The New Era of Cost Analysis in Spine Surgery Utilizing Time-Driven Activity Based Costing: A Systematic Review and Introduction of an Enabling Technology Value Index.

Background Context: Recent studies have demonstrated that time driven activity-based costing (TDABC) may be able to provide a robust and reproducible mechanism that can detect variability of time-based care within several areas of spine care.

Purpose: The purpose of this systematic review is to provide a summary of the growing applications of TDABC in spine care and introduce a value index in which it can be applied to rigorously evaluate various innovations in a reproducible and accurate fashion.

Study Design: Systematic Review METHODS: : The authors performed a systematic literature search of the PubMed and Embase databases using search terms related to spine surgery and TDABC. Three independent reviewers screened the article titles and abstracts for relevance. Studies which described the application of TDABC analysis to any aspect of the episode of care surrounding spinal pathology were included.

Results: A total of 33 studies were identified with 10 included for final review after exclusions. Four studies focused on anterior cervical discectomy and fusion (ACDF), four on single-level lumbar fusion, one on a multidisciplinary spine conference, and one on outpatient spine clinic care. Comparative analyses in the ACDF and lumbar fusion studies identified key cost drivers, including case volume, number of levels fused, intraoperative magnification, patient BMI, discharge timing, and screw navigation methods. Process mapping was primarily conducted using electronic medical records (EMR), direct observation, and third-party resources. Total cost estimates ranged from $201.78 per patient for a spine conference to $30,566 for two-level ACDF. The highest cost drivers were materials/implants, operating room time, and hospitalization duration, with fewer unnecessary outpatient referrals and reduced complication rates in multidisciplinary conferences also highlighted as significant findings. Utilizing the various TDABC applications, an enabling technology value index algorithm was proposed in which costing, as measured by TDABC methods, serve as the costing arm and denominator for the value analysis.

Conclusions: TDABC has demonstrated its utility in accurately calculating costs and identifying meaningful variability across different spine surgery contexts. As value-based care models continue to evolve, integrating TDABC can help align quality with cost-efficiency. This approach is particularly promising for evaluating enabling technologies, offering a cost-accounting framework to support value-based decision-making across healthcare systems. While further efforts are needed to overcome barriers to widespread implementation, TDABC holds significant potential for guiding resource allocation and enhancing the overall value of spine care.