Comparing five alternative methods of breast reconstruction surgery: a cost-effectiveness analysis

A Novel Fat-Augmented Omentum-Based Construct Is a Cost-Effective Alternative for Autologous Breast Reconstruction

Background/Objectives: The omental fat-augmented free flap (O-FAFF) is a novel technique for autologous breast reconstruction in patients who cannot use or who elect not to use more traditional donor sites. While the clinical outcomes of O-FAFF have been well studied, associated costs and resource utilization have not yet been investigated. The O-FAFF technique involves the use of an acellular dermal matrix and a two-team approach for laparoscopic harvest of the omentum, thereby increasing surgical and materials costs. This study compares the longitudinal cost-effectiveness study of O-FAFF breast reconstruction compared to reconstruction using implants or abdominal donor sites (deep inferior epigastric artery flap or transverse rectus abdominis myocutaneous flap). Methods: This cost-effectiveness analysis compared O-FAFF to abdominal free flap and implant-based reconstruction in adults. Markov cohort modeling was used to study cost-effectiveness from the payer perspective. Results: Compared to implant-based reconstruction, the incremental cost of O-FAFF reconstruction was USD 9227 and the incremental gain in breast quality-adjusted life-year (B-QALY) was 0.95, resulting in an incremental cost-effectiveness ratio of USD 9712.64/B-QALY gained, which is well under the acceptable cost-effectiveness threshold of USD 50,000 per B-QALY. Compared to abdominal flap reconstruction, O-FAFF reconstruction was associated with an incremental decrease in direct costs of USD 1410.10 and an incremental gain in B-QALYs of 0.36 and was thus the dominant strategy. Conclusions: The O-FAFF breast reconstruction technique is a cost-effective alternative to more traditional methods of breast reconstruction, including abdominal free flap techniques and implant-based reconstruction. As such, the O-FAFF technique represents an important novel modality for primary autologous reconstruction.

Systematic review of cost-effectiveness in breast reconstruction: deep inferior epigastric perforator flap vs. implant-based breast reconstruction

BACKGROUND

There are several techniques for reconstructing breasts after mastectomy, but little scientific evidence for which technique is superior. The aim of this systematic review was to compare the cost-effectiveness of implant-based and autologous reconstruction and to evaluate the overall certainty of evidence, as well as the quality of reporting of the included studies.

METHODS

Studies investigating the cost-effectiveness of breast reconstruction with a deep inferior epigastric perforator (DIEP) flap compared to implant-based reconstruction, meeting criteria defined in a PICO (population, intervention, comparison, and outcome), were included. Medline, PubMed, Embase, Cochrane library, CinahL, EconLit, and NHS EED databases were searched. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence, and the Consolidated Health Economic Evaluation Reporting Standard (CHEERS) 2022 was used to evaluate the quality of reporting.

RESULTS AND CONCLUSIONS

A total of 256 abstracts were retrieved from the search, and after scrutiny, seven studies were included. The findings of this present systematic review should be interpreted with caution as the overall certainty of evidence is low (GRADE ƟƟОО). The included studies suggest that DIEP-flaps are cost-effective compared with implant-based breast reconstruction when the applied cost-effectiveness thresholds of $50,000 to $100,000 per quality-adjusted life years are used. It is noteworthy that no high level evidence exists regarding cost-effeciency, to support recommendations and decision in breast reconstruction. Methodological issues that can be improved in future studies are presented.

Consecutive bilateral breast reconstruction using different autologous flaps: can symmetrical results still be achieved? A case report

We report a 60-year-old patient who underwent bilateral mastectomy at different times, followed by immediate autologous reconstruction with different flaps: deep-inferior epigastric-perforator flap on one breast, and fat-augmented latissimus dorsi on the contralateral side. At 20-month follow-up, good symmetry was recorded; patient-reported outcome measurements revealed high satisfaction scores.

A Prospective Cohort Study Re-examining Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction

BACKGROUND

The goal of inpatient monitoring after microsurgical breast reconstruction is to detect vascular compromise before flap loss. Near-infrared tissue oximetry (NITO) is commonly used for this purpose, but recent reports challenge its specificity and utility in current practice. Fifteen years after Keller published his initial study using this technology at our institution, we re-evaluate the role and limitations of this popular monitoring device.

METHODS

A 1-year prospective study was performed for patients undergoing microsurgical breast reconstruction and monitored postoperatively using NITO. Alerts were evaluated, and clinical endpoints relating to an unplanned return to the operating room or flap loss were recorded.

RESULTS

A total of 118 patients reconstructed with 225 flaps were included within the study. There were no cases of flap loss at the time of discharge. There were 71 alerts relating to a drop in oximetry saturation. Of these, 68 (95.8%) were deemed to be of no significance. In 3 cases (positive predictive value of 4.2%), the alert was significant, and there were concerning clinical signs apparent at that point. A sensor in an inframammary fold position was associated with nearly twice the average number of alerts as compared with areolar or periareolar positions ( P = 0.01). In 4 patients (3.4%), a breast hematoma required operative evacuation, and these cases were detected by nursing clinical examination.

CONCLUSIONS

The monitoring of free flaps after breast reconstruction through tissue oximetry shows a poor positive predictive value for flap compromise and requires clinical corroboration of alerts but missed no pedicle-related adverse events. With a high sensitivity for pedicle-related issues, NITO may be helpful postoperatively, but the exact timeframe for use must be weighed at the institutional level.

Comparison of nine methods of immediate breast reconstruction after resection of localized breast cancer: A cost-effectiveness Markov decision analysis of prospective studies

BACKGROUND

Women undergoing immediate breast reconstruction without radiation therapy have reconstruction methods available with uncertain long-term costs associated with complications requiring surgery and revisions. We evaluated cost-effectiveness of nine methods of immediate breast reconstruction for women with localized breast cancer.

METHODS

Markov modeling was performed over 10-years for unilateral/bilateral breast reconstructions from healthcare/societal perspectives. PubMed, Embase, Cochrane, Scopus, and CINAHL were searched to derive data from 13,744 patients in 79 prospective studies. Complications requiring surgery (mastectomy necrosis, total/partial flap necrosis, seroma, hematoma, infection, wound dehiscence, abdominal hernia, implant removal/explantation) and revisions (fat necrosis, capsular contracture, asymmetry, scars/redundant tissue, implant rupture/removal, fat grafting) were evaluated over yearly cycles. Reconstructions included: direct-to-implant (DTI), tissue expander-to-implant (TEI), latissimus dorsi flap-to-implant (LDI), latissimus dorsi (LD), pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator/superficial inferior epigastric artery (DIEP/SIEA), thigh-based, or gluteal based flaps. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50,000 and $100,000.

