The Costs of Breast Reconstruction and Implications for Episode-Based Bundled Payment Models.

BACKGROUND: Implementation of payment reform for breast reconstruction following mastectomy demands a comprehensive understanding of costs related to the complex process of reconstruction. Bundled payments for services to women with breast cancer may profoundly impact reimbursement and access to breast reconstruction. The authors' objectives were to determine the contribution of cancer therapies, comorbidities, revisions, and complications to costs following immediate reconstruction and the optimal duration of episodes to incentivize cost containment for bundled payment models. METHODS: The cohort was composed of women who underwent immediate breast reconstruction between 2009 and 2016 from the MarketScan Commercial Claims and Encounters database. Continuous enrollment for 3 months before and 24 months after reconstruction was required. Total costs were calculated within predefined episodes (30 days, 90 days, 1 year, and 2 years). Multivariable models assessed predictors of costs. RESULTS: Among 15,377 women in the analytic cohort, 11,592 (75 percent) underwent tissue expander, 1279 (8 percent) underwent direct-to-implant, and 2506 (16 percent) underwent autologous reconstruction. Adjuvant therapies increased costs at 1 year [tissue expander, $39,978 (p < 0.001); direct-to-implant, $34,365 (p < 0.001); and autologous, $29,226 (p < 0.001)]. At 1 year, most patients had undergone tissue expander exchange (76 percent) and revisions (81 percent), and a majority of complications had occurred (87 percent). Comorbidities, revisions, and complications increased costs for all episode scenarios. CONCLUSIONS: Episode-based bundling should consider separate bundles for medical and surgical care with adjustment for procedure type, cancer therapies, and comorbidities to limit the adverse impact on access to reconstruction. The authors' findings suggest that a 1-year time horizon may optimally capture reconstruction events and complications.

Trends in Physician Payments for Breast Reconstruction.

BACKGROUND: Prosthetic breast reconstruction rates have risen in the United States, whereas autologous techniques have stagnated. Meanwhile, single-institution data demonstrate that physician payments for prosthetic reconstruction are rising, while payments for autologous techniques are unchanged. This study aims to assess payment trends and variation for tissue expander and free flap breast reconstruction. METHODS: The Blue Health Intelligence database was queried from 2009 to 2013, identifying women with claims for breast reconstruction. Trends in the incidence of surgery and physician reimbursement were characterized by method and year using regression models. RESULTS: There were 21,259 episodes of breast reconstruction, with a significant rise in tissue expander cases (incidence rate ratio, 1.09; p < 0.001) and an unchanged incidence of free flap cases (incidence rate ratio, 1.02; p = 0.222). Bilateral tissue expander cases reimbursed 1.32 times more than unilateral tissue expanders, whereas bilateral free flaps reimbursed 1.61 times more than unilateral variants. The total growth in adjusted tissue expander mean payments was 6.5 percent (from $2232 to $2378) compared with -1.8 percent (from $3858 to $3788) for free flaps. Linear modeling showed significant increases for tissue expander reimbursements only. Surgeon payments varied more for free flaps (the 25th to 75th percentile interquartile range was $2243 for free flaps versus $987 for tissue expanders). CONCLUSIONS: The incidence of tissue expander cases and reimbursements rose over a period where the incidence of free flap cases and reimbursements plateaued. Reasons for stagnation in free flaps are unclear; however, the opportunity cost of performing this procedure may incentivize the alternative technique. Greater payment variation in autologous reconstruction suggests the opportunity for negotiation with payers.

Assessing value in breast reconstruction: A systematic review of cost-effectiveness studies.

INTRODUCTION: Breast reconstruction is one of the most common procedures performed by plastic surgeons and is achieved through various choices in both technology and method. Cost-effectiveness analyses are increasingly important in assessing differences in value between treatment options, which is relevant in a world of confined resources. A thorough evaluation of the cost-effectiveness literature can assist surgeons and health systems evaluate high-value care models. METHODS: A systematic review of PubMed, Web of Science, and the Cost-Effectiveness Analysis Registry was conducted. Two reviewers independently evaluated all publications up until August 17, 2017. RESULTS: After removal of duplicates, 1996 records were screened, from which 53 studies underwent full text review. All the 13 studies included for final analysis mention an incremental cost-effectiveness ratio. Five studies evaluated the cost-effectiveness of technologies including acellular dermal matrix (ADM) in staged prosthetic reconstruction, ADM in direct-to-implant (DTI) reconstruction, preoperative computed tomography angiography in autologous reconstruction, indocyanine green dye angiography in evaluating anastomotic patency, and abdominal mesh reinforcement in abdominal tissue transfer. The remaining eight studies evaluated the cost-effectiveness of different reconstruction methods. Cost-effective strategies included free vs. pedicled abdominal tissue transfer, DTI vs. staged prosthetic reconstruction, and fascia-sparing variants of free abdominal tissue transfer. CONCLUSIONS: Current evidence demonstrates multiple cost-effective technologies and methods in accomplishing successful breast reconstruction. Plastic surgeons should be well informed of such economic models when engaging payers and policymakers in discussions regarding high-value breast reconstruction.

