#PRSJournalClub Wrap-Up: Is Single-Stage Prosthetic Reconstruction Cost Effective? A Cost-Utility Analysis for the Use of Direct-to-Implant Breast Reconstruction Relative to Expander-Implant Reconstruction in Postmastectomy Patients

A #PRSJournalClub Wrap-Up blog of the September 2016 Journal Club Live Twitter Discussion selection:
Is Single-Stage Prosthetic Reconstruction Cost Effective? A Cost-Utility Analysis for the Use of Direct-to-Implant Breast Reconstruction Relative to Expander-Implant Reconstruction in Postmastectomy Patients.
Plastic & Reconstructive Surgery: September 2016 – Volume 138 – Issue 3 – p 537–547 doi: 10.1097/PRS.0000000000002428

by Raja Mohan, MD (@RajaMohanMD)

September brought us another riveting #PRSJournalClub featuring an article that assesses the cost-utility analysis of direct to implant breast reconstruction compared to two-stage expander-implant based breast reconstruction. The discussion featured responses from Dr. Mo Nahabedian (@DrMoSLS) and Dr. Naveen Krishnan (@prince_naveenk) who have both co-authored a number of cost-utility analysis studies.

Two-stage expander-implant based breast reconstruction is the most common form of reconstruction in the United States. In comparison, direct-to-implant breast reconstruction would obviate the need for a second surgery and potentially save costs but in the literature, it has shown to be associated with a higher incidence of re-operations secondary to skin flap necrosis and device failure. Whether or not this modality is cost-effective has not been proven and this study’s aim was to analyze the cost and quality of life in patients undergoing single-stage or expander-implant based breast reconstruction.

A cost-utility analysis was conducted to compare both forms of breast reconstruction by employing advanced statistical methods. Based on the results of this analysis, direct-to-implant reconstruction resulted in a similar rate of complications relative to expander-implant reconstruction. Single stage reconstruction with direct-to-implant was associated with higher rates of skin flap necrosis and capsular contracture whereas expander-implant based reconstruction was associated with more hematomas and seromas. The sophisticated analysis showed that there was a cost decrease of $525.25 for direct-to-implant based reconstruction when using medicare reimbursement rates.
The authors even showed that direct-to-implant breast reconstruction using acellular dermal matrix was more cost effective than expander-implant breast reconstruction without acellular dermal matrix. Therefore, the authors argue that single stage reconstruction is more cost-effective but should only be employed in patients who are appropriate candidates for this procedure. Some limitations of this study include the fact that it is retrospective in nature and the patient cohorts undergoing single-stage and expander-implant based reconstruction are different. In addition, many assumptions were made in the model to perform the cost-utility analysