Time-Driven, Activity-Based Costing of Presurgical Infant Orthopedics: A Critical Component of Establishing Value of Latham Appliance and Nasoalveolar Molding

Abstract

Background: Value-based health-care reform requires assessment of outcomes and costs of medical interventions. In cleft care, presurgical infant orthopedics is still being evaluated for clinical benefits and risks; however, the cost of these procedures has been largely ignored. This study uses robust accounting methods to quantify the cost of providing two types of presurgical infant orthopedics: Latham appliance treatment and nasoalveolar molding. Methods: This is a prospective study of patients with nonsyndromic cleft lip and/or palate who underwent treatment with presurgical infant orthopedics from 2017 to 2019 at two academic centers. Costs were measured using time-driven activity-based costing. Personnel costs, facility costs (operating room, clinic, and inpatient ward), and equipment costs were included. Travel expenses were incorporated as an estimate of direct costs borne by the family, but indirect costs (e.g., time off from work) were not considered. Results: Twenty-three patients were treated with Latham appliance treatment and 14 were treated with nasoalveolar molding. For Latham appliance treatment, average total cost was $7553 per patient ($1041 for personnel, $637 for equipment, $4871 for facility, and $1004 for travel over 6.5 visits). Unilateral and bilateral costs were $6891 and $8860, respectively. For nasoalveolar molding, average cost totaled $2541 ($364 for personnel, $151 for equipment, $300 for facility, and $1726 for travel over 13 visits); $2120 for unilateral and $3048 for bilateral treatment. Conclusions: The major difference in cost is attributable to operative placement of the Latham device. Travel cost for nasoalveolar molding is often higher because of frequent clinical encounters required. Future investigation should focus on whether outcomes achieved by presurgical infant orthopedics justify the $2100 to $8900 expenditure for these adjunctive procedures.

Current Presurgical Infant Orthopedics Practices Among American Cleft Palate Association–Approved Cleft Teams in North America

“…The use of the Latham appliance seems to have decreased since the previous study as well, from 14.7% reported in 2019 to only 5% in our reported data 23. Aside from the associated controversy regarding its invasive nature and resultant growth restriction, the Latham appliance is also significantly more costly to employ 7,43. As it requires an additional operation under anesthesia to place, the Latham appliance costs over $7000 on average.…”

“…The NAM appliance, in comparison, has an average treatment cost of $2500. This accounts for personnel, equipment, facility, and travel over the duration of treatment 43. Many centers may be abandoning this technique as it is difficult to justify almost triple the expenditure 29…”

“…23 Aside from the associated controversy regarding its invasive nature and resultant growth restriction, the Latham appliance is also significantly more costly to employ. 7,43 As it requires an additional operation under anesthesia to place, the Latham appliance costs over $7000 on average. The NAM appliance, in comparison, has an average treatment cost of $2500.…”

Cost and Satisfaction Implications of Using Telehealth for Plagiocephaly

“…It has been used to improve patient care and illuminate inefficiencies in the treatment of distal radius and hip fractures and detection of cancer; within craniofacial surgery, it has previously been used for process improvement in outpatient plagiocephaly care as well for calculating costs of surgical interventions including the use of presurgical infant orthopedics in cleft lip and palate. [2][3][4][5][6][7][8][9][10] This study compared hospital-based and patientincurred expenses for both in-person and telehealth visit types. We also gauged patient and provider desire for and satisfaction with each visit type while weighing technological considerations for telehealth consultations.…”

“…It has been used to improve patient care and illuminate inefficiencies in the treatment of distal radius and hip fractures and detection of cancer; within craniofacial surgery, it has previously been used for process improvement in outpatient plagiocephaly care as well for calculating costs of surgical interventions including the use of presurgical infant orthopedics in cleft lip and palate. 2–10…”