A comparison of the superficial inferior epigastric artery flap and deep inferior epigastric perforator flap in postmastectomy reconstruction: A cost-effectiveness analysis

Cost analysis of pre-pectoral implant-based breast reconstruction

With improvement in mastectomy skin flap viability and increasing recognition of animation deformity following sub-pectoral implant placement, there has been a transition toward pre-pectoral breast reconstruction. While studies have explored the cost effectiveness of implant-based breast reconstruction, few investigations have evaluated cost with respect to pre-pectoral versus sub-pectoral breast reconstruction. A retrospective review of 548 patients who underwent mastectomy and implant-based breast reconstruction was performed from 2017 to 2020. The demographic and surgical characteristics of the pre-pectoral and sub-pectoral cohorts were well matched, except for reconstructive staging, as patients who underwent pre-pectoral reconstruction were more likely to undergo single-stage instead of two-stage reconstruction. Comparison of institutional cost ratios by reconstructive technique revealed that the sub-pectoral approach was more costly (1.70 ± 0.44 vs 1.58 ± 0.31, p < 0.01). However, further stratification by laterality and reconstructive staging failed to demonstrate difference in cost by reconstructive technique. These results were confirmed by multivariable linear regression, which did not reveal reconstructive technique to be an independent variable for cost. This study suggests that pre-pectoral breast reconstruction is a cost-effective alternative to sub-pectoral breast reconstruction and may confer cost benefit, as it is more strongly associated with direct-to-implant breast reconstruction.

Comparing the Clinical and Cost-Effectiveness of Abdominal-based Autogenous Tissue and Tissue-Expander Implant: A Feasibility Study

Background

To determine the superiority of autologous abdominal tissue (AAT) or tissue-expander implant (TE/I) reconstruction, a robust comparative cohort study is required. This study sought to determine the feasibility of a future large pragmatic cohort study comparing clinical and cost-effectiveness of AAT and TE/I at 12 months postoperative.

Methods

Potential participants were screened during consultation with their surgeon. Three health-related quality-of-life scales, the Health Utility Index Mark 3, the 12-Item Short Form Health Survey, and the BREAST-Q were used preoperatively, 1, 6, and 12 months postoperatively. Direct medical costs and postoperative patient/caregiver productivity loss were collected using patient diaries. Feasibility was assessed through patient recruitment rates and compliance of patients and study staff to complete required study documentation.

Results

Sixty-three patients consented to participate, 44 completed baseline questionnaires; the feasibility objective of recruiting 80% of eligible patients was not met. A 90% completion rate for patient questionnaires was seen at 1-month follow-up and decreased up to 12 months. Quality-adjusted life years were calculated at 0.77 and 0.89 for the AAT and TE/I group, respectively. Case report form completion by study staff and patient diary completion was moderate and low, respectively. Collaborating with hospital case-costing specialists to identify direct medical costs was reliable and efficient.

Conclusions

A future large-scale study is feasible. However, due to a diminishing rate of questionnaire completion, almost twice as many patients need to be recruited than expected to have adequate power. Cost data collection from hospital sources was reliable. Case report forms need to be tailored more toward a busy hospital setting.

Cost-effectiveness Analysis of Abdominal-based Autogenous Tissue and Tissue-expander Implant following Mastectomy

Patients who had undergone both autologous abdominal tissue (AAT) and tissue expander and implant (TE/I) breast reconstruction reported satisfaction with their reconstruction. While aesthetics and quality of life are important, the cost associated with these procedures must also be considered when choosing one method over the other. The objective of this study was to determine whether AAT-based breast reconstruction is cost-effective compared with 2-stage TE/I reconstruction at a 12-month follow-up.

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.

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.

Immediate versus delayed breast reconstruction in breast cancer patients in Colombia: A costutility analysis

