Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Filmless versus film-based systems in radiographic examination costs: an activity-based costing method

  • Hiroshi Muto1,
  • Yuji Tani2,
  • Shigemasa Suzuki3,
  • Yuki Yokooka1,
  • Tamotsu Abe1,
  • Yuji Sase1,
  • Takayoshi Terashita1 and
  • Katsuhiko Ogasawara1Email author
BMC Health Services Research201111:246

https://doi.org/10.1186/1472-6963-11-246

Received: 24 September 2010

Accepted: 30 September 2011

Published: 30 September 2011

Abstract

Background

Since the shift from a radiographic film-based system to that of a filmless system, the change in radiographic examination costs and costs structure have been undetermined. The activity-based costing (ABC) method measures the cost and performance of activities, resources, and cost objects. The purpose of this study is to identify the cost structure of a radiographic examination comparing a filmless system to that of a film-based system using the ABC method.

Methods

We calculated the costs of radiographic examinations for both a filmless and a film-based system, and assessed the costs or cost components by simulating radiographic examinations in a health clinic. The cost objects of the radiographic examinations included lumbar (six views), knee (three views), wrist (two views), and other. Indirect costs were allocated to cost objects using the ABC method.

Results

The costs of a radiographic examination using a filmless system are as follows: lumbar 2,085 yen; knee 1,599 yen; wrist 1,165 yen; and other 1,641 yen. The costs for a film-based system are: lumbar 3,407 yen; knee 2,257 yen; wrist 1,602 yen; and other 2,521 yen. The primary activities were "calling patient," "explanation of scan," "take photographs," and "aftercare" for both filmless and film-based systems. The cost of these activities cost represented 36.0% of the total cost for a filmless system and 23.6% of a film-based system.

Conclusions

The costs of radiographic examinations using a filmless system and a film-based system were calculated using the ABC method. Our results provide clear evidence that the filmless system is more effective than the film-based system in providing greater value services directly to patients.

Background

In Japanese healthcare institutions, the costs and cost structures of radiographic examinations have changed following installation of picture achieving and communication system (PACS) to improve the efficiency and quality of radiology departments operations. However, precisely estimating the cost of the examination is difficult from an efficiency viewpoint because it comprises several overheads common to various examinations (e.g., equipment expenses labor costs). While direct costs can be readily and conveniently traced to a particular examination, this is not true for indirect costs. In traditional costing systems, the ratio of costs to charges (RCC) and relative value units (RVUs), usually allocate indirect costs to individual examinations based on a measure of volume. The major management limitation of the traditional cost system is that it is not strategic; that is, it allows cross-subsidies between examinations. Therefore, the changes in the examination costs, shifting from a film-based system to a filmless system, are unclear. In addition, Japanese medical personnel generally have a poor awareness of costs, one reason why costs cannot be precisely estimated.

One particular cost accounting methodology is activity-based costing (ABC). The ABC method measures the cost and performance of activities, resources, and cost objects [1, 2]. Works are classified into activities, then resources are assigned to activities, and the latter are assigned to cost objects based on their use. The ABC method recognizes the causal relationships between cost drivers and activities. The advantages of ABC versus RCC and RVUs are as follows: (1) resources consumed at treatment level are more precisely defined and reflected; and (2) resources consumed by a particular cost object are directly tracked and identified to a greater degree [1]. The disadvantages are as follows: (1) ABC is the newest of the three methods, and therefore not as well known; and (2) the calculation method is complicated because of many allocation bases. ABC has been applied to health care organizations [36], and several researchers have applied ABC to radiographic examinations [79].

To our knowledge, no study has specifically addressed the changing costs structures of radiographic examinations, resulting the shift from a film-based system to a filmless system. To provide an efficient examination as part of a medical service, it is necessary for the radiologic technologist to understand the actual costs and to apply cost management processes in a filmless system. ABC can accurately calculate to a greater degree the cost of changing resources or procedures by focusing on each activity.

The primary purpose of this study is to identify the cost structure of a radiographic examination, comparing a filmless system with that of a film-based system using the ABC method. To clarify these changing costs and cost structures within the medical service, we simulated radiographic examinations in a health clinic to simplify the flow of duties.

Methods

Setting and subject

Two radiologic technologists were interviewed regarding the resources and flows (radiology procedures or activities) of radiographic examinations. An orthopedic health clinic was simulated for a film-based system and a filmless system. The cost objects of the radiographic examinations were lumbar (six views), knee (three views), wrist (two views), and other. The setting was such that radiographic examinations were conducted by a radiologic technologist. The ratio of new patients to re-examined patients in the out-patients department was 6:1. The number of radiographic examinations is given in Table 1.
Table 1

Annual number of radiographic examinations

Cost objects

New patients

Re-examined patients

Lumbar (six views)

900

600

Knee (three views)

600

400

Wrist (two views)

600

400

Other

900

600

Total

3,000

2,000

Costs of radiographic examinations

We calculated the costs of a radiographic examination in a filmless and a film-based system, and assessed the costs or cost components. The direct costs (film cost, film-envelope cost, and film-disposal cost) were traced to each examination.

The indirect cost were allocated to cost objects based on the ABC method. First, we extracted the resources consumed by radiographic examinations. The resources assumed the following costs depreciation costs of the equipment/system (CR system, X-ray equipment, dry film imager, viewbox (Schaukasten), information system (PACS, etc)); maintenance costs of the equipment/system (CR system, X-ray equipment, dry film imager, information system (PACS, etc)); labor costs (radiologic technologist, medical office personnel); and other administrative expenses (hospital administration and equipment, expenses for lighting and fuel). Labor costs were calculated by multiplying the time spent doing examination activity with the hourly rate taken from the annual salary (radiologic technologist: 6,000,000 yen; medical office personnel: 2,000,000 yen (1,000 yen/h)).

Second, we defined and classified the activities carried out during radiographic examinations. These activities were recognized as a measurable minimum unit of the consumption of resources. We then classified the activities as main (directly associated with an examination) or support activities (one that supported the examination). In addition, we classified main activities as either primary or secondary activities. Primary activities included face-to-face contact with the patient, and secondary activities supported primary activities [1]. Cost pools, where the costs were grouped together, represented a single activity--similar activities were bound together into a cost pool.

Finally, we set the resource and activity drivers, which were the allocation base. These drivers are the cause of the activity and reveal the effect of the driver. The resource drivers assigned the cost of resources to activities (cost pools) and activity drivers assigned the cost of activities to cost objects.

We also set the time spent on the activity and the machine for the CR system, X-ray equipment, dry film imager, and viewbox as the allocation base.

Sensitivity analysis

We performed sensitivity analyses to evaluate the factors that influence the cost price. Examination costs were calculated by changing each factor ("the number of examinations," "labor costs," "depreciation costs of the equipment/system," "maintenance costs of the equipment/system," "time (increasing and decreasing by the skill of the personnel or by the disease severity in the patients)," and "other administrative expenses") by 80% or 120%.

Results

Examination workflow and length of time

We simplified the radiographic examination workflow as follows: (1) checking previous patient's images; (2) preparing room and equipment/system; (3) patient's positioning; (4) irradiation; (5) reading images; and (6) aftercare. For each examination, we estimated the time of radiographic examination (Tables 2 and 3).
Table 2

Estimation of length of examination in minutes

 

Lumbar

(6 views)

Knee

(3 views)

Wrist

(2 views)

Other

Typically

    

