>
</td>
<td>
<p>5429</p>
</td>
<td>
<p>30</p>
</td>
<td>
<p>(5399)</p>
</td>
</tr>
<tr>
<td>
<p>Live dosimetry</p>
</td>
<td>
<p>2519</p>
</td>
<td>
<p>112</p>
</td>
<td>
<p>(2407)</p>
</td>
</tr>
</table>
<p>Source: authors’ elaboration.</p>
<p>The analysis found that the cost of each process is higher than the level of reimbursements provided by the national
health system. The main problem is related to the physical-dosimetry study, and live dosimetry is less considered by
the health service due to the high cost. </p>
<p>More generally, the analysis addressed a problem regarding examinations under sedation. The healthcare system applies
the same reimbursement without sedation for abdomen CT and Thoracic spine radiology. This contributes to the higher
cost of these two examinations. </p>
<p>This paper focuses on a precise methodology reporting the entire cycle of care in the department, contributing
to the knowledge of healthcare managers and policymakers. At the same time, the authors compared the results with the
reimbursement tariffs, which required the calculation of indirect costs (Keel et al., 2017). </p>
<p>Healthcare departments should consider this methodology as a standard tool for evaluating the cost of care and
improving the standardised process. Additionally, national health systems should employ new and more innovative cost
methodologies, such as TDABC, as an accurate measuring technique. </p>
<p>This paper, as every research, has its limitations, however they provide opportunities for pursuing interesting new
avenues of future research. Firstly, this method required a multi-professional team to evaluate all the care cycles,
so many researchers needed to implement an analysis. Secondly, the study was conducted in a single Italian hospital
dealing with the care of children. Future studies could extend the sample of hospitals studied long-term to Italy and
other countries in this setting. Thirdly, the study applied the TDABC method to a radiology department, one of the
less complex medical services. Future studies could enlarge the sample and extend the analysis to ordinary and
extraordinary wards to validate the results. </p>
<p>6. Conclusion</p>
<p>This analysis provides a detailed view of direct and indirect costs in the Imaging field. The authors applied the
TDABC methodology in the Department of Diagnostic Imaging to value costs (Chen, 2016; Demeere et al., 2009; Laviana et
al., 2016). According to Rubin (2017), Kaplan and Porter (2011) and Keel et al. (2017), this method also considers the
cost of the effective time of procedures, and in this case the total minutes for activities include training, meetings
and other support activities. </p>
<p>The main innovation of the study was to apply the methodology in a departmental context while considering the whole
map of processes to enhance the value of patient care. As stated by Kaplan and Porter (2011), their first pilot study
with a departmental cost-control system, TDABC made it possible to increase processes and restructure care delivery.
These results and the reimbursement rates suggest that this kind of analysis should be repeated periodically to
evaluate staff and management processes changes. In this sense, the article showed an underestimation of costs.
However, these derive from a precise accounting of TDBAC, and should reflect the healthcare system including all the
expense elements in the reimbursements.</p>
<p>Moreover, the public health service treats reimbursement on examinations involving patient sedation as standard as
they are not recognised.</p>
<p>Thus this analysis also provides several theoretical and practical implications. </p>
<p>In terms of theory, the study contributes to the growing literature of TDABC as a cost-accounting method that
considers costs according to the actual time frame of the healthcare professional. In addition, the authors show how
the theoretical premise of the method can also be applied to a real case study of a paediatric radiology department.
</p>
<p>The article revealed a gap between direct and indirect costs concerning national reimbursements in terms of the
practical implications. Furthermore, it demonstrates that excellent healthcare departments that deliver high-quality
services often do so on an internal accounting basis, thus adding to their internal budget.</p>
<p>This method is a real challenge for healthcare managers, policymakers, and personnel to manage healthcare expenditure
and assess real healthcare activities and patient treatment (Shankar et al., 2020). Finally, these findings could be
applied to inform all the stakeholders, especially in the case of future expenditure management. </p>
<p>Abbreviations</p>
<p>TDABC – Time-Driven Activity-Based Costing; CT – Computed Tomography; DRG – Diagnostic Related Group; CEA –