Comparison of two cadaveric acellular dermal matrices for immediate breast reconstruction: A prospective randomized trial.

AlloDerm RTU® and AlloMaxTM are two acellular dermal matrices (ADMs) used in implant-based breast reconstruction. In this study, we examined whether different processing methods for the ADMs lead to a disparity in histologic, clinical, and financial outcomes after breast reconstruction. Thirty patients undergoing implant-based breast reconstruction were randomized into AlloMax or AlloDerm arms (n = 15, each). ADM was placed at the time of immediate reconstruction. Patients were evaluated for complications on postoperative days 7, 14, and 30. During implant exchange, ADM biopsies were taken and compared histologically for vascular and cellular infiltration. Patient satisfaction was evaluated using the BRECON-31 questionnaire 1 year after implant exchange. A cost analysis was performed comparing the two ADMs. Patient demographics and complication rates were similar between the two groups (p > 0.05). Histologically, vessel density and fibroblast/inflammatory cell infiltrate were greater on the dermal side than on the implant side (p < 0.01) in both ADMs, suggesting greater vascular and cellular in-growth from the dermal side. Vessel density in the middle portion of the Allomax biopsies was significantly higher than the same site in the Alloderm biopsies (p < 0.05). The extent of fibroblast/inflammatory cell infiltration was similar in both arms (p > 0.05). The BRECON-31 satisfaction questionnaire yielded similar responses across all metrics between the two study arms. The negotiated price was slightly different when comparing the two ADMs, with no significant difference in ADM reimbursement. In this study, AlloDerm RTU and AlloMax were successfully used for implant-based breast reconstruction with comparable outcomes.

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.

A Longitudinal Assessment of Outcomes and Healthcare Resource Utilization After Immediate Breast Reconstruction-Comparing Implant- and Autologous-based Breast Reconstruction.

OBJECTIVES: Immediate breast reconstruction (IBR) after mastectomy for cancer has increased in recent years, yet long-term, modality-specific comparative data are lacking. We performed this study to compare short- and long-term outcomes after expander, autologous (AT), and direct-to-implant (DI) breast reconstruction. METHODS: Using four state-level inpatient and ambulatory surgery databases, we conducted a retrospective cohort study of adult women who underwent mastectomy with immediate breast reconstruction from 2008 to 2009. Our primary outcomes were complications within 90 days of surgery, rate of secondary breast surgery within 3 years, and cumulative healthcare charges. RESULTS: The final cohort included 15,154 women who underwent mastectomy with tissue expander (TE: 70.5%), autologous (AT: 18.1%), or direct to implant (DI: 11.3%) reconstruction. Ninety-day complications were lowest after expander and highest after AT breast reconstruction (TE = 6.5% [reference] vs AT = 13.1% [2.09, 1.82-2.41] vs DI = 6.6% [1.03, 0.84-1.27], P < 0.001). However, adjusted rates of secondary breast procedures were most frequent after expander (2021/1000 discharges) and least frequent after AT (949.0/1000 discharges) reconstruction (P < 0.001). Specifically, unplanned revisions were highest among the tissue expander cohort (TE = 59.2% vs AT = 34.4% vs DI = 45.9%, P < 0.001). The cumulative, adjusted healthcare charges for secondary breast procedures differed slightly across groups (TE = $63,806 vs AT = $66,882 vs DI = $64,145, P < 0.001). CONCLUSIONS: Complications and secondary breast procedures, including unplanned revisions, after breast reconstruction are common and vary by reconstructive modality. The frequency of these secondary procedures adds substantial healthcare charges to the care of the breast reconstruction patient.

The cost of major complications associated with immediate two-stage expander/implant-based breast reconstruction.