   Transportation of film/order slip

0.50

0.50

0.50

0.50

   Registration of patient information

0.50

0.50

0.50

0.50

   Preparing room

0.25

0.25

0.25

0.25

   Calling patient

0.50

0.50

0.50

0.50

   Explanation of scan

0.50

0.50

0.50

0.50

   Changing clothes

2.00

2.00

0.00

1.33

   Positioning

4.50

3.00

1.50

3.00

   Irradiation

1.50

0.75

0.50

0.92

   Reading image

6.00

3.00

2.00

3.67

   Aftercare

0.50

0.50

0.50

0.50

   Changing clothes

2.00

2.00

0.00

1.33

   Opinion/transmission

1.50

0.75

0.50

0.92

   Transportation of film/order slip

0.50

0.50

0.50

0.50

Filmless system only

    

   Searching/checking previous image

1.00

1.00

1.00

1.00

Film-based system only

    

   Preparation of previous film image

2.00

2.00

2.00

2.00

   Checking previous film image

1.00

1.00

1.00

1.00

   Printing film

6.00

3.00

2.00

3.67

   Preparation of film envelope

0.50

0.50

0.50

0.50

   Checking film image

1.50

0.75

0.50

0.92

Table 3

Estimation of length of activity and machine per annu m in minutes

 

Filmless system

Film-based system

CR system

30,500

30,500

X-ray equipment

43,375

43,375

Viewbox

 

6,875

Radiologic technologist

48,250

72,625

Medical office personnel

2,500

6,500

Resources and resource drivers

The resources used in the radiographic examinations and the resource drivers are given in Tables 4 and 5.
Table 4

Resources per annu m and resource drivers for a filmless system

 

Cost (yen)

Resource driver (yen)

Direct costs

   

   Total

0

  

Indirect costs

   

   CR system

1,600,000

52.5

/minute

   Depreciation of CR system

1,000,000

2000

/examination

   X-ray equipment

600,000

13.8

/minute

   Depreciation of X-ray equipment

1,000,000

200.0

/examination

   Information system

1,000,000

50.0

/view

   Depreciation of information system

500,000

100.0

/examination

   Radiologic technologist

2,412,500

50.0

/minute

   Medical office personnel

41,667

16.7

/minute

   Administration

200,000

40.0

/examination

   Total

8,354,167

  

Total cost

8,354,167

  
Table 5

Resources per annum and resource drivers for a film-based system

 

Cost (yen)

Resource driver (yen)

Direct costs

   

   Film (B5)

3,180,000

159.0

/film

   Film envelope

100,000

20.0

/examination

   Film disposal

600,000

30.0

/film

   Total

3,880,000

  

Indirect costs

   

   CR system

1,600,000

52.5

/minute

   Depreciation of CR system

1,000,000

2000

/examination

   X-ray equipment

600,000

13.8

/minute

   Depreciation of X-ray equipment

1,000,000

200.0

/examination

   Dry film imager

400,000

20.0

/film

   Depreciation of dry film imager

300,000

60.0

/examination

   Viewbox

30,000

4.4

/minute

   Radiologic technologist

3,631,250

50.0

/minute

   Medical office personnel

108,333

16.7

/minute

   Administration

200,000

40.0

/examination

   Total

8,869,583

  

Total cost

12,749,583

  

In the filmless system, the direct cost was 0 yen and the indirect cost was 8,354,000 yen per annum. In the film-based system, the direct cost was 3,880,000 yen and the indirect cost was 8,870,000 yen per annum. It was shown that the cost of a radiographic examination was reduced by 34.5% using a filmless system. Resource drivers were identified as "number of films (irradiation)," "number of examinations," and "activity or machine time" for each resource.

Cost of radiographic examination and cost structure

Activity costs and examination costs are given in Tables 6 and 7. During a radiographic examination in a filmless system there are 13 main activities, 3 support activities, and 12 cost pools. In a film-based system, there are 18 main activities 2 support activities, and 17 cost pools.
Table 6

Cost of radiographic examination for a filmless system

Cost objects

Lumbar (6 views)

Knee (3 views)

Wrist (2 views)

Other

Total

Indirect costs

        

Activity (Cost pool)

Activity driver

Cost (yen)

Cost (yen)

Cost (yen)

Cost (yen)

Cost (yen)

Rate

Main activity

        

