COMPARISON OF EXPECTED AND REAL-WORLD COSTS OF SUSPECTED ACUTE CORONARY SYNDROME MANAGEMENT USING A CLINICAL PATHWAY IN AN EMERGENCY DEPARTMENT

Abstract

As Malaysia transitions toward a case-mix system for Emergency Department (ED) reimbursement, establishing accurate cost-unit accounting is essential for economic survival and efficient resource allocation. This study focused on Acute Coronary Syndrome (ACS), a primary driver of hospital costs, which often exhibits wide variations in medical practice due to its clinical heterogeneity. The objective was to evaluate the expected costs derived from a standardized Clinical Pathway (CP) against actual real-world treatment costs incurred during ACS Clinical Pathway implementation. A cross-sectional study was conducted in which direct medical costs were estimated for 203 suspected ACS patients managed using established ACS CP between June and October 2023. Cost calculations utilised combined top-down and bottom-up activity-based costing (ABC), with overhead costs calculated using allocation method. Comparisons were made between theoretical "Expected Standard CP Costs" and "Real CP Costs". Theoretical expected treatment costs pervisit ranged from RM 380.85 (low-risk chest pain) to RM 1,458.42 (STEMI requiring thrombolysis). Actual treatment expenditures were consistently higher than theoretical estimates across all diagnostic categories. The most substantial variance occurred in Stable Angina cases (+RM 188.24 per visit), while non-thrombolysis STEMI cases showed the highest predictive accuracy (+RM 16.91). Standardising ACS management via CPs provides a replicable framework for hospital budgeting but reveals that theoretical models often fail to capture the exhaustive resources required for real-world clinical "rule-out" burdens and diagnostic uncertainty. Higher direct medical costs associated with standardised care represent a necessary strategic investment in quality to prevent expensive long-term complications.