Introduction. Breast reconstruction, either immediate or delayed, is part of the treatment of breast cancer. Each country and health system pays for and evaluates these procedures in different ways. Thus, it is important to determine which strategy is most cost-effective in Colombia. Objective: To evaluate the cost-utility of breast cancer treatment with immediate reconstruction compared with delayed reconstruction. Materials and methods: We used a decision tree model and a one-year time horizon from the perspective of the third-party payer; the cost data were taken from the Colombian Instituto de Seguros Sociales 2001 rate manual plus a 30% adjustment according to the methodology of the Instituto de Evaluación Tecnológica en Salud, IETS, and the billing model of the Centro Javeriano de Oncología at the Hospital Universitario San Ignacio. The transition probabilities and profits were obtained from medical specialists, patients, and the medical literature. We also conducted univariate and probabilistic sensitivity analyses. Results: The expected costs per capita were COP$ 26,710,605 (USD$ 11,165) for the immediate reconstruction and COP$ 26,459,557 (USD$ 11,060) for the deferred reconstruction. Immediate reconstruction generated an incremental cost of COP$ 251,049 (USD$ 105) and 0.75 quality-adjusted life years (QALY), while deferred reconstruction generated 0.63 QALYs, with an incremental cost-utility ratio of COP$ 2,154,675 per QALY (USD$ 901). Conclusions: The cost per QALY did not exceed the acceptability threshold of the Gross Domestic Product (GDP) per capita. The costs for the first year were similar. Both techniques are favorable for the Colombian health system, but the utility reported by patients and the literature is greater with the immediate reconstruction.

Cost analysis of postmastectomy reconstruction: A comparison of two staged implant reconstruction using tissue expander and acellular dermal matrix with abdominal-based perforator free flaps

BACKGROUND AND OBJECTIVES

Two staged tissue expander-implant with acellular dermal matrix (TE/I + ADM) and deep inferior epigastric perforator (DIEP) flap are the most common implant and autologous methods of reconstruction in the U.S. Implant-based techniques are disproportionally more popular, partially due to its presumed cost effectiveness. We performed a comprehensive cost analysis to compare TE/I + ADM and DIEP flap.

METHODS

A comparative cost analysis of TE/I + ADM and DIEP flap was performed. Medicare reimbursement costs for each procedure and their associated complications were calculated. Pooled probabilities of complications including cellulitis, seroma, skin necrosis, implant removal, flap loss, partial flap loss, and fat necrosis, were calculated using published studies from 2010 to 2016.

RESULTS

Average actual cost for successful TE/I + ADM and DIEP flap were $13 304.55 and $10 237.13, respectively. Incorporating pooled complication data from published literature resulted in an increase in cost to $13 963.46 for TE/I + ADM and $12 624.29 for DIEP flap. The expected costs for successful TE/I + ADM and DIEP flap were $9700.35 and $8644.23, which are lower than the actual costs.

CONCLUSIONS

DIEP flap breast reconstruction incurs lower costs compared to TE/I + ADM. These costs are lower at baseline and when additional costs from pooled complications are incorporated.

Abdominal perforator vs. muscle sparing flaps for breast reconstruction

Abdominally based free flaps have become the mainstay for women that desire to use their own tissue as a means of breast reconstruction after mastectomy. As the techniques have evolved, significant effort has been invested in finding the best means of minimizing morbidity to the abdominal donor site while ensuring a viable reconstructed breast that is aesthetically pleasing. This manuscript reviews and compares the muscle sparing free transverse rectus abdominis myocutaneous (MsfTRAM), the deep inferior epigastric artery perforator (DIEP), and the superficial inferior epigastric artery (SIEA) flaps, regarding flap success rate, operative times, abdominal donor site morbidity and residual functionality, hospital lengths of stay and associated costs, impact of co-morbid conditions, and resilience after adjuvant radiation treatment.

A methodological analysis of the plastic surgery cost-utility literature using established guidelines

BACKGROUND

Cost-utility studies, common in medicine, are rare within plastic surgery despite their capability of measuring the value of procedures by considering the societal costs of improving quality of life. The objectives of this study were to analyze the design quality of the plastic surgery cost-utility literature and to identify areas of needed improvement for future studies.

METHODS

A scoring tool was constructed based on the Recommendations of the Panel on Cost-Effectiveness in Health and Medicine. A PubMed search through October of 2012 was conducted for English-language plastic surgery utility studies. Articles were selected using two inclusion criteria and evaluated using the scoring tool.

RESULTS

A 9-point scoring tool was created, and 37 publications were selected. Their average score was 3 out of 9 points. Thirty studies (81 percent) used population preferences in utility measurements. Fifteen studies (41 percent) measured costs, but only four (11 percent) included indirect costs and only five (14 percent) applied discount rates to calculate the value of treatments over time. Three studies (8 percent) earned zero points. The highest scoring study earned 8 points.

CONCLUSIONS

The identified studies manifest the potential of cost-utility analyses in plastic surgery. Nonetheless, they are inconsistent in applying established cost-utility guidelines, especially in measuring costs and conducting recommended sensitivity analysis. Following this simple scoring tool can help future studies achieve some necessary improvements.