RESULTS

From a healthcare perspective for unilateral reconstruction, compared to LD, the ICER for DTI was -$42,109.35/quality-adjusted life-years (QALY), LDI was -$25,300.83/QALY, TEI was -$22,036.02/QALY, DIEP/SIEA was $8307.65/QALY, free TRAM was $8677.26/QALY, pedicled TRAM was $13,021.44/QALY, gluteal-based was $17,698.99/QALY, and thigh-based was $23,447.82/QALY. NMB of DIEP/SIEA was $404,523.47, free TRAM was $403,821.40, gluteal-based was $392,478.64, thigh-based was $387,691.70, pedicled TRAM was $376,901.83, LD was $370,646.93, DTI was $339,668.77, LDI was $334,350.30, and TEI was $329,265.84.

CONCLUSIONS

All nine methods of immediate breast reconstruction were considered cost-effective from healthcare/societal perspectives. LD provided the lowest costs, while DIEP/SIEA provided the greatest effectiveness and NMB.

A cost-effectiveness analysis of delayed breast reconstruction with pedicled flaps from the back

BACKGROUND

Variability in breast reconstruction methods provides an opportunity to investigate whether a method is superior to another with regard to cost, quality, or both. We performed a cost-effectiveness analysis (CEA) study based on tertiary endpoint data from a randomized clinical trial to compare the cost-effectiveness of delayed breast reconstruction by either a latissimus dorsi flap (LD) or a thoracodorsal artery perforator flap (TAP).

MATERIAL & METHODS

A total of 50 women were included for unilateral delayed breast reconstruction and were randomized to reconstruction by either the LD flap (n = 18) or the TAP flap (n = 22). The CEA was based on differences in shoulder function after the reconstruction. Direct and indirect costs relating to the two procedures were assessed by the Danish Diagnosis-Related Groups tariffs.

RESULTS

Our analysis showed a significant positive effect of introducing the TAP flap on the total shoulder score with an additional cost of $2779. The incremental cost-effectiveness ratio was $4481 and based on a willingness to pay (WTP) $500, we found an estimated net benefit of $519, which was statistically significant (p = 0.0375). The cost-effectiveness acceptability curve indicated that there is a 96.3% probability for the TAP flap being cost-effective to the LD flap at a WTP threshold of $500.

CONCLUSION

From a societal perspective, our cost-effective analysis demonstrated that the TAP flap is the more cost-effective method of breast reconstruction compared to the LD flap with respect to patient-reported shoulder-related disability.

A Systematic Review of Health State Utility Values in the Plastic Surgery Literature

Cost-utility analyses assess health gains acquired by interventions by incorporating weighted health state utility values (HSUVs). HSUVs are important in plastic and reconstructive surgery (PRS) because they include qualitative metrics when comparing operative techniques or interventions. We systematically reviewed the literature to identify the extent and quality of existing original utilities research within PRS.

Methods

A systematic review of articles with original PRS utility data was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis guidelines. Subspecialty, survey sample size, and respondent characteristics were extracted. For each HSUV, the utility measure [direct (standard gamble, time trade off, visual analog scale) and/or indirect], mean utility score, and measure of variance were recorded. Similar HSUVs were pooled into weighted averages based on sample size if they were derived from the same utility measure.

Results

In total, 348 HSUVs for 194 disease states were derived from 56 studies within seven PRS subspecialties. Utility studies were most common in breast (n = 17, 30.4%) and hand/upper extremity (n = 15, 26.8%), and direct measurements were most frequent [visual analog scale (55.4%), standard gamble (46.4%), time trade off (57.1%)]. Studies surveying the general public had more respondents (n = 165, IQR 103-299) than those that surveyed patients (n = 61, IQR 48-79) or healthcare professionals (n = 42, IQR 10-109). HSUVs for 18 health states were aggregated.

Conclusions

The HSUV literature within PRS is scant and heterogeneous. Researchers should become familiar with these outcomes, as integrating utility and cost data will help illustrate that the impact of certain interventions are cost-effective when we consider patient quality of life.

Protocol for a national cohort study to explore the long-term clinical and patient-reported outcomes and cost-effectiveness of implant-based and autologous breast reconstruction after mastectomy for breast cancer: the brighter study

INTRODUCTION

Breast reconstruction (BR) is offered to improve quality of life for women with breast cancer undergoing mastectomy. As most women will be long-term breast cancer survivors, high-quality information regarding the long-term outcomes of different BR procedures is essential to support informed decision-making. As different techniques vary considerably in cost, policymakers also require high-quality cost-effectiveness evidence to inform care. The Brighter study aims to explore the long-term clinical and patient-reported outcomes (PROs) of implant-based and autologous BR and use health economic modelling to compare the long-term cost-effectiveness of different reconstructive techniques.

METHODS AND ANALYSIS

Women undergoing mastectomy and/or BR following a diagnosis of breast cancer between 1 January 2008 and 31 March 2009 will be identified from hospital episode statistics (HES). Surviving women will be contacted and invited to complete validated PRO measures including the BREAST-Q, EQ-5D-5L and ICECAP-A, or opt out of having their data included in the HES analysis. Long-term clinical outcomes will be explored using HES data. The primary outcome will be rates of revisional surgery between implant-based and autologous procedures. Secondary outcomes will include rates of secondary reconstruction and reconstruction failure. The long-term PROs of implant-based and autologous reconstruction will be compared using BREAST-Q, EQ-5D-5L and ICECAP-A scores. Multivariable regression will be used to examine the relationship between long-term outcomes, patient comorbidities, sociodemographic and treatment factors. A Markov model will be developed using HES and PRO data and published literature to compare the relative long-term cost-effectiveness of implant-based and autologous BR.

ETHICS AND DISSEMINATION

The Brighter study has been approved by the South-West -Central Bristol Research Ethics Committee (20/SW/0020), and the Confidentiality Advisory Group (20/CAG/0021). Results will be published in peer-reviewed journals and presented at national meetings. We will work with the professional associations, charities and patient groups to disseminate the results.

Evaluating the Quality of Cost-Effectiveness Literature in Breast Surgery: What Do We Do Well and How Can We Do Better? A Systematic Review

BACKGROUND

Surgical options for breast cancer are numerous and span multiple surgical disciplines. Decision analyses aid surgeons in making the most cost-effective choice, thus reducing health care expenditure while maximizing patient outcome. In this study, we aimed to evaluate existing breast surgery cost-effectiveness literature against the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) validated scoring system.

METHODS

A PRISMA search was performed for cost-effectiveness within breast surgery. Articles were scored with CHEERS criteria on a 0-24 scale and qualitative data were collected. Subgroup analysis was performed comparing pre-CHEERS (published in 2013 or earlier) and post-CHEERS (published in 2014 or later) cohorts. Chi-squared analysis was performed to compare where studies lost points between cohorts.

