An observational and descriptive study was carried out from April 2017 to June 2018 in the Department of Cardiology, Cardio-Thoracic Centre (CTC) of All India Institute of Medical Sciences, New Delhi, India. All India Institute of Medical Sciences is one of the leading healthcare institute in the country and CTC began functioning in 1982 with 200 hospital beds for Cardiology and Cardiothoracic & Vascular Surgery patients. It has all the facilities required for comprehensive cardiac care including a catherization laboratory, cardiac anesthesia, cardiac radiology, cardiac biochemistry, cardiac pathology, nuclear medicine, stem cell facility, organ retrieval & banking organization, blood transfusion services etc. It has four general wards, 8 Operating rooms, two intensive care units having 34 beds, eight ICU beds exclusively for the neonatal & infant intensive care, five cardiac catheterisation laboratory and one coronary care unit (CCU). CTC runs various super-specialty clinics (Coronary Clinic, Prosthetic valve Clinic, Hypertension Clinic, Arrhythmia/ Pacemaker Clinic, Heart Failure Clinic, Aortic disease Clinic).
This study was conducted as part of post graduate residency programme in the Department of Hospital Administration after obtaining necessary approval from the Institute Ethics Committee for Post Graduate Research vide IECPG-685/19.01.2017, RT31/16.02.2017. Study did not involve any patients and ethical guidelines as deemed appropriate for this study were adhered. It entailed identifying various cost centres, classifying costs and tracing all costs related to treating cardiovascular diseases through detailed and thorough perusal of various records including inpatient records to ascertain resource consumption during hospitalisation.
CVDs such as Coronary Artery Disease (CAD), Rheumatic Heart Disease (RHD), Cardiomyopathy, Congenital heart diseases, Cardiac Arrhythmias etc. were included in the study as classified by WHO and as per the expert guidance.(13) A total of 100 admitted patients of various CVDs were enrolled in the study using prevalence-based sampling and were followed up till discharge. Patients who were admitted for less than 24 hours, admissions through emergency department were excluded from the study. There was no interaction or involvement of any patient or public.
‘Process mapping’ of various patient care services during the hospital stay was conducted. It was done through direct observations and in-depth discussions with the key informants i.e. faculty members, resident doctors and nurses etc. Since the availability of data was a challenge due to lack of robustness in record keeping practices, combination of methodology utilizing using Traditional Costing and Time Driven Activity Based Costing (TDABC) were used for cost computation. Replacement method of cost computation employing Cost Inflation Index (As notified under the Finance Act) was adopted for arriving at the current day cost from the historical costs of various capital assets (CII in the year 2010 - 11 was 167, while for the year 2017- 18, it was 280, hence, CII factorial increase was calculated to be 1.89). Annualised cost was calculated for various cost centres and subsequently per bed per day cost was arrived. (Table 1)
Building and its maintenance cost: Measurement of the patient care areas (in sqm) were taken from the engineering department for the purpose of calculation of construction cost as per Central Public Works Department (CPWD) Manual 2007 (CII multiplication index 2.29). It was estimated that life of the building would be 100 years and therefore, an annual depreciation of 1% would be a reasonable estimation of the annual cost of the building. As per repair & service cost index as on 24/04/2018 issued by office of Director General, CPWD regulation, the maintenance rate for engineering works was Rs 6668.56/- per Sq.m. per year for the hospital building. No cost has been attributed to the land since the land belongs to the Government of India.
Cost of equipment, fixtures, and its maintenance Cost: A list of equipment used in the Cath lab, CCU and inpatient wards was populated, and its procurement cost was collected from hospital stores section. Straight-line method of depreciation (useful life 10/ & 7 years) was used to arrive at an annualized equipment cost. As per the prevailing practices five percent of the total procurement cost of an equipment was taken as maintenance cost and same was added to the annualized equipment cost to arrive at the total cost of equipment or an asset. For catheterization lab procedures, activity-based costing was utilized, while for CCU and wards, traditional method of costing was used.
Human Resource: Monthly gross salary was computed for various categories of staff. Time spent by various categories of staff during Cath lab procedures was decided in consultation with key informants (Consultants, Residents and Nursing Officers), thereafter, apportioning was done. While, in CCU and ward, the gross monthly salary of different manpower under various categories was computed by considering the actual number of manpower multiplied by the gross salary in that category.
Medicines, surgical and other consumables: Treatment file of each enrolled patient was studied for ascertaining consumption of carious consumables. Consumption pattern of various items i.e. general items, surgical items, stationary, linen store etc. over a period of six months was generated from hospital MIS database of the respective areas. Unit cost of each item was taken from the hospital stores and cost of various items consumed over a period of six months was calculated.
Air Conditioning & electricity costs: Cost for total tonnage of refrigeration (TR), Air handling unit (AHUs), condenser and chiller pumps, cooling tower was taken from engineering services division. Operational cost was taken based on its tonnage of refrigeration and electricity consumed per day including labor, spares, and material. Wattage and usage of various electrical appliances and fixtures was ascertained. Total number of units consumed in 24 hours by all the appliances and fixtures was calculated and total cost was arrived at.
Support Services Cost: Reference costs for support services was taken from the various studies carried out inhouse by the Department of Hospital Administration at AIIMS, New Delhi. Total per day load of dirty linen (in kg) of various categories generated from patient care areas under study was calculated with the help of Nursing Officer In charges and laundry supervisor. Cost of washing per kilogram of dirty linen was taken as Rs 23.22.(14) Cost of serving one meal in the general ward was estimated to be Rs. 86.77, while unit cost of breakfast was taken as 15% of the cost of a meal.(15) Cost of sterilizing items was estimated to be Rs. 33.9 per bed per day.(16) The number of total medical gas outlets for each patient care area was calculated and Rs 25.56 was taken as cost per manifold point.(17) Cost for managing biomedical waste management per day per bed was calculated. Additional 10% cost was added to the overall cost under the administrative head. All costs were calculated in INR and US $ (1US $ = 64.8 INR)