Transportation of order slip

8.33

/examination

12,500

8,333

8,333

12,500

41,667

0.5%

Registration of patient information

51.23

/examination

76,844

51,230

51,230

76,844

256,148

3.1%

Searching/checking previous image

50.00

/examination

30,000

20,000

20,000

30,000

100,000

1.2%

Preparating room

63.83

/minute

23,937

15,958

15,958

23,937

79,791

1.0%

Calling patient

63.83

/minute

47,875

31,916

31,916

47,875

159,582

1.9%

Explanation of scan

63.83

/minute

47,875

31,916

31,916

47,875

159,582

1.9%

Changing clothes

63.83

/minute

191,499

127,666

0

127,666

446,830

5.3%

Take photographs (reading image)

116.29

/minute

1,046,627

436,095

232,584

683,215

2,398,520

28.7%

Aftercare

116.29

/minute

87,219

58,146

58,146

87,219

290,730

3.5%

Changing clothes

13.83

/minute

41,499

27,666

0

27,666

96,830

1.2%

Opinion/Transmission

24.97

/view

224,769

74,923

49,949

149,846

499,488

6.0%

Transportation of order slip

25.00

/examination

37,500

25,000

25,000

37,500

125,000

1.5%

Support activity

        

Imaging administration by PACS

50.00

/view

450,000

150,000

100,000

300,000

1,000,000

12.0%

Maintenance of the equipment/system

500.00

/examination

750,000

500,000

500,000

750,000

2,500,000

29.9%

Other administration

40.00

/examination

60,000

40,000

40,000

60,000

200,000

2.4%

Indirect costs total

  

3,128,143

1,598,849

1,165,032

2,462,142

8,354,167

100.0%

Direct cost

        

Direct costs total

  

0

0

0

0

0

0.0%

Total cost

  

3,128,143

1,598,849

1,165,032

2,462,142

8,354,167

100.0%

Cost of radiographic examination

  

2,085

1,599

1,165

1,641

  
Table 7

Cost of radiographic examination for a film-based system

Cost objects

Lumbar (6 views)

Knee (3 views)

Wrist (2 views)

Other

Total

Indirect costs

        

Activity (Cost pool)

Activity driver

Cost (yen)

Cost (yen)

Cost (yen)

Cost (yen)

Cost (yen)

Rate

Main activity

        

Prepare previous film image

33.33

/examination

20,000

13,333

13,333

20,000

66,667

0.5%

Transportation of film/order slip

8.33

/examination

12,500

8,333

8,333

12,500

41,667

0.3%

Registration of patient information

51.23

/examination

76,844

51,230

51,230

76,844

256,148

2.0%

Checking previous film image

54.36

/examination

32,618

21,745

21,745

32,618

108,727

0.9%

Preparing room

63.83

/minute

23,937

15,958

15,958

23,937

79,791

0.6%

Calling patient

63.83

/minute

47,875

31,916

31,916

47,875

159,582

1.3%

Explanation of scan

63.83

/minute

47,875

31,916

31,916

47,875

159,582

1.3%

Changing clothes

63.83

/minute

191,499

127,666

0

127,666

446,830

3.5%

Take photographs (reading image)

116.29

/minute

1,046,627

436,095

232,584

683,215

2,398,520

18.8%

Aftercare

116.29

/minute

87,219

58,146

58,146

87,219

290,730

2.3%

Changing clothes

13.83

/minute

41,499

27,666

0

27,666

96,830

0.8%

Opinion/Transmission

24.97

/view

224,769

74,923

49,949

149,846

499,488

3.9%

Printing film (preparation of film envelope)

68.75

/view

618,750

206,250

137,500

412,500

1,375,000

10.8%

Checking film image

13.25

/view

119,260

39,753

26,502

79,507

265,023

2.1%

Transportation of film/order slip

25.00

/examination

37,500

25,000

25,000

37,500

125,000

1.0%

Support activity

        

