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Background With the movement towards bundled payments, stakeholders should know the true cost of the care they deliver. Time-driven activity-based costing (TDABC) can be used to estimate costs for each episode of care. In this analysis, TDABC is used to both estimate the costs of anesthesia care and identify the primary drivers of those costs of 11 common oncologic outpatient surgical procedures. Methods Personnel cost were calculated by determining the hourly cost of each provider and the associated process time of the 11 surgical procedures. Using the anesthesia record, drugs, supplies and equipment costs were identified and calculated. The current staffing model was used to determine baseline personnel costs for each procedure. Using the costs identified through TDABC analysis, the effect of different staffing ratios on anesthesia costs could be predicted. Results Costs for each of the procedures were determined. Process time and costs are linearly related. Personnel represented 79% of overall cost while drugs, supplies and equipment represented the remaining 21%. Changing staffing ratios shows potential savings between 13-28% across the 11 procedures. Conclusions TDABC can be used to estimate the costs of anesthesia care. This costing information is critical to assessing the anesthesiology component in a bundled payment. It can also be used to identify areas of cost savings and model costs of anesthesia care. CRNA to anesthesiologist staffing ratios profoundly influence the cost of care. This methodology could be applied to other medical specialties to help determine costs in the setting of bundled payments.

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137 Background: ERAS efforts across surgical specialties have been evolving since 2012. At MD Anderson Cancer Center (MDACC), surgical and anesthesia services have been participating in this movement. In 2017, anesthesia, surgical, internal medicine, physical medicine and rehabilitation (PM&R), and nutrition teams collaborated to pilot a prehabilitation clinical pathway. Our goal was to develop a preoperative pathway using validated screening tools to incorporate prehabilitation for patients preparing for cancer surgery. Methods: This pilot included patients with thoracic and gynecological cancers who were at least 3 weeks prior to surgery. They were screened using the validated FRAIL index (Morley) and the Centers for Disease Control and Prevention fall risk screening tool. (Questions below) All patients who scored > / = 2 were referred to the PM&R clinic. Each patient received an individualized prehabilitation program including exercise, nutrition, and underwent screening for mood impairments: Fatigue: Are you fatigued at rest or with activities of daily living?; Resistance: Do you have any difficulty walking up one flight of steps without stopping for rest?; Aerobic: Are you unable to walk at least one block at a brisk pace and without stopping for rest?; Illness: Do you have more than five illnesses?; Loss of weight: Have you had unintended weight loss of more than 5% of your weight in the past 6 months?; Have you fallen in the past year?; Do you feel unsteady when standing or walking?; Do you worry about falling? Results: 27 referrals were received. 21 patients seen by PM&R (six were not seen due to scheduling conflicts). Average age was 70 years, 38% male. Baseline functional status was below aged-related normal values. Mean values for functional tests include: 6 minute walk test distance was 301 meters, five-times sit-to-stand was 12.4 seconds, and dynamic gait index score was 20.1. Conclusions: Prehabilitation as part of the team-based approach in cancer care is becoming an important part of ERAS pathways. Screening surgical patients for functional issues and fall risk is vital as these patients require prehabilitation to optimize them prior to surgery.

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