MAPPING THE PATIENT JOURNEY: TIME-DRIVEN ACTIVITY-BASED COSTING (TDABC) IN A HIGH-VOLUME HAND TRAUMA CLINIC

Background Hand trauma generates substantial demand on orthopaedic services; however, limited literature quantifies pathway-level costs within consultant-led clinics. Time-Driven Activity-Based Costing (TDABC) enables granular, patient-level economic analysis aligned with value-based healthcare. The University Hospital Wales model demonstrates lower costs than established UK fracture clinic models, though underlying drivers remain unclear. This study applied TDABC to identify cost drivers and variation within a tertiary hand trauma clinic. Methods A prospective TDABC evaluation of 223 patients was performed. Clinical activities were observed and timed, recording diagnosis and staff involvement. Staff costs were derived from NHS Wales and Agenda for Change 2025/2026 pay scales, with a 1.3 paybill multiplier. Capacity cost rates utilised theoretical annual working hours with 80% practical capacity. Total pathway cost was derived from aggregated time-based activity costs. Results 223 pathways were analysed. Mean pathway cost was £20.03, higher for initial consultations (£23.05) than follow-ups (£18.34), and lower than established standards (mean £20.03 vs £36.81; 45.59% reduction, based on Glasgow Royal Infirmary model). Fractures, particularly distal radius fractures, were most resource-intensive, driven by surgical consent (£16.97), hand therapy (£20.20), and casting (£4.73). Consultants had shorter activity times than fellows (4m41s vs 6m24s; 37% reduction). Consultant involvement, following band 5 procedures, occurred in 42.6% of cases, generating 6.85 minutes mean waiting time and £3.22 non-value-added cost per pathway. Hand therapy was the primary cost driver (>£1370 total). Conclusions TDABC identifies cost drivers within consultant-led hand trauma care. Optimising hand therapy workflow and reducing non-value-added waiting enhances efficiency, maintaining high-value, specialist-led care.