Maintenance of the equipment/system

460.00

/examination

690,000

460,000

460,000

690,000

2,300,000

18.0%

Other administration

40.00

/examination

60,000

40,000

40,000

60,000

200,000

1.6%

Indirect costs total

  

3,378,772

1,669,931

1,204,113

2,616,767

8,869,583

69.6%

Direct costs

        

Film (B5)

159.0

/film

1,431,000

477,000

318,000

954,000

3,180,000

24.9%

Film envelope

20.0

 

30,000

20,000

20,000

30,000

100,000

0.8%

Film disposal

30.0

/film

270,000

90,000

60,000

180,000

600,000

4.7%

Direct costs total

  

1,731,000

587,000

398,000

1,164,000

3,880,000

30.4%

Total cost

  

5,109,772

2,256,931

1,602,113

3,780,767

12,749,583

100.0%

Cost of radiographic examination

  

3,407

2,257

1,602

2,521

  

The cost of various radiographic examinations using a filmless system are as follows: lumbar (6 views) 2,085 yen; knee (3 views) 1,599 yen; wrist (2 views) 1,165 yen, and other 1,641 yen. With regard to the cost structure of radiographic examinations using a filmless system, "maintenance of the equipment/system" represented 29.9% of the total cost, "take photographs (reading image)" 28.7%, and "imaging administration by PACS" 12.0%.

The examination costs for a film-based system are as follows lumbar (6 views) 3,407 yen; knee (3 views) 2,257 yen; wrist (2 views) 1,602 yen, and other 2,521 yen. The greatest cost in the cost structure was that of film costs (24.9% of the total cost), then "take photographs (reading image)" at 18.8%, "maintenance of the equipment/system" was 18.0%, and "printing film (preparation of film envelope)" was 10.8%.

The primary activities were "calling patient," "explanation of scan," "take photographs," and "aftercare" for both filmless and film-based systems. These activities cost 36.0% of the total cost for a filmless system and 23.6% for a film-based system.

Sensitivity analysis

The result of the sensitivity analyses are given in Tables 8 and 9. "The number of examinations" was the parameter that most influenced the examination costs for both systems; however, it had a greater influence on examination costs under a filmless system than that of a film-based system. For example, lumbar examinations in a filmless system ranged from 1,844 yen (88.4%) to 2,447 yen (117.3%), whereas the costs ranged from 3,201 yen (94.0%) to 3,715 yen (109.1%) for a film-based system.
Table 8

Sensitivity analyses of examination costs for a filmless system

  

Lumbar(yen)

Knee(yen)

List(yen)

Other(yen)

Number of examinations

80%

2,447

117.3%

1,876

117.3%

1,384

118.8%

1,933

117.7%

 

120%

1,844

88.4%

1,414

88.4%

1,019

87.5%

1,447

88.2%

Labor costs

80%

1,958

93.9%

1,501

93.9%

1,107

95.0%

1,546

94.2%

 

120%

2,213

106.1%

1,697

106.1%

1,223

105.0%

1,737

105.8%

Depreciation costs of equipment

80%

1,964

94.2%

1,515

94.8%

1,118

96.0%

1,557

94.8%

 

120%

2,207

105.8%

1,683

105.2%

1,212

104.0%

1,726

105.2%

Depreciation costs of system

80%

2,025

97.1%

1,569

98.1%

1,145

98.3%

1,601

97.6%

 

120%

2,145

102.9%

1,629

101.9%

1,185

101.7%

1,681

102.4%

Maintenance costs of equipment

80%

1,985

95.2%

1,499

93.7%

1,065

91.4%

1,541

93.9%

 

120%

2,185

104.8%

1,699

106.3%

1,265

108.6%

1,741

106.1%

Maintenance costs of system

80%

2,065

99.0%

1,579

98.7%

1,145

98.3%

1,621

98.8%

 

120%

2,105

101.0%

1,619

101.3%

1,185

101.7%

1,661

101.2%

Time (skill of personnel)