RESULTS

Of 2279 articles screened, 46 articles were included. The average CHEERS score was 18.18. Points were most often lost for characterizing heterogeneity, followed by discount rate, incremental costs and outcomes, and abstract. Quality-adjusted life year was the most commonly used health outcome, with visual model or analog scales as the most commonly used measure of effectiveness obtained primarily from surgeons or physicians. Most articles characterized uncertainty by deterministic sensitivity analysis, followed by both deterministic and probabilistic, then probabilistic. Average CHEERS scores were similar between pre- and post-CHEERS cohorts (17.67 vs. 18.40, P > .05) There were several significant differences in where articles lost points between pre- and post-CHEERS cohorts.

DISCUSSION

In order to standardize the reporting of results, cost-effectiveness studies in breast surgery should adhere to the current CHEERS criteria and aim to better characterize heterogeneity in their analyses.

Cost-utility analysis of four common surgical treatment pathways for breast cancer

BACKGROUND

The aim was to evaluate the cost-utility of four common surgical treatment pathways for breast cancer: mastectomy, breast-conserving therapy (BCT), implant breast reconstruction (BR) and autologous-BR.

METHODS

Patient-level healthcare consumption data and results of a large quality of life (QoL) study from five Dutch hospitals were combined. The cost-effectiveness was assessed in terms of incremental costs and quality adjusted life years (QALYs) over a 10-year follow-up period. Costs were assessed from a healthcare provider perspective.

RESULTS

BCT resulted in comparable QoL with lower costs compared to implant-BR and autologous-BR and showed better QoL with higher costs than mastectomy (€17,246/QALY). QoL outcomes and costs of especially autologous-BR were affected by the relatively high occurrence of complications. If reconstruction following mastectomy was performed, implant-BR was more cost-effective than autologous-BR.

CONCLUSION

The occurrence of complications had a substantial effect on costs and QoL outcomes of different surgical pathways for breast cancer. When this was taken into account, BCT was most the cost-effective treatment. Even with higher costs and a higher risk of complications, implant-BR and autologous-BR remained cost-effective over mastectomy. This pleas for adapting surgical pathways to individual patient preferences in the trade-off between the risks of complications and expected outcomes.

A short-term comparison of expander prosthesis and DIEP flap in breast reconstructions: A prospective randomized study

BACKGROUND

There is yet no clear consensus on which method is preferable in secondary breast reconstructions, prosthesis, or autologous tissue.

METHODS

In this first prospective randomized study, 29 women underwent reconstruction with expander prosthesis (EP) and 44 with deep inferior epigastric perforator (DIEP) flap. Inclusion started in 2012 and ended in 2018. Demographic data, complications, surgery time, hospital days, and consulting visits were recorded. Patient satisfaction was evaluated pre- and postoperatively using the BREAST-Q questionnaire. Health care costs were calculated based on rates from the financial year 2018. Here, we report the results related to the surgery and the first 30 postoperative days.

RESULTS

The two groups were comparable regarding demographics and clinical characteristics. Satisfaction with breasts, measured with BREAST-Q, was significantly higher in patients who had undergone reconstruction with DIEP flap compared with EP. Within 30 days after breast reconstruction, significantly fewer women (n = 2) in the EP group suffered complications compared to the DIEP flap group (n = 16; p < 0.01). The health care cost was also significantly higher in the DIEP flap group relative to the EP group (p < 0.01).

DISCUSSION

This patient cohort will be studied systematically over time, and results concerning the need for complementary surgery, costs, esthetics, and the patient-reported outcome (PRO) will be reported in future work. In this short-term report, EP seems to be preferable in regard to cost and complications, and DIEP flap is to choose from the patient's perspective.

Autologous Breast Reconstruction in Low Body Mass Index Patients: Strategies for Maximizing Skin Envelope and Breast Volume

Pure autologous breast reconstruction in thin patients creates challenges. This review highlights techniques to optimize the scarce donor tissue available, approaches to reconstruction, and microsurgical techniques. A systematic approach to maximize breast volume and the skin envelope in patients who underwent pure autologous breast reconstruction by a single senior surgeon is presented with a clinical case series. Included in the study were 125 patients (217) with autologous breast reconstructions. Although DIEP flaps were the commonest flap used overall (79%), within in the low body mass index (<22) group, there was a greater use of Latissimus (32%), and thigh-based flaps (>50%).

Combining vascularized lymph node transfer with autologous breast reconstruction: A Surveillance, Epidemiology and End Results (SEER) Database cost-utility analysis

BACKGROUND

The cost effectiveness of combining vascularized lymph node transfer (VLNT) with autologous breast reconstruction has not been established. Herein we describe the use of Markov modeling to evaluate the cost utility of VLNT with delayed autologous breast reconstruction for patients with breast cancer related lymphedema (BCRL).

METHODS

We conducted a cost effectiveness analysis using a Markov model with microsimulation. The characteristics and associated life expectancy of the hypothetical patients were derived from the Surveillance, Epidemiology, and End Results database. Costs of were derived from the publicly available sources and health economics literature. The utilities were based on the best available literature. The relative effectiveness of VLNT was derived from a meta-analysis of the literature. A specific strategy is considered attractive if the estimate of incremental cost effectiveness ratio (ICER) is less than the amount decision makers are willing to pay for an additional quality-adjusted life-year (QALY) gain. A baseline willingness to pay of $50,000 USD per additional QALY was used for analysis.

RESULTS

The base case situation demonstrated an overall ICER of $13898.76/QALY for adding VLNT to delayed autologous abdominally based breast reconstruction in the situation where lymphedema is already present, which suggests it is cost-effective at the chosen willingness to pay.

DISCUSSION

This cost-utility simulation demonstrates that it is cost effective to combine delayed breast reconstruction with VLNT in patients with existing lymphedema. This could have implications for the application of the evolving technique of VLNT in the treatment of different subpopulations of breast cancer patients, and future clinical research.

Use of Decision Analysis and Economic Evaluation in Breast Reconstruction: A Systematic Review

Background:

Decision analysis allows clinicians to compare different strategies in the context of uncertainty, through explicit and quantitative measures such as quality of life outcomes and costing data. This is especially important in breast reconstruction, where multiple strategies can be offered to patients. This systematic review aims to appraise and review the different decision analytic models used in breast reconstruction.

Methods:

A search of English articles in PubMed, Ovid, and Embase databases was performed. All articles regardless of date of publishing were considered. Two reviewers independently assessed each article, based on strict inclusion criteria.

Results:

Out of 442 articles identified, 27 fit within the inclusion criteria. These were then grouped according to aspects of breast reconstruction, with implant-based reconstruction (n = 13) being the most commonly reported. Decision analysis (n = 19) and/or economic analyses (n = 27) were employed to discuss reconstructive options. The most common outcome was cost (n = 27). The decision analysis models compared and contrasted surgical strategies, management options, and novel adjuncts.

Conclusions:

Decision analysis in breast reconstruction is growing exponentially.The most common model used was a simple decision tree. Models published were of high quality but could be improved with a more in-depth sensitivity analysis. It is essential for surgeons to familiarize themselves with the concept of decision analysis to better tackle complicated decisions, due to its intrinsic advantage of being able to weigh risks and benefits of multiple strategies while using probabilistic models.

