Comprehensive cost estimation of an enhanced recovery pathway in hip and knee arthroplasty using an expanded time-driven activity-based costing framework.

Abstract

Background Total hip (THA) and total knee arthroplasty (TKA) are among the most frequently performed surgeries worldwide, creating a substantial financial burden. Enhanced recovery after surgery (ERAS) pathways aim to improve outcomes while reducing costs, aligning with the principles of value-based healthcare (VBHC). Time-driven activity-based costing (TDABC) is recommended for VBHC cost calculation, yet its application to ERAS is rarely reported. This study calculated total and ERAS-related costs of a comprehensive ERAS pathway for THA and TKA using TDABC. Methods A retrospective single-center cohort study (February to September 2023) was performed in Belgium for 99 THA and 120 TKA patients following an uncomplicated ERAS pathway. Using the TDABC method and the “TDABC in Healthcare Consortium” framework, costs from first surgical consultation until the 3-months follow-up were divided into five categories. Direct costs (medication and material) and TDABC-allocated costs (personnel, infrastructure, and departmental overheads) were aggregated to determine total and ERAS-related costs. All costs are reported in euros (EUR) and converted to United States dollars (USD) using the average exchange rate (1 EUR = 1.08 USD) for 2023. Results The mean total costs were €6,682.3 ($7,216.9) for THA and €8,091.3 ($8,738.6) for TKA. Material and personnel accounted for approximately 90% of total pathway costs. The ERAS-related costs represented approximately 10% of total pathway costs (€673.7/$727.6 THA; €744.2/$803.7 TKA). The highest ERAS costs were noted in the preoperative phase, whereas postoperative elements (e.g., early mobilization) had relatively low costs. Conclusion The TDABC revealed that ERAS costs represented only 10% of the total pathway cost and highlighted key (ERAS) cost components for further pathway improvement. This study offers a TDABC framework to standardize cost evaluation and support ERAS implementation, optimization, and sustainability within VBHC strategies.