80%

1,978

94.9%

1,524

95.3%

1,103

94.7%

1,559

95.0%

 

120%

2,193

105.1%

1,675

104.7%

1,226

105.2%

1,724

105.0%

Time (disease severity of patients)

80%

2,006

96.2%

1,530

95.7%

1,137

97.6%

1,583

96.5%

 

120%

2,165

103.8%

1,667

104.2%

1,194

102.5%

1,700

103.5%

Other administrative expenses

80%

2,077

99.6%

1,591

99.5%

1,157

99.3%

1,633

99.5%

 

120%

2,093

100.4%

1,607

100.5%

1,173

100.7%

1,649

100.5%

Table 9

Sensitivity analyses of examination costs for a film-based system

  

Lumbar(yen)

Knee(yen)

List(yen)

Other(yen)

Number of examinations

80%

3,715

109.1%

2,503

110.9%

1,797

112.2%

2,773

110.0%

 

120%

3,201

94.0%

2,093

92.7%

1,472

91.9%

2,352

93.3%

Labor costs

80%

3,203

94.0%

2,120

93.9%

1,517

94.7%

2,374

94.2%

 

120%

3,610

106.0%

2,394

106.1%

1,687

105.3%

2,667

105.8%

Depreciation costs of equipment

80%

3,260

95.7%

2,160

95.7%

1,546

96.5%

2,418

96.0%

 

120%

3,553

104.3%

2,354

104.3%

1,658

103.5%

2,623

104.0%

Maintenance costs of equipment

80%

3,315

97.3%

2,165

95.9%

1,510

94.3%

2,429

96.3%

 

120%

3,499

102.7%

2,349

104.1%

1,694

105.7%

2,613

103.7%

Time (skill of personnel)

80%

3,320

97.5%

2,196

97.3%

1,542

96.3%

2,449

97.2%

 

120%

3,531

103.7%

2,343

103.8%

1,671

104.3%

2,615

103.8%

Time (disease severity of patients)

80%

3,328

97.7%

2,188

97.0%

1,574

98.2%

2,462

97.7%

 

120%

3,486

102.3%

2,325

103.0%

1,631

101.8%

2,579

102.3%

Other administrative expenses

80%

3,399

99.8%

2,249

99.6%

1,594

99.5%

2,513

99.7%

 

120%

3,415

100.2%

2,265

100.4%

1,610

100.5%

2,529

100.3%

Discussion

In this study, we calculated the costs of radiographic examinations in both a filmless system and a film-based system using the ABC method. Our results indicate that examination costs and cost structures can be expressed by identifying activity costs.

In recent times, hospital management has both emphasized and relied on knowledge regarding the cost of clinical examinations. However, estimating actual examination costs using traditional costing methods is difficult because radiographic examinations include many indirect costs, and the implementation of filmless systems has increased this trend. The ABC method can visualize the operation from a cost standpoint using costing based on relevant activities. Therefore when an operation is improved or evaluated and an equipment/system is introduced or updated, the ABC method can manage the cost of the procedure or support decision-making by clarifying the issue or estimating the improvement effect. Additionally, ABC may be able to heighten the awareness of medical personnel regarding costs by calculating accessible activity costs.

The introduction of filmless systems has resulted in various cost reductions in the use of different types of photography: the higher the number of images, the greater the reduction in costs. The rate of reduction in costs was higher for lumbar examinations (6 views) (38.78%). This result demonstrates that the reduction in film cost had the greatest impact on total cost: film cost was 24.9% of the total cost.

The rate of primary activity increased by 23.6-36.0% because of the implementation of the filmless system. In particular, the activity rate of "take photographs" increased by 18.8-27.8%. This increase in the primary activity rate indicates that the system is cost-effective; therefore such primary activities can provide greater value directly to patients.