High-Risk Plastic Surgery: An Analysis of 108,303 Cases From the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)

BACKGROUND

There is a lack of large-scale data that examine complications in plastic surgery. A description of baseline rates and patient outcomes allows better understanding of ways to improve patient care and cost-savings for health systems. Herein, we determine the most frequent complications in plastic surgery, identify procedures with high complication rates, and examine predictive risk factors.

METHODS

A retrospective analysis of the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Program plastic surgery data set was conducted. Complication rates were calculated for the entire cohort and each procedure therein. Microsurgical procedures were analyzed as a subgroup, where multivariate logistic regression models determined the risk factors for surgical site infection (SSI) and related reoperation.

RESULTS

We identified 108 303 patients undergoing a plastic surgery procedure of which 6 264 (5.78%) experienced ≥1 complication. The outcome with the highest incidence was related reoperation (3.31%), followed by SSI (3.11%). Microsurgical cases comprised 6 148 (5.68%) of all cases, and 1211 (19.33%) experienced ≥1 complication. Similar to the entire cohort, the related reoperation (12.83%) and SSI (5.66%) were common complications. Increased operative time was a common independent risk factor predictive of a related reoperation or development of an SSI (P < 001). Of all microsurgeries, 23.3% had an operative time larger than 10 hours which lead to faster increase in reoperation likelihood.

CONCLUSIONS

The complication rate in plastic surgery remains relatively low but is significantly increased for microsurgery. Increased operative time is a common risk factor. Two-team approaches and staged operations could be explored, as a large portion of microsurgeries are vulnerable to increased complications.

Autologous versus implant-based breast reconstruction: A systematic review and meta-analysis of Breast-Q patient-reported outcomes

OBJECTIVE

Breast reconstruction following mastectomy can increase the quality of life of patients. Reconstruction methods can broadly be divided into implant-based and autologous tissue reconstruction. Patient-reported outcomes following breast reconstruction are one of the most important success parameters. In this systematic review and meta-analysis, we aimed to compare the two methods using the recognized Breast-Q questionnaire.

METHODS

We performed a systematic search in PubMed and EMBASE databases. Meta-analysis was performed on the five most commonly reported Breast-Q modules. RevMan 5.3 was used for statistical analysis. Methodological quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies.

RESULTS

The search strategy resulted in 219 studies of which nine studies were included in the analysis, yielding 2129 implant-based and 825 autologous breast reconstructions. Overall satisfaction with outcome as well as breast was significantly higher among patients with autologous breast reconstructions (mean Breast-Q difference between the two groups was 9.82 [3.09, 16.54], p = 0.004, and 10.33 [95% CI 5.93, 14.74], p<0.00001, respectively). Sexual and psychosocial well-being was higher among autologous breast reconstructions. There was no difference in the physical well-being.

CONCLUSION

This is the first systematic review and meta-analysis to compare patient-reported outcomes of implant-based and autologous breast reconstruction. We found that autologous reconstruction yields a higher satisfaction with overall outcome and breast. These findings can aid clinicians when discussing breast reconstruction options with patients.

A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay

BACKGROUND

The number of free flap take-backs and successful salvages following microsurgical breast reconstruction decreases as time from surgery increases. As a result, the cost of extended inpatient monitoring to achieve a successful flap salvage rises rapidly with each postoperative day. This study introduces a simplified cost-utility model of inpatient flap monitoring and identifies when cost-utility exceeds the thresholds established for other medical treatments.

METHODS

A retrospective review of a prospectively maintained database was performed of patients who underwent microsurgical breast reconstruction to identify flap take-back and salvage rates by postoperative day. The number of patients and flaps that needed to be kept on an inpatient basis each day for monitoring to salvage a single failing flap was determined. Quality-of-life measures and incremental cost-effectiveness ratios for inpatient flap monitoring following microsurgical breast reconstruction were calculated and plotted against a $100,000/quality-adjusted life-year threshold.

RESULTS

A total of 1813 patients (2847 flaps) were included. Overall flap take-back and salvage rates were 2.4 percent and 52.3 percent, respectively. Of the flaps taken back, the daily take-back and salvage rates were 56.8 and 60.0 percent (postoperative day 0 to 1), 13.6 and 83.3 percent (postoperative day 2), 11.4 and 40.0 percent (postoperative day 3), 9.1 and 25.0 percent (postoperative day 4), and 9.1 and 0.0 percent (>postoperative day 4), respectively. To salvage a single failing flap each day, the number of flaps that needed to be monitored were 121 (postoperative day 0 to 1), 363 (postoperative day 2), 907 (postoperative day 3), 1813 (postoperative day 4), and innumerable for days beyond postoperative day 4. The incremental cost-effectiveness ratio of inpatient flap monitoring begins to exceed a willingness-to-pay threshold of $100,000/quality-adjusted life-year by postoperative day 2.

CONCLUSION

The health care cost associated with inpatient flap monitoring following microsurgical breast reconstruction begins to rise rapidly after postoperative day 2.

Proximal Row Carpectomy versus Four-Corner Arthrodesis for the Treatment of Scapholunate Advanced Collapse/Scaphoid Nonunion Advanced Collapse Wrist: A Cost-Utility Analysis

BACKGROUND

Two mainstay surgical options for salvage in scapholunate advanced collapse and scaphoid nonunion advanced collapse are proximal row carpectomy and four-corner arthrodesis. This study evaluates the cost-utility of proximal row carpectomy versus three methods of four-corner arthrodesis for the treatment of scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist.

METHODS

A cost-utility analysis was performed in accordance with the Second Panel on Cost-Effectiveness in Health and Medicine. A comprehensive literature review was performed to obtain the probability of potential complications. Costs were derived using both societal and health care sector perspectives. A visual analogue scale survey of expert hand surgeons estimated utilities. Overall cost, probabilities, and quality-adjusted life-years were used to complete a decision tree analysis. Both deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Forty studies yielding 1730 scapholunate advanced collapse/scaphoid nonunion advanced collapse wrists were identified. Decision tree analysis determined that both four-corner arthrodesis with screw fixation and proximal row carpectomy were cost-effective options, but four-corner arthrodesis with screw was the optimal treatment strategy. Four-corner arthrodesis with Kirschner-wire fixation and four-corner arthrodesis with plate fixation were dominated (inferior) strategies and therefore not cost-effective. One-way sensitivity analysis demonstrated that when the quality-adjusted life-years for a successful four-corner arthrodesis with screw fixation are lower than 26.36, proximal row carpectomy becomes the optimal strategy. However, multivariate probabilistic sensitivity analysis confirmed the results of our model.

CONCLUSIONS

Four-corner arthrodesis with screw fixation and proximal row carpectomy are both cost-effective treatment options for scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist because of their lower complication profile and high efficacy, with four-corner arthrodesis with screw as the most cost-effective treatment. Four-corner arthrodesis with plate and Kirschner-wire fixation should be avoided from a cost-effectiveness standpoint.

