High flow, at a higher cost? A pilot study comparing direct vs. indirect bypass for Moyamoya disease using time-driven activity-based costing

BACKGROUND AND OBJECTIVE: In the management of adult moyamoya disease (MMD), there is clinical equipoise regarding direct bypass (DB) vs indirect bypass (IB). One factor that may influence the choice of procedure is cost. Therefore, we sought to compare the true intraoperative costs (not charges or reimbursement) of DB vs. IB using a novel costing methodology, time-driven activity-based costing (TDABC). METHODS: A retrospective cohort study (2017-22) was conducted of all patients undergoing revascularization for symptomatic MMD. TDABC was used to calculate intraoperative costs. Supply cost was calculated as the aggregate of expenses related to implants, consumables, medications, and surgical tray sterilization. Personnel cost was determined by multiplying the per-minute wages of all intraoperative personnel by the amount of time they spent intraoperatively. Software was developed to automate this data from the electronic medical record. Multivariable regression was performed to compare the costs of DB vs. IB, adjusting for age, smoking status, hypertension, and coronary artery disease. RESULTS: Of 38 patients undergoing revascularization for MMD, 22 (57.9%) underwent DB, while 16 (42.1%) underwent IB. The median total cost of DB surgery was $7,802 (IQR: $7,802 - $9,881), compared to $6,120 (IQR: $5,609 - $6,900)for IB surgery (p < 0.05). On descriptive analysis, DB also had higher median supply cost ($3,793 vs. $2,855, p < 0.01), which was driven by higher cost of consumables ($2,268 vs. $1,996, p < 0.01), surgical tray sterilization ($137 vs. $129, p < 0.01), and implants ($1,022 vs. $568, p < 0.05). On multivariable analysis, DB was associated with significantly higher total cost (β:$1,758±$768, p = 0.027) and supply cost (β:$1,032±$333, p = 0.004), with no significant differences in personnel cost (β:$726±$526,p = 0.175). CONCLUSIONS: Using granular costing methodology, we demonstrate the individual drivers of cost which are responsible for differences in expenditures between DB and IB. This framework may inform surgical decision-making, guide institutional budgeting, and optimize resource allocation for the treatment of MMD.