Patient Time Cost

Patient Time Cost in Economic Evaluation

Every hour a patient spends on a bus to the clinic, in a waiting room or in an infusion chair is an hour taken from paid work, unpaid work at home or leisure. Health economists treat that hour as a resource used up by care, valued as an opportunity cost in the same way as staff time or a hospital bed. Russell argues that leaving it out understates the burden of disease and tilts cost-effectiveness analysis towards treatments that demand more of patients' time. Whether it is counted at all depends on the perspective of the analysis, which is why the item appears in some reference cases and not in others.

Why patients' time is a resource

Good costing practice, in Russell's account, rests on two principles, which are to measure every important use of a resource and to value it consistently with other resources. Patients' time is used by almost every intervention, so a costing that counts clinic staff minutes but ignores the patient's own hours is incomplete. Yabroff and colleagues describe the time spent travelling to and from care, waiting for appointments, consulting providers and receiving care as time not spent on usual activities, including work and leisure.

The point matters most when the options being compared differ in how they are delivered. A weekly hospital infusion and a daily tablet may cost the health service similar amounts yet ask very different things of patients. Russell notes that time costs can be a large part of an intervention's costs, sometimes larger than direct medical costs, and can affect patients' willingness to take part in it.

Measuring patient time from service counts and diaries

A practical method starts from counts of services that a cost analysis already records. Russell suggests that counts of formal medical services can be the starting point for valuing patients' time, even when other uses of time cannot be measured. Each service type is given an average time for travel, waiting and the service itself, and the total is multiplied by an hourly value.

$$C^{T} = w \sum_{k=1}^{K} n_k \left( t^{\mathrm{travel}}_k + t^{\mathrm{wait}}_k + t^{\mathrm{care}}_k \right)$$

Here $C^{T}$ is the patient time cost for one person over the period, $w$ is the hourly value of time, $K$ is the number of service types, $n_k$ is the number of uses of service type $k$, and the three $t$ terms are the hours spent travelling, waiting and receiving that service.

Yabroff and colleagues applied this approach to national survey data for the United States. They added round-trip travel time to every service, added waiting time to office visits, chemotherapy and radiation therapy, and counted each night in hospital as 16 waking hours that could otherwise be spent on usual activities. The service-based method misses preparation at home, recovery at home and time spent dealing with insurers, which the authors suggest are better captured by surveys, micro-costing or time-and-motion methods.

A diary study measures time directly. Jonas and colleagues asked patients booked for screening colonoscopy to record time spent on preparation, travel, waiting, the procedure and recovery, and they defined several time intervals to value.

Choosing a value for an hour of patient time

Valuation follows the opportunity cost principle. Russell explains why the wage is a reasonable proxy for the value patients place on their own time and notes that wage data are well measured and readily available. In practice analysts choose between a single average or median wage applied to everyone and person-specific values.

Yabroff and colleagues used the median hourly wage in the United States, USD 16.57 in 2011, for every patient in the base case, so that each person's time counted equally. In a sensitivity analysis they used actual wages for people in paid employment and a value of home production, USD 5.32 per hour, for those who were not employed. For survivors aged 65 and over, annual time costs fell from USD 913 to USD 359, and for people of the same age without a cancer history from USD 607 to USD 241. The authors warn that valuing time differently for different groups may lead to inequities, particularly for low-income and other vulnerable groups.

Tranmer and colleagues reviewed the human capital method, the friction cost method and the Washington Panel approach for valuing patient and carer time. They found inconsistent methods and little research on time lost from unpaid work and leisure. The human capital approach and the friction cost method were built for lost work output, so applying them to time in care is a choice that should be stated.

Where patient time sits under each perspective

The Second Panel on Cost-Effectiveness in Health and Medicine recommended in 2016 that every analysis report two reference cases, one from a health care sector perspective and one from a societal perspective. It also recommended an impact inventory, a structured table of consequences inside and outside the formal health care sector. Breslau and colleagues describe how the inventory lists patient-time costs, unpaid caregiver-time costs and transport costs under the informal health care sector.