Cost-effectiveness studies; RCC – Ratio of cost to charges; RVU – Relative Value Units; OPBG – Ospedale Pediatrico
Bambino Gesù; IRCCS – Institute for Scientific Hospitalisation and Care; MRI – Magnetic Resonance Imaging; NM –
Nuclear Medicine. </p>
<p>Competing interest</p>
<p>The authors declare that they have no competing interests. </p>
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<p>Appendix</p>
<p><span>Table </span><span>7.</span><span> </span>Direct<a> costs per exam in euro</a></p>
<table class="table table-bordered">
<colgroup>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
<col></col>
</colgroup>
<tr>
<td>
<p>Examinations</p>
</td>
<td>
<p>Radiologists cost per exam (Cost per minute × Average performance time)</p>
</td>
<td>
<p>Cost depreciation per exam (Cost per minute × Average performance time)</p>
</td>
<td>
<p>Nurse cost per exam</p>
<p>(Cost per minute × Average performance time)</p>
</td>
<td>
<p>Radiographer cost per exam (Cost per minute × Average performance time)</p>
</td>
<td>
<p>Personnel costsper exams</p>
</td>
</tr>
<tr>
<td>
<p>Abdomen CT </p>
</td>
<td>
<p>33 (1.03 × 33)</p>
</td>
<td>
<p>2 (0.28 × 9)</p>
</td>
<td>
<p>10 (0.47 × 21)</p>
</td>
<td>
<p>19 (0.89 × 22)</p>
</td>
<td>
<p>65</p>
</td>
</tr>
<tr>
<td>
<p>Thorax CT</p>
</td>
<td>
<p>37 </p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>15</p>
</td>
<td>
<p>19</p>
</td>
<td>
<p>73</p>
</td>
</tr>
<tr>
<td>
<p>Thoracic spine radiography</p>
</td>
<td>
<p>10</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>15</p>
</td>
<td>
<p>29</p>
</td>
</tr>
<tr>
<td>
<p>Standard chest X-RAY</p>
</td>
<td>
<p>7</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>16</p>
</td>
<td>
<p>27</p>
</td>
</tr>
<tr>
<td>
<p>Skeletal survey </p>
</td>
<td>
<p>31</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>28</p>
</td>
<td>
<p>63</p>
</td>
</tr>
<tr>
<td>
<p>US of the lower abdomen</p>
</td>
<td>
<p>21</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>9</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>33</p>
</td>
</tr>
<tr>
<td>
<p>Muscoloskeletal ultrasound</p>
</td>
<td>
<p>22</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>10</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>36</p>
</td>
</tr>
<tr>
<td>
<p>MRI of the brain and brainstem</p>
</td>
<td>
<p>77</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>17</p>
</td>
<td>
<p>41</p>
</td>
<td>
<p>138</p>
</td>
</tr>
<tr>
<td>
<p>Segmentary scintigraphy after total body scintigraphy</p>
</td>
<td>
<p>31</p>
</td>
<td>
<p>8</p>
</td>
<td>
<p>7</p>
</td>
<td>
<p>15</p>
</td>
<td>
<p>61</p>
</td>
</tr>
<tr>
<td>
<p>Physical-dosimetric study</p>
</td>
<td>
<p>93</p>
</td>
<td>
<p>8</p>
</td>
<td>
<p>-</p>
</td>
<td>
<p>2</p>
</td>
<td>
<p>102</p>
</td>
</tr>
<tr>
<td>
<p>Live dosimetry</p>
</td>
<td>
<p>93</p>
</td>
<td>
<p>8</p>
</td>
<td>
<p>66</p>
</td>
<td>
<p>560</p>
</td>
<td>
<p>727</p>
</td>
</tr>
</table>
<p>Source: authors’ elaboration.</p>
<p>Szacowanie kosztów usług radiologii dziecięcej z wykorzystaniem rachunku kosztów działań
sterowanego czasem (TDABC)</p>
<p><span>Streszczenie: </span>Szacowanie kosztów jest istotnym elementem analiz rachunków zdrowia w krajach rozwiniętych
i rozwijających się. Celem niniejszego opracowania jest określenie metodologii w kwestii systemów i metod rachunku
kosztów stosowanych do wszystkich świadczeń zdrowotnych realizowanych na dużą skalę, które charakteryzują się
ograniczoną zmiennością zasobów (jak czas, materiały, zasoby ludzkie). Stosujemy rachunek kosztów działań uzależniony
od czasu (TDABC). Średni czas działań zdrowotnych oszacowano na podstawie bezpośredniej obserwacji działań i wywiadów
w placówce radiologii dziecięcej. Koszty bezpośrednie i pośrednie obliczono z uwzględnieniem ceny za minutę dla każdej
kategorii usług zdrowotnych. TDABC pozwala na obliczenie praktycznych wydatków na usługi radiologiczne. Metoda ta
ujawnia wyższe wydatki niż te, które są refundowane przez państwową służbę zdrowia. Badanie wykazuje wysoki poziom
kosztów w przypadku tomografii komputerowej i radiologii kręgosłupa piersiowego w sedacji, których krajowy system
opieki zdrowotnej nie uwzględnia. TDABC może być wykorzystywane przez menedżerów służby zdrowia do oceny poziomu
kosztów i porównania wyników wewnętrznych z taryfami refundacyjnymi krajowej służby zdrowia. </p>
<p><span>Słowa kluczowe:</span> radiologia, koszty, nośniki, TDABC, zarządzanie zdrowiem.</p>
<div>
<div>
<p><a href="#footnote-10400-1-backlink">1</a> The approach used takes one year as the
reference period. However, considering the length of the time span, in some cases it was necessary to perform
calculations over shorter time horizons, considering corrections or other factors that may affect fluctuations in
the variables used in the calculation. </p>
</div>
</div>