Previous studies assessing the costs associated with two stage expander/implant (E/I) reconstruction rarely include the cost of complications. The purpose of this study is to analyze the complication costs associated with a single institution experience with immediate E/I reconstruction. All immediate two stage E/I reconstructions at a single institution between March 2005-April 2011 were reviewed. The reconstruction database was retrospectively queried for reconstructive details, complications, and cost. Statistical analyses were performed to determine which complications significantly increased reconstructive cost. 327 E/I reconstructions in 195 patients were analyzed. The major complications analyzed included haematoma requiring evacuation (1.2% of reconstructions), major infection (6.1% of reconstructions), E/I exposure (3.1% of reconstructions), and E/I rupture (2.4% of reconstructions); 2.1% of patients experienced reconstructive failure. The mean reconstructive cost was $22,323 ± 9,072. Costs were increased $12,554 by E/I infection (p < 0.001) and $17,153 by prosthetic exposure (p < 0.001). Pre- or postoperative radiation or chemotherapy did not significantly affect reconstructive costs. Unplanned readmissions or unplanned visits to the operative room significantly increased total reconstructive costs (p < 0.001 and p < 0.001, respectively). In conclusion, prosthetic infection and prosthetic exposure significantly increased costs associated with immediate two-stage E/I reconstruction, as did unplanned readmissions and unplanned visits to the operative room. In the current state of the US healthcare system, it is becoming more important for surgeons to be conscious of the economic burden associated with poor reconstructive outcomes.

Breast reconstruction modality outcome study: a comparison of expander/implants and free flaps in select patients.

BACKGROUND: Choosing a breast reconstructive modality after mastectomy is a critical step involving complex decisions. The authors provide outcomes data comparing two common reconstructive modalities to assist patients and surgeons in preoperative counseling and discussions. METHODS: A prospectively maintained database was queried identifying select patients undergoing expander/implant and abdominally based free flaps for breast reconstruction between 2005 and 2008. Variables evaluated included comorbidities, operations, time to reconstruction, complications, overall outcome, clinic visits, revisions, and costs. RESULTS: One hundred forty-two patients received free flaps and 60 received expander/implants. Expander/implant patients required more procedures (p < 0.001) but had shorter overall hospital lengths of stay (p < 0.001). The two cohorts experienced a similar rate of revision (p = 0.17). Free flap patients elected to undergo nipple-areola reconstruction more frequently (p = 0.01) and were able to sooner (p < 0.0001). Patients undergoing expander/implant reconstruction had a higher rate of failure (7.3 versus 1.3 percent, p = 0.008). Free flap patients achieved a stable reconstruction significantly faster (p = 0.0005), with fewer visits (p = 0.02). Cost analysis demonstrated total cost trended toward significantly lower in the free flap cohort (p = 0.15). Reconstructive modality was the only independent factor associated with time to stable reconstruction and reconstructive failure (p < 0.001 and p = 0.05, respectively). CONCLUSIONS: The authors' analysis revealed that free flap reconstructions required fewer procedures, had lower rates of complications and failures, had fewer clinic visits, and achieved a final, complete reconstruction faster than expander/implant reconstructions. Although autologous reconstruction is still not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, III.

440 Consecutive immediate, implant-based, single-surgeon breast reconstructions in 281 patients: a comparison of early outcomes and costs between SurgiMend fetal bovine and AlloDerm human cadaveric acellular dermal matrices.

BACKGROUND: A 2010 nationwide survey of plastic and reconstructive surgeons indicated that approximately 83 percent performed predominantly implant-based breast reconstruction, with acellular dermal matrix used by approximately half of those practitioners. Although the medical literature documents well over 2000 cases of breast reconstruction with matrices, relatively few cases using other than human cadaveric acellular dermal matrices have been reported. The author compared complications and costs using SurgiMend fetal bovine and AlloDerm human cadaveric acellular dermal matrices. METHODS: A retrospective review of a single surgeon's 5-year experience was performed for consecutive, nonrandomized immediate breast reconstructions with acellular dermal matrix from 2005 to 2010. RESULTS: Two hundred eighty-one patients had 440 implant-based reconstructions using SurgiMend [222 patients (79.0 percent)] or AlloDerm [59 patients (21.0 percent)]. No significant differences in complication rates were observed between SurgiMend and AlloDerm for hematoma, infection, major skin necrosis, or breast implant removal. Seroma was the most prevalent complication; the seroma rate for AlloDerm (15.7 percent) was significantly greater than that for SurgiMend (8.3 percent). Using recent product costs for equivalently sized AlloDerm and SurgiMend units, the cost of SurgiMend was $1024 less per breast than AlloDerm. CONCLUSIONS: SurgiMend fetal bovine and AlloDerm human cadaveric acellular dermal matrices demonstrate similar rates of major early complications in breast reconstruction in this study. This similarity in complication rates between SurgiMend and AlloDerm and the cost savings seen with the use of SurgiMend are factors for the surgeon to consider in choosing a matrix for breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, III.

Cost comparison of immediate one-stage and tissue-expander breast reconstructions after mastectomy in commercially insured patients.

OBJECTIVE: Growing acceptance of nipple-sparing mastectomy and rising rates of prophylactic mastectomy due to genetic findings make immediate one-stage implant breast reconstruction an attractive option for many American women facing post-mastectomy breast reconstruction. We compared medical services utilization and cost of immediate one-stage reconstruction with that of the more common tissue-expander (TE) breast reconstruction. DESIGN: Retrospective administrative claims database analysis. METHODS: We obtained commercial insurance claims on patients in the U.S. who had undergone one-stage or TE post-mastectomy implant breast reconstructions in 2008, and we compared 18-month results in terms of the frequency and cost of return visits for additional procedures and/or for the treatment of complications. Return visits were categorized as planned, planned with revision, or unplanned. RESULTS: Among 1,316 immediate implant breast reconstructions, 95 (7%) were one-stage procedures and 1,221 (93%) were TE reconstructions. The data showed a modest, nonsignificant trend toward fewer return visits after one-stage reconstruction versus TE reconstruction (191 vs. 242 visits per 100 patients, respectively; relative risk [RR]: 0.95). Patients with TE reconstructions returned more often for planned returns and planned returns with revisions. Patients with one-stage reconstructions returned more often for unplanned events. The total costs over 18 months were $34,839 and $39,062 for one-stage and TE reconstructions, respectively, for a difference of -$4,223 (P = 0.38). The initial reconstruction, including the mastectomy, accounted for 64% of the 18-month costs with one-stage reconstructions and for 54% of the 18-month costs for TE reconstructions. CONCLUSION: Costs and utilization trended lower over 18 months for one-stage versus TE reconstructions following post-mastectomy breast reconstructions but did not achieve statistical significance.

Cost-effectiveness of a topically applied pre-operative tissue expansion device for radial forearm free flaps: a cohort study.

OBJECTIVES: The objective of this study is to test the hypothesis that using a non-invasive and inexpensive pre-operative tissue expansion device (DynaClose) for radial forearm free-flap donor sites will result in a significant reduction in the cost of both in-hospital and out-of-hospital wound care compared with that of unexpanded radial forearm free-flap donor sites. DESIGN: A cohort study consisting of patients previously randomised in a randomised controlled trial. An intention to treat design was utilised. SETTING: A large tertiary care centre in eastern Ontario, Canada. PATIENTS: Thirty-four patients presenting to Otolaryngology Head and Neck clinic were enroled. Of these patients, 29 were previously enroled in a randomised controlled trial, while an additional five patients were enroled and randomised for the purpose of this study. INTERVENTIONS: Patients were randomised to either the treatment (pre-operative tissue expansion, DynaClose Expansion System) or control group. MAIN OUTCOME MEASURES: Wound care costs (in US dollars) were calculated for all patients for both in-hospital care and for patients requiring home care. Non-parametric data analysis was utilised for statistical assessment. RESULTS: There was a 93% reduction in the use of split-thickness skin grafts in the treatment group. There was a significant reduction in total wound care cost for patients in the treatment group versus the control group (P < 0.0001). Patients in the treatment group required a mean (SD) total of $36.00 (23.50) per patient, while the control group required $277.00 (325.00) of wound care. After excluding the cost of home care, the treatment group continued to have a significant reduction in total and in-hospital wound care costs compared with the control group (P < 0.001). CONCLUSIONS: Using a simple, inexpensive and non-invasive method of pre-operative tissue expansion results in a significant reduction in the costs of wound care for both in-hospital and out-of-hospital treatment. The DynaClose dynamic skin expansion system results in a cost-effective method to reduce the need of a split-thickness skin graft for coverage of a radial forearm free-flap donor site.