Kim and colleagues defined a limited societal perspective as one that adds patient time, patient transport, unpaid carer time and productivity loss to the costs counted from a health care sector perspective. In their review of published analyses from 1974 to 2018, registry reviewers judged that 74% took a health care sector or payer perspective. In 2017 and 2018 only 11 cost-per-QALY studies, 1.0% of the total, included an impact inventory.

The NICE manual (PMG36) sets the reference-case perspective on costs as that of the NHS and personal social services. The manual does not mention patients' own time, but on that perspective such time would fall outside the reference case. Costs paid by patients may be included when the NHS or personal social services reimburse them, and unreimbursed patient costs may be presented separately. The manual also allows the time of family members who provide care that the NHS or social services would otherwise provide to be considered, shown separately and tested with other valuation methods.

Evidence that time costs are large

Several detailed estimates come from studies of cancer care. In colorectal cancer, Yabroff and colleagues found net patient time costs equal to 19.3% of direct medical costs in the initial phase of care, 15.8% in the continuing phase and 36.8% in the terminal phase. A later study of people aged 65 and over with 11 cancers found net time costs in the initial phase from USD 271 for melanoma of the skin to USD 5,605 for ovarian cancer, and national time costs for the initial phase of USD 2.3 billion in 2005.

Using national survey data on adults, Yabroff and colleagues found that cancer survivors aged 18 to 64 spent 30.2 hours a year on medical care against 13.6 hours for people without a cancer history, with annual time costs of USD 500 and USD 226. In the colonoscopy diary study, mean occupied time was 23.2 hours, worth USD 432 at the 2005 average wage. Adding it to a published model raised the cost per life-year saved by screening colonoscopy by 68%, from USD 13,100 to USD 22,000, with a range of 17% to 224% depending on the time interval valued.

Worked example with an infusion and an oral treatment

The figures below are hypothetical and chosen for illustration. A new infusion is compared with an oral treatment over one year, so no discounting is needed. The infusion needs 26 hospital visits, each with 1.0 hour of travel, 0.5 hours of waiting and 3.0 hours in the chair. The oral treatment needs 12 clinic visits, each with 1.0 hour of travel, 0.5 hours of waiting and a 0.5 hour consultation.

Step 1 (hours). The infusion uses $h_I = 26 \times 4.5 = 117$ hours and the oral treatment $h_O = 12 \times 2.0 = 24$ hours, a difference of 93 hours.

Step 2 (value). At an illustrative GBP 15 per hour, time costs are $C^{T}_I = 117 \times 15 = 1{,}755$ and $C^{T}_O = 24 \times 15 = 360$ GBP, so the incremental time cost is $\Delta C^{T} = 1{,}755 - 360 = 1{,}395$ GBP.

Step 3 (health service view). The infusion costs the health service 1,500 GBP more and gains 0.10 QALYs, so the ICER is $\mathrm{ICER} = 1{,}500 / 0.10 = 15{,}000$ GBP per QALY.

Step 4 (adding patient time). From a limited societal perspective, the incremental cost becomes $\Delta C = 1{,}500 + 1{,}395 = 2{,}895$ GBP and the ICER is $\mathrm{ICER} = 2{,}895 / 0.10 = 28{,}950$ GBP per QALY, which is 93% higher.

Step 5 (a lower value of time). At GBP 7 per hour the incremental time cost is $\Delta C^{T} = 819 - 168 = 651$ GBP, the incremental cost is $\Delta C = 1{,}500 + 651 = 2{,}151$ GBP and the ICER is $\mathrm{ICER} = 2{,}151 / 0.10 = 21{,}510$ GBP per QALY.

The infusion still costs more and gains more, but its ICER nearly doubles, so an option close to a threshold could cross it once patient time is counted. Cutting the hourly value from GBP 15 to GBP 7 cuts the rise in the ICER from 13,950 to 6,510 GBP per QALY, which is why the valuation choice belongs in the sensitivity analysis. The 0.10 QALY gain is assumed to capture any effect of treatment on health-related quality of life, so only the hours spent in care are costed.

