The Transition From Pedicle Transverse Rectus Abdominis Myocutaneous to Perforator Flap: What Is the Cost of Opportunity?

Reimbursement for reconstruction by tissue transfer-a European comparison

Background

Case payment mechanisms have become the principal means of remunerating hospitals in most developed countries. Our purpose was to analyse the reimbursement for different types of tissue transfer in five European countries.

Methods

We looked at common surgical options for pedicled and free flaps. The recipient site of a flap and the principal diagnosis were systematically modified and processed with national grouper software in order to identify Diagnosis-Related Groups from which the proceeds were derived. The primary data originated from the database of the German Institute for the Hospital Remuneration System as aggregate information. We conducted eight specialist interviews to transfer the available data into clinical practice. Data of real patients were not available and we rather simulated standard patients to avoid dilution of results.

Results

Altogether, payment for pedicled flaps averaged 5933€ and was 8517€ for free flaps. The comparison of both flap types within a country revealed significant differences in Germany, Austria and Sweden only (p < 0.001). Italy has the highest mean proceeds for pedicled flaps, followed by Sweden, Germany, Austria and the UK. This relationship changes for free flaps with Sweden achieving the highest payments. Overall, reimbursement conformity is higher for free flaps.

Conclusions

Most countries have procedure-driven payment systems for flap surgery, which additionally can strongly depend on the diagnosis. Nevertheless the latter does not always justify existing price differences. For the first time, clinical cases in tissue transfer were compared internationally. In today`s dynamic world of health care, we should observe other countries` compensation systems to identify ways of improving our own.

The management of abdominal contour defects following TRAM flap breast reconstruction

BACKGROUND

Incisional hernia can develop following breast reconstruction with abdominal tissue regardless of technique, and the management is often challenging.

OBJECTIVES

The authors characterize hernias following transverse rectus abdominis musculocutaneous (TRAM) flap procedures and evaluate outcomes of different strategies for repair.

METHODS

All patients who underwent repair of a TRAM-related hernia or bulge between 2003 and 2011 at a single institution were retrospectively reviewed. A minimum of 2 years' follow-up was required for inclusion in this series. Outcomes of different techniques for repair were compared and risk factors for hernia recurrence identified.

RESULTS

Forty-three patients underwent repair of a TRAM-related hernia or bulge, most often with mesh (74.4%, n=32). At a mean overall follow-up of 5.2 years, 9 patients (20.9%) developed recurrent hernia or bulge. Compared to primary suture closure, the use of mesh was protective against recurrence (odds ratio, 0.05; 95% confidence interval, 0.00-0.65; P=.02), with the best results observed with fascial closure and underlay mesh reinforcement.

CONCLUSIONS

Incisional hernia following TRAM flap breast reconstruction can be a challenging problem. Attention to surgical technique and the use of mesh minimize the risk of recurrence.