Furthermore, the present study confirms that the number of examinations had the greatest influence on examination costs using a filmless system compared with a film-based system. If the number of examinations increased or decreased using a film-based system, the effect on the examination cost was slight because the direct cost rate (e.g., film or film envelope) is higher. Conversely, for a filmless system, the number of examinations had a much greater impact on examination cost; hence a plan to increase the number of examinations is necessary.

The present study does have its limitations. First, clinic costs need to be allocated to each department to accurately calculate examination costs. However, we were interested in the change in costs or cost structures with the introduction of the new system. Therefore, in this study, a clinic's general expenses were not considered. Second, the cost objects only included the main examinations, and operations only included examination flow. Ideally every examination should be included, and re-imaging or the time required for administrative work should also be considered. In addition, the accurate measurement of time is indispensable to determine the actual cost of examinations.

Conclusions

The costs and cost structures of radiographic examinations using a filmless system and a film-based system were calculated using the ABC method. The cost objects were lumbar (6 views), knee (3 views), wrist (2 views), and other, with costs of 2,085, 1,599, 1,165, and 1,641 yen, respectively for a filmless system.3,407, 2,257, 1,602, and 2,521 yen, respectively, for a film-based system. Our results provide clear evidence that the filmless system is more effective than the film-based system in providing services of greater value directly to patients.

Declarations

Authors’ Affiliations

(1)
Graduate School of Health Sciences, Hokkaido University
(2)
Department of Radiology, Itoh Orthopaedic Hospital
(3)
Faculty of Management, Dohto University

References

  1. Baker Judith: Activity-based costing and activity-based management for health care. Aspen Publishers, Gaithersburg, Maryland. 1998Google Scholar
  2. Kaplan RS, Anderson SR: Time-driven activity-based costing. Harv Bus Rev. 2004, 82 (11): 131-138.PubMedGoogle Scholar
  3. Laurila J, Suramo I, Brommels M, Tolppanen EM, Koivukangas P, Standertskjold-Nordenstam G: Activity-based costing in radiology. Application in a pediatric radiological unit. Acta Radiol. 2000, 41 (2): 189-195. 10.1080/028418500127345037.View ArticlePubMedGoogle Scholar
  4. Storfjell JL, Omoike O, Ohlson S: The balancing act: patient care time versus cost. J Nurs Adm. 2008, 38 (5): 244-249. 10.1097/01.NNA.0000312771.96610.df.View ArticlePubMedGoogle Scholar
  5. Demeere N, Stouthuysen K, Roodhooft F: Time-driven activity-based costing in an outpatient clinic environment: development, relevance and managerial impact. Health Policy. 2009, 92 (2-3): 296-304. 10.1016/j.healthpol.2009.05.003.View ArticlePubMedGoogle Scholar
  6. Cao P, Toyabe S, Kurashima S, Okada M, Akazawa K: A modified method of activity-based costing for objectively reducing cost drivers in hospitals. Methods Inf Med. 2006, 45 (4): 462-469.PubMedGoogle Scholar
  7. Krug B, Van Zanten A, Pirson AS, Crott R, Borght TV: Activity-based costing evaluation of a [(18)F]-fludeoxyglucose positron emission tomography study. Health Policy. 2009, 92 (2-3): 234-43. 10.1016/j.healthpol.2009.04.002.View ArticlePubMedGoogle Scholar
  8. Suthummanon S, Omachonu VK, Akcin M: Applying activity-based costing to the nuclear medicine unit. Health Serv Manage Res. 2005, 18 (3): 141-50. 10.1258/0951484054572538.View ArticlePubMedGoogle Scholar
  9. Nisenbaum HL, Birnbaum BA, Myers MM, Grossman RI, Gefter WB, Langlotz CP: The costs of CT procedures in an academic radiology department determined by an activity-based costing (ABC) method. J Comput Assist Tomogr. 2000, 24 (5): 813-23. 10.1097/00004728-200009000-00026.View ArticlePubMedGoogle Scholar
  10. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/246/prepub

Copyright

© Muto et al; licensee BioMed Central Ltd. 2011

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.