Boundaries with productivity, carer time and travel costs

Patient time cost overlaps with several nearby items, and each must be counted once. Productivity cost is the value of lost paid work from illness or death. When time in care is taken from paid work, the same hour should not appear both as patient time and as lost output. Fares and fuel for getting to care are direct non-medical costs, often paid out of pocket, and the Second Panel's inventory lists transport separately from time. The time of relatives who drive or sit with the patient is carer time, and it often adds to caregiver burden.

In cancer care, Gupta and colleagues have proposed a related measure called time toxicity, defined as any day with physical contact with the health care system. Such days are counted rather than valued in money. It describes the same burden in days, which is useful in trials, while patient time cost puts a money value on hours so they can enter an economic evaluation.

Limitations and common misreadings

Patient time is easy to leave out because no invoice records it. Kim and colleagues also found that study authors often mis-specified or did not state the perspective they used, which hides whether time was counted.

1. Patient time is free because no one is paid for it. Time has an opportunity cost whether or not money changes hands, and Russell notes that leaving it out biases results towards interventions that use more time.
2. Counting time once in costs and once in QALYs. Kim and colleagues note an open question over whether lost productivity from illness is already captured in QALYs, and the same care is needed for time spent unwell.
3. A wage rate is the only defensible value. Actual wages, a home production value and a single median wage give very different answers, and the choice carries equity implications.
4. Service counts capture all patient time. Preparation, recovery at home and administrative time are usually missed, so service-based estimates tend to understate the total.

Sources

• Russell LB. Completing costs: patients' time. Medical Care. 2009;47(7 Suppl 1):S89-S93. https://doi.org/10.1097/MLR.0b013e31819bc077
• Yabroff KR, Guy GP, Ekwueme DU, et al. Annual patient time costs associated with medical care among cancer survivors in the United States. Medical Care. 2014;52(7):594-601. https://doi.org/10.1097/MLR.0000000000000151
• Yabroff KR, Warren JL, Knopf K, Davis WW, Brown ML. Estimating patient time costs associated with colorectal cancer care. Medical Care. 2005;43(7):640-648. https://doi.org/10.1097/01.mlr.0000167177.45020.4a
• Yabroff KR, Davis WW, Lamont EB, et al. Patient time costs associated with cancer care. Journal of the National Cancer Institute. 2007;99(1):14-23. https://doi.org/10.1093/jnci/djk001
• Jonas DE, Russell LB, Sandler RS, Chou J, Pignone M. Value of patient time invested in the colonoscopy screening process: time requirements for colonoscopy study. Medical Decision Making. 2008;28(1):56-65. https://doi.org/10.1177/0272989X07309643
• Tranmer JE, Guerriere DN, Ungar WJ, Coyte PC. Valuing patient and caregiver time: a review of the literature. PharmacoEconomics. 2005;23(5):449-459. https://doi.org/10.2165/00019053-200523050-00005
• Sanders GD, Neumann PJ, Basu A, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: Second Panel on Cost-Effectiveness in Health and Medicine. JAMA. 2016;316(10):1093-1103. https://doi.org/10.1001/jama.2016.12195
• Breslau RM, Cohen JT, Diaz J, Malcolm B, Neumann PJ. A review of HTA guidelines on societal and novel value elements. International Journal of Technology Assessment in Health Care. 2023;39(1):e31. https://doi.org/10.1017/S026646232300017X
• Kim DD, Silver MC, Kunst N, Cohen JT, Ollendorf DA, Neumann PJ. Perspective and costing in cost-effectiveness analysis, 1974-2018. PharmacoEconomics. 2020;38(10):1135-1145. https://doi.org/10.1007/s40273-020-00942-2
• National Institute for Health and Care Excellence. NICE technology appraisal and highly specialised technologies guidance: the manual (PMG36), sections 4.2 and 4.4. Published 31 January 2022; last updated 13 October 2026. https://www.nice.org.uk/process/pmg36
• Gupta A, O'Callaghan CJ, Zhu L, et al. Evaluating the time toxicity of cancer treatment in the CCTG CO.17 trial. JCO Oncology Practice. 2023;19(6):e859-e866. https://doi.org/10.1200/OP.22.00737