Cost-Effectiveness Analysis of Silicone versus Saline Implant-Based Breast Reconstruction Using the BREAST-Q

BACKGROUND

The most common type of breast reconstruction is implant-based breast reconstruction. Implant-based reconstruction has been reported to impact quality-of-life outcomes. Therefore, the authors sought to evaluate the cost-effectiveness of saline versus silicone implants.

METHODS

The authors retrospectively reviewed data from patients who underwent breast reconstruction with saline or silicone implants at their institution. This included type of procedure, acellular dermal matrix use, complications, and number of revisions. Costs were estimated using the Centers for Medicare and Medicaid Services physician fee schedule and hospital costs. Effectiveness was measured using BREAST-Q-adjusted life-years, a measure of years of perfect breast health, based on BREAST-Q data collected before mastectomy and reconstruction and at 12 months after final reconstruction. The incremental cost-effectiveness ratio was obtained for silicone and saline reconstruction.

RESULTS

The authors identified 134 women, among which 77 (57 percent) underwent silicone and 57 (43 percent) underwent saline breast reconstruction. The cost of saline reconstruction was $1288.23 less compared with silicone. BREAST-Q-adjusted life-years were 28.11 for saline and 23.57 for silicone, demonstrating higher cost-effectiveness for saline. The incremental cost-effectiveness ratio for saline was -$283.48, or $283.48 less per year of perfect breast-related health postreconstruction than silicone.

CONCLUSIONS

The authors' results indicate that saline breast reconstruction may be more cost-effective compared with silicone at 12 months after final reconstruction. Silicone was both more expensive and less effective than saline. However, given the relatively small cost difference, surgeon and patient preference may be important in determining type of implant used.

Silicone Implant Coated with Tranilast-Loaded Polymer in a Pattern for Fibrosis Suppression

Pathologic fibrosis around silicone implants is problematic, and thus, these implants have been coated with a mixture of a biocompatible polymer and antifibrotic drug for sustained drug release to prevent fibrosis. However, a coating applied over an entire surface would be subject to mechanical instability as the implant would be severely crumpled for implant insertion. Therefore, in this work, we proposed localized, patterned coating dots, each composed of poly(lactic-co-glycolic acid) (PLGA) and tranilast, to be applied on the surface of silicone implants. The drug loaded in the pattern-coated implant herein was well retained after a cyclic tensile test. Due to the presence of PLGA in each coating dot, the tranilast could be released in a sustained manner for more than 14 days. When implanted in a subcutaneous pocket in living rats for 12 weeks, compared with the intact implant, the pattern-coated implant showed a decreased capsule thickness and collagen density, as well as less transforming growth factor-β (TGF-β) expression and fewer fibroblasts; importantly, these changes were similar between the surfaces with and without the coating dots. Therefore, we conclude that the pattern-coating strategy proposed in this study can still effectively prevent fibrosis by maintaining the physical stability of the coatings.

A Systematic Review of Utility Score Assessments in the Breast Surgery Cost-Analysis Literature

BACKGROUND

Surgery for breast cancer can have significant impact on patient quality-of-life. Cost-utility analysis provides a way to analyze the economic impact of a surgical procedure with the change in a patient's quality of life. Utility scores are used in these analyses to quantify the impact on quality of life. We undertook a systematic review of the literature on breast cancer surgical procedures to compile a repository of utility scores and to assess gaps in the current literature.

METHODS

Following PRISMA guidelines, a systematic review was performed for studies reporting utility scores for breast surgery and breast reconstruction. The health states and utility scores were extracted and grouped into seven procedural categories based on oncologic and reconstructive methods. Mean utility score and ranges were calculated and reported for each procedural category.

RESULTS

Nineteen articles met the inclusion criteria assessing 118 health states. Most utility scores were obtained from healthcare professionals. Breast-conserving therapy yielded the highest mean utility score at 0.79, whereas mastectomy yielded a mean utility score of 0.75. Among reconstruction health states, implant reconstruction had a lower score than autologous reconstruction (0.64 implant vs. latissimus dorsi 0.69 and TRAM/DIEP 0.71). No utility scores were found associated with oncoplasty or nipple-sparing mastectomy procedures.

CONCLUSIONS

A reliable body of utility scores is important in enabling future cost-utility and value-based analysis comparisons for breast surgical oncology. Additional work is needed to obtain health state assessments from the patient perspective, as well as assessment of more modern surgical and reconstructive approaches.

"The validity of the EQ-5D-5L in measuring quality of life benefits of breast reconstruction"

BACKGROUND

The EuroQol EQ-5D-5L instrument is the most widely used quality of life (QoL) measure in health economic evaluations. It is unclear whether such a generic instrument is valid enough to estimate the benefits of breast reconstruction (BR), given the specific changes observed in QoL after BR. Hence, we aimed to evaluate the validity of the EQ-5D-5L in patients who had undergone postmastectomy BR.

METHODS

In a 10-year cross-sectional cohort study, 463 mastectomy patients completed an online survey: 202 patients with autologous-BR (A-BR), 103 with implant-based-BR (I-BR), and 158 without BR (MAS). The results were used to evaluate the psychometric performance of the EQ-5D-5L with respect to the ceiling effect and to known-group, convergent, and discriminant validity, by comparing it with the Breast-Q, the cancer-specific (EORTC-QLQ-C30), and breast cancer-specific (EORTC-QLQ-BR23) questionnaires.

RESULTS

The EQ-5D-5L was able to discriminate between patients with and without complications, MAS with or without BR and MAS versus the general population. It was, however, not able to discriminate between A-BR vs. I-BR as well as BR vs. general population. It is not clear whether this was due to the insensitivity of the instrument, insufficient sample sizes, or because there were no actual differences in QoL between these groups. Good convergent and discriminant validity of both the EQ-5D-5L and its individual dimensions were demonstrated. Additional support for the instrument's validity was revealed by moderate correlations between the generic EQ-5D-5L and specific QoL aspects of BR such as sexuality and body image.

CONCLUSIONS

The results of this study support the validity of the EQ-5D-5L as an outcome measure in health economic evaluations of BR.

Single-Stage Breast Reconstruction Using an All-In-One Adjustable Expander/Implant

Background

When tissue expansion is necessary in breast reconstruction, a single-stage approach is possible using adjustable expander/implants, with or without the use of acellular dermal matrix. We aimed to present the senior author's single-stage experience over a period of 12 years using combined expander/implants in breast reconstruction.

Methods

This is a Single-institution, retrospective review of breast reconstruction with combined expander/implants from 2002 to 2014. Logistic regression was performed to evaluate the impact of multiple variables on long-term outcomes.

