Defined and determine the cost drivers (three-level classification)

Based on the review results of the relevant cost studies discussed in chapter 2, several key cost drivers were identified (such as drug cost and personnel cost). To ensure that all the resources were thoroughly considered, the cost drivers/items that should be estimated were further checked and identified by focus group meetings (composed by haematologists, research nurses, and the managers of financial department in hospital) with the application of three-level classification, according to three different and distinct characteristics. In each classification level, only one characteristic was used. This was done mainly in order to avoid problems in categorizing some resources, as it is easy to count the same resource twice or forget to count the resource altogether [176]. The details of the three-level classification and the cost items identified are described below:

5.2.1 First level of cost classification by treatments/services

Although there are many ways to classify the resource input (such as activity, level at which resources are used, currency and others), it was decided that the ‘classification by treatments/services (activity)’ should be used for the purposes of the current study. This decision was made for two reasons. Firstly, classifying or identifying the resource inputs by treatment/services is a relatively straight-forward process [44]. Secondly, classifying resources by treatment matches the main purpose of the study, which was to estimate the individual overall cost from the patient treatment pathway by summing up all the treatment event costs. Under the treatments/services classification, the costs were divided into 12 categories according to the types of treatment/service given to the AML/APML patients:

a. Treatment costs identified from the HMRN database

Ten treatment costs were identified from the HMRN database: costs of chemotherapy (including treatment given a part of a clinical trial), clinical trail, supportive care (including erythropoietin, steroids, G-CSF, and transfusion), venesection, splenectomy, palliative care, transplantation, radiotherapy, immunosuppressive therapy, and follow-up.

These treatment costs occurred when they are given to patients.

b. Service cost identified from the HILIS database

Only one service cost item was identified from the HILIS database, namely the Laboratory test cost. Test costs can be defined as the costs that occur when patients

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receive the lab testing service. Normally, the lab test is used for confirming the diagnosis, monitoring the effectiveness of treatment, and monitoring the progress of the disease.

c. Care cost derived from the central register

Only one care cost was identified from the central register: the end-of-life care. The care cost (dying cost) is the cost that occurs when a patient dies at healthcare institutes, such as hospitals and nursing homes, without receiving any aggressive treatment. The end-of-life care normally only involves basic daily care and emotional / psychological support.

5.2.2 Second level of cost classification by information availability

According to the availability of the detailed treatment information, the treatment costs were further divided into two types: the cost can be estimated by bottom-up costing and the cost that can not.

a. cost type 1: cost that can be estimated by bottom-up costing method

The costs can be estimated by bottom-up costing method when the treatment details are available. For example, chemotherapy treatment cost falls into this category as the regimen details are available in the HMRN database.

b. cost type 2: cost that can not be estimated by bottom-up costing method

The cost can not be estimated by bottom-up costing method when the treatment details are not obtainable. For example, transplantation cost falls into this category as the treatment details of transplantation are not available from any of the databases used in the current study.

Based on the cost type, the treatment costs that can not be obtained by bottom-up costing method were estimated by substituting their values with the national average cost (from

‘Reference Cost Schedule’). As for the treatment costs that can be estimated by bottom-up costing method, they were further identified with the third level classification.

5.2.3 Third level of cost classification by functions

According to the cost functions (derived from practical experience, expert opinions, literature mentioned in Chapter 2, and relevant publications [44, 176, 177]), the cost drivers/items that had to be estimated for all the treatments were listed below.

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a. Drug costs (product costs): the costs for the delivered medicine/products of the treatment, such as the drug costs, regimen costs, and cost of blood products.

b. Personnel costs: the costs of human resources used for the treatment, but not for care or support duties/purposes.

c. Overheads and capital overheads costs: overheads costs are the resources serving different departments or treatments for supporting purposes (for example, administration, management, utility, central laundry, porter, outsource cleaning, and even infectious medical waste treatment expenditure or similar [44]). Capital overheads costs are the resources that are used to purchase the capital assets required by the treatment, such as equipment, buildings, vehicles, and land.

d. Ward/clinic costs: the resources that are used in ward or outpatient clinic for care duties, such as changing beddings, providing medicine and meals and space cost.

e. Complication treatment costs: the resources that are used to treat the side effects caused by treatments.

This three-level cost classification ensures that all the relevant activities are captured and reported. Once all the costs were identified, different types of costs for each treatment were able to be calculated through different methodologies. The structure of cost measurement methods is discussed below.