Results

A total of 162 implants in 105 patients were included in this study. Mean follow-up time was 81.7 months (SD, ± 39.2; range, 15-151). Complication rates were as follows: 0.62% extrusion, 1.2% mastectomy flap necrosis, 1.2% hematoma, 1.9% dehiscence, 2.5% seroma, 4.9% infection, and 15.4% deflation. The following associations were identified by logistic regression: adjuvant radiotherapy and capsular contracture (P = 0.034), tumor size and deflation (P = 0014), and smoking history and infection (P = 0.013).

Conclusions

Overall, 81% of breasts were successfully reconstructed in a single stage. Single-stage reconstruction using all-in-one expander/implants reduces costs by eliminating the need for a second procedure under general anesthesia and can achieve results comparable with other alloplastic reconstructions reported in the literature.

Protocol for a systematic review and meta-analysis on the clinical outcomes and cost of deep inferior epigastric perforator (DIEP) flap versus implants for breast reconstruction

BACKGROUND

Mastectomy in the context of breast malignancy can have a profoundly negative impact on a woman's self-image, impairing personal, sexual and social relationships. The deep inferior epigastric perforator (DIEP) flap and implants are the two commonest reconstructive modalities that can potentially overcome this psychological trauma. The comparative data on clinical outcomes and costs of the two modalities is limited. We aim to synthesise the current evidence on DIEP versus implants to establish which is the superior technique for breast reconstruction, in terms of clinical outcomes and cost-effectiveness.

METHODS

A comprehensive search will be undertaken of EMBASE, MEDLINE, Google Scholar, CENTRAL and Science citation index databases (1994 up to August 2017) to identify studies relevant for the review. Primary human studies evaluating clinical outcomes and cost of DIEP and implant-based reconstruction in context of breast malignancy will be included. Primary outcomes will be patient satisfaction and cosmetic outcome from patient-reported outcome measures (scores from validated tools, e.g. BREAST-Q tool), complications and cost-analysis. The secondary outcomes will be duration of surgery, number of surgical revisions, length of stay, availability of procedures and total number of clinic visits.

DISCUSSION

This will be the first systematic review and meta-analysis in available literature comparing the clinical outcomes and cost-effectiveness of DIEP and implants for breast reconstruction. This review is expected to guide worldwide clinical practice for breast reconstruction.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017072557 .

Radiation Therapy and Immediate Breast Reconstruction: Novel Approaches and Evidence Base for Radiation Effects on the Reconstructed Breast

Patients who undergo breast reconstruction experience higher complication rates if they have had a history of radiotherapy. However, implant-based reconstruction confers significantly higher complication and reconstruction failure rates compared with autologous reconstruction. This article analyses the factors that contribute to the complications of the different breast reconstruction modalities and the strategies described to mitigate these problems.

Prepectoral Implant-Based Breast Reconstruction

Background:

The development of acellular dermal matrices (ADMs) has facilitated single-stage implant breast reconstruction (IBR) following skin-sparing mastectomy. The conventional approach of postpectoral implant placement with lower pole ADM confers a good cosmetic result by improving lower pole projection and control, while minimizing issues of implant visibility, palpability, and rippling. This is balanced with potential disadvantages including pain, disruption of pectoral muscle function, and animation. We report the results of a prospective study of prepectoral IBR with total ADM coverage.

Methods:

Prepectoral IBR with total ADM coverage was performed in 106 patients (166 breasts) in our institution from 2013 to 2017. The cohort included patients undergoing immediate IBR (113 breasts) and revision of existing submuscular IBR (53 breasts). Patient demographics, surgical complications, and outcomes from a prospective database were analyzed.

Results:

At a mean follow-up of 485 days, patient satisfaction and cosmetic outcomes have been good, with no significant capsular contractures or animation deformity. Minor complications including delayed healing, red breast, or seroma occurred in 14 breasts (8.4%). Major complications including necrosis and implant loss occurred in 5 breasts (3 patients), with a total explantation rate of 3%. No patients required more than an overnight stay in hospital, and there were no delays to adjuvant treatment in therapeutic cases.

Conclusion:

Prepectoral implant placement with ADM cover is emerging as an alternative approach for IBR. This method facilitates breast reconstruction with a good cosmetic outcome for patients who want a quick recovery without potential compromise of pectoral muscle function and associated problems.

The financial impact and drivers of hospital charges in contralateral prophylactic mastectomy and reconstruction: a Nationwide Inpatient Sample hospital analysis

PURPOSE

Rates of contralateral prophylactic mastectomy (CPM) have increased over the last decade; it is important for surgeons and hospital systems to understand the economic drivers of increased costs in these patients. This study aims to identify factors affecting charges in those undergoing CPM and reconstruction.

METHODS

Analysis of the Healthcare Cost and Utilization Project National Inpatient Sample was undertaken (2009-2012), identifying women aged ≥18 with unilateral breast cancer undergoing unilateral mastectomy with CPM and immediate breast reconstruction (IBR) (CPM group), in addition to unilateral mastectomy and IBR alone (UM group). Generalized linear modeling with gamma regression and a log-link function provided mean marginal hospital charge (MMHC) estimates associated with the presence or absence of patient, hospital and operative characteristics, postoperative complications, and length of stay (LOS).

RESULTS

Overall, 70,695 women underwent mastectomy and reconstruction for unilateral breast cancer; 36,691 (51.9%) in the CPM group, incurring additional MMHCs of $20,775 compared to those in the UM group (p < 0.001). In the CPM group, MMHCs were reduced in those aged >60 years (p < 0.001), while African American or Hispanic origin increased MMHCs (p < 0.001). Diabetes, depression, and obesity increased MMHCs (p < 0.001). MMHCs increased with larger (p < 0.001) hospitals, Western location (p < 0.001), greater household income (p < 0.001), complications (p < 0.001), and increasing LOS (p < 0.001). MMHCs decreased in urban teaching hospitals and Midwest or Southern regions (p < 0.001).

CONCLUSION

There are many patient and hospital factors affecting charges; this study provides surgeons and hospital systems with transparent, quantitative charge data in patients undergoing contralateral prophylactic mastectomy and immediate breast reconstruction.

Free Versus Pedicled TRAM Flaps: Cost Utilization and Complications

INTRODUCTION

Conventionally, free transverse rectus abdominis myocutaneous (fTRAM) flap breast reconstruction has been associated with decreased donor site morbidity and improved flap inset. However, clinical success depends upon more sophisticated technical expertise and facilities. This study aims to characterize postoperative outcomes undergoing free versus pedicled TRAM (pTRAM) flap breast reconstruction.

METHODS

Nationwide inpatient sample database (2008-2011) was reviewed for cases of fTRAM (ICD-9-CM 85.73) and pTRAM (85.72) breast reconstruction. Inclusion criteria were females undergoing pTRAM or fTRAM breast reconstruction; males were excluded. We examined demographics, hospital setting, insurance information, patient income, and comorbidities. Clinical endpoints included postoperative complications, length-of-stay (LOS), and total charges (TC). Bivariate/multivariate analyses were performed to identify independent risk factors associated with increased complications and resource utilization.

RESULTS

Overall, 21,655 cases were captured. Seventy-percent were Caucasian, 95 % insured, and 72 % treated in an urban teaching hospital. There were 9 pTRAM and 6 fTRAM in-hospital mortalities. On bivariate analysis, the fTRAM cohort was more likely to be obese (OR 1.2), undergo revision (OR 5.9), require hemorrhage control (OR 5.7), suffer hematoma complications (OR 1.9), or wound infection (OR 1.8) (p < 0.003). The pTRAM cohort was more likely to suffer pneumonia (OR 1.6) and pulmonary embolism (OR 2.0) (p < 0.004). Reconstruction type did not affect risk of flap loss or seroma occurrence. TC were higher with fTRAM (p < 0.001). LOS was not affected by procedure type. On risk-adjusted multivariate analysis, fTRAM was an independent risk factor for increased LOS (OR 1.6), TC (OR 1.8), and postoperative complications (OR 1.3) (p < 0.001).

CONCLUSION

Free TRAM has an increased risk of postoperative complications and resource utilization versus pTRAM on the current largest risk-adjusted analysis. Further analyses are required to elucidate additional factors influencing outcomes following these procedures.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the A3 online Instructions to Authors. www.springer.com/00266 .

Cost-Effectiveness Analysis of Breast Reconstruction Options in the Setting of Postmastectomy Radiotherapy Using the BREAST-Q

BACKGROUND

A consensus is lacking on a uniform reconstructive algorithm for patients with locally advanced breast cancer who require postmastectomy radiotherapy. Both delayed autologous and immediate prosthetic techniques have inherent advantages and complications. The study hypothesis is that implants are more cost effective than autologous reconstruction in the setting of postmastectomy radiotherapy because of immediate restoration of the breast mound.

METHODS

A cost-effectiveness analysis model using the payer perspective was created comparing delayed autologous and immediate prosthetic techniques against the do-nothing option of mastectomy without reconstruction. Costs were obtained from the 2010 Nationwide Inpatient Sample database. Effectiveness was determined using the BREAST-Q patient-reported outcome measure. A breast quality-adjusted life-year value was considered 1 year of perfect breast health-related quality of life. The incremental cost-effectiveness ratio was calculated for both treatments compared with the do-nothing option.

RESULTS

BREAST-Q scores were obtained from patients who underwent immediate prosthetic reconstruction (n = 196), delayed autologous reconstruction (n = 76), and mastectomy alone (n = 71). The incremental cost-effectiveness ratios for immediate prosthetic and delayed autologous reconstruction compared with mastectomy alone were $57,906 and $102,509, respectively. Sensitivity analysis showed that the incremental cost-effectiveness ratio for both treatment options decreased with increasing life expectancy.

CONCLUSIONS

For patients with advanced breast cancer who require postmastectomy radiotherapy, immediate prosthetic-based breast reconstruction is a cost-effective approach. Despite high complication rates, implant use can be rationalized based on low cost and health-related quality-of-life benefit derived from early breast mound restoration. If greater life expectancy is anticipated, autologous transfer is cost effective as well and may be a superior option.

Benefits of two or more senior microsurgeons operating simultaneously in microsurgical breast reconstruction: Experience in a swedish medical center

BACKGROUND

The aim of this study is to evaluate how the number of senior microsurgeons, performing autologous microvascular breast reconstruction together, influences operating time and postoperative complications.

METHODS

A retrospective study was carried out in one hundred consecutive patients who underwent unilateral delayed deep inferior epigastric perforator flap reconstruction at a single institution. All patients followed our institution's surgical protocol and were divided into groups depending on the number of senior microsurgeons that simultaneously performed the procedure. Operating time and complications were compared between the groups.

RESULTS

Sixteen of the patients were operated by one single microsurgically trained specialist, 64 by two and 20 by three specialists. The mean operating time for the one microsurgeon's group was 286 ± 84 min, for the two-microsurgeons' group 265 ± 57 min and for the three-microsurgeons' group 251 ± 59 min. There was a trend of decreasing operating times when more microsurgeons performed surgery together, however the difference between groups was not statistically significant (P = 0.251). Total flap failure rate was 2% (2/100). Both cases occurred in the group operated by one single microsurgeon (2/16) compared with two microsurgeon's group (0/64) and three microsurgeon's group (0/20; P < 0.005).

CONCLUSIONS

By optimising the surgical experience available during microvascular breast reconstruction, operating time can be reduced and efficiency improved. In the current setting, two microsurgically trained surgeons achieved optimal operation flow with the lowest complication rate. © 2016 Wiley Periodicals, Inc. Microsurgery 37:416-420, 2017.

A comparison of long-term cost and clinical outcomes between the two-stage sequence expander/prosthesis and autologous deep inferior epigastric flap methods for breast reconstruction in a public hospital

BACKGROUND

Postmastectomy breast reconstruction involves the use of large amounts of hospital resources. This study provides comparative data on the clinical results and long-term economic costs of two methods of breast reconstruction in a public hospital.

METHODS

A prospective cohort study was performed to evaluate the costs incurred by delayed unilateral breast reconstruction performed using either the two-stage sequence expander/prosthesis (E-P) or autologous deep inferior epigastric flap (DIEP) method during 2005-2013 in 134 patients. The major evaluated variables included previous clinical records, history of radiotherapy, and number of surgical procedures. Total costs accounted for both direct intra- and extra-hospital costs derived from the initial reconstruction and those resulting from associated reoperations due to aesthetic retouches and/or complications.

RESULTS

Patients undergoing E-P reconstruction required a higher number of surgery sessions to complete the reconstruction (3.07 vs. 2.32, p < 0.001) and showed higher rates of surgery-related complications (40.29% vs. 32.82%). No statistically significant differences were found between the two surgical methods in terms of total costs (€18857.77 DIEP vs. €20502.08 E-P; p = 0.89). In the E-P cohort, active smoking and history of radiotherapy were statistically significant risk factors of complications. In the DIEP group, only active smoking was significantly associated with complications.

CONCLUSIONS

Compared to the E-P method, breast reconstruction using the DIEP method is more cost-effective and involves fewer serious complications that result in reconstruction failure or undesirable aesthetic results. E-P reconstruction presents a higher number of complications that may cause surgical failure or poor outcomes.

Cost-effectiveness analysis of implants versus autologous perforator flaps using the BREAST-Q

BACKGROUND

Reimbursement has been recognized as a physician barrier to autologous reconstruction. Autologous reconstructions are more expensive than prosthetic reconstructions, but provide greater health-related quality of life. The authors' hypothesis is that autologous tissue reconstructions are cost-effective compared with prosthetic techniques when considering health-related quality of life and patient satisfaction.

METHODS

A cost-effectiveness analysis from the payer perspective, including patient input, was performed for unilateral and bilateral reconstructions with deep inferior epigastric perforator (DIEP) flaps and implants. The effectiveness measure was derived using the BREAST-Q and interpreted as the cost for obtaining 1 year of perfect breast health-related quality-adjusted life-year. Costs were obtained from the 2010 Nationwide Inpatient Sample. The incremental cost-effectiveness ratio was generated. A sensitivity analysis for age and stage at diagnosis was performed.

RESULTS

BREAST-Q scores from 309 patients with implants and 217 DIEP flap reconstructions were included. The additional cost for obtaining 1 year of perfect breast-related health for a unilateral DIEP flap compared with implant reconstruction was $11,941. For bilateral DIEP flaps compared with implant reconstructions, the cost for an additional breast health-related quality-adjusted life-year was $28,017. The sensitivity analysis demonstrated that the cost for an additional breast health-related quality-adjusted life-year for DIEP flaps compared with implants was less for younger patients and earlier stage breast cancer.

CONCLUSIONS

DIEP flaps are cost-effective compared with implants, especially for unilateral reconstructions. Cost-effectiveness of autologous techniques is maximized in women with longer life expectancy. Patient-reported outcomes findings can be incorporated into cost-effectiveness analyses to demonstrate the relative value of reconstructive procedures.

Changes in use of autologous and prosthetic postmastectomy reconstruction after medicaid expansion in New York state

BACKGROUND

With Medicaid expansion beginning in 2014, it is important to understand the effects of access to reconstructive services for new beneficiaries. The authors assessed changes in use of breast cancer reconstruction for Medicaid beneficiaries after expansion in New York State in 2001.

METHODS

The authors used the State Inpatient Database for New York (1998 to 2006) for all patients aged 19 to 64 years who underwent breast reconstruction. An interrupted time series design with linear regression modeling evaluated the effect of Medicaid expansion on the proportion of breast reconstruction patients that were Medicaid beneficiaries.

RESULTS

The proportion of breast reconstructions provided to Medicaid beneficiaries increased by 0.28 percent per quarter after expansion (p < 0.001), resulting in a 5.5 percent increase above predicted trajectory without expansion. This corresponds to a population-adjusted increase of 1.8 Medicaid cases per 1 million population per quarter. On subgroup analysis, there was no significant increase in the proportion of autologous reconstructions (p = 0.4); however, the proportion of prosthetic reconstructions for Medicaid beneficiaries had a significant increase of 0.41 percent per quarter (p < 0.001), resulting in a 7.5 percent cumulative increase. This indicates that 135 additional prosthetic reconstruction operations were provided to Medicaid beneficiaries within 5 years of expansion.

CONCLUSIONS

Surgeons increased the volume of breast reconstructions provided to Medicaid beneficiaries after expansion. However, there are disparities between autologous and prosthetic reconstruction. If Medicaid expansion is to provide comprehensive care, with adequate access to all reconstructive options, these disparities must be addressed.

Comprehensive breast reconstruction in an academic surgical practice: an evaluation of the financial impact

BACKGROUND

This study assessed the financial implications of providing all forms of breast reconstruction at a single academic institution with insurance as the primary mode of reimbursement.

METHODS

Billing records of 152 patients who underwent postmastectomy breast reconstruction offered at the University of Michigan for the 2012 fiscal year were reviewed. Professional and facility revenue, cost, and earnings for the first stage of reconstruction were calculated by applying actual collections and charges. Similar financial data were compiled for a subset of 49 patients who went on to complete reconstruction.

RESULTS

The professional revenue and expenses allocated to breast reconstruction were $647,437 and $591,184, respectively (8.7 percent margin). Health care system facility revenue and costs were $2,762,797 and $2,773,131, respectively (-0.4 percent margin). Physician reimbursement by surgical time was highest for delayed tissue expander placement ($3505 per operating room hour). Abdominal free flap reconstructions resulted in greater professional revenue for the first stage of reconstruction ($7801 versus $2961) and for completed reconstructions ($14,943 versus $7703) relative to implant reconstructions. The facility also did better fiscally after the first stage of abdominally based reconstruction compared with implant reconstructions (10 percent versus -10.4 percent margin).

CONCLUSIONS

Postmastectomy breast reconstruction for this academic surgical practice remains fiscally profitable. Implant-based reconstruction compared with abdominal flap reconstruction produces greater revenue per operative hour but ultimately generates less total revenue and results in financial losses for the facility. Abdominally based perforator flap reconstruction reimbursed through standard insurance plans can be financially advantageous for the academic surgical practice and health care system.

Replacing ambulatory surgical follow-up visits with mobile app home monitoring: modeling cost-effective scenarios

Background

Women’s College Hospital (WCH) offers specialized surgical procedures, including ambulatory breast reconstruction in post-mastectomy breast cancer patients. Most patients receiving ambulatory surgery have low rates of postoperative events necessitating clinic visits. Increasingly, mobile monitoring and follow-up care is used to overcome the distance patients must travel to receive specialized care at a reduced cost to society. WCH has completed a feasibility study using a mobile app (QoC Health Inc, Toronto) that suggests high patient satisfaction and adequate detection of postoperative complications.

Objective

The proposed cost-effectiveness study models the replacement of conventional, in-person postoperative follow-up care with mobile app follow-up care following ambulatory breast reconstruction in post-mastectomy breast cancer patients.

Methods

This is a societal perspective cost-effectiveness analysis, wherein all costs are assessed irrespective of the payer. The patient/caregiver, health care system, and externally borne costs are calculated within the first postoperative month based on cost information provided by WCH and QoC Health Inc. The effectiveness of telemedicine and conventional follow-up care is measured as successful surgical outcomes at 30-days postoperative, and is modeled based on previous clinical trials containing similar patient populations and surgical risks.

Results

This costing assumes that 1000 patients are enrolled in bring-your-own-device (BYOD) mobile app follow-up per year and that 1.64 in-person follow-ups are attended in the conventional arm within the first month postoperatively. The total cost difference between mobile app and in-person follow-up care is $245 CAD ($223 USD based on the current exchange rate), with in-person follow-up being more expensive ($381 CAD) than mobile app follow-up care ($136 CAD). This takes into account the total of health care system, patient, and external borne costs. If we examine health care system costs alone, in-person follow-up is $38 CAD ($35 USD) more expensive than mobile app follow-up care over the first postoperative month. The baseline difference in effect is modeled to be zero based on clinical trials examining the effectiveness of telephone follow-up care in similar patient populations. An incremental cost-effectiveness ratio (ICER) is not reportable in this scenario. An incremental net benefit (INB) is reportable, and reflects merely the cost difference between the two interventions for any willingness-to-pay value (INB=$245 CAD). The cost-effectiveness of mobile app follow-up even holds in scenarios where all mobile patients attend one in-person follow-up.

Conclusions

Mobile app follow-up care is suitably targeted to low-risk postoperative ambulatory patients. It can be cost-effective from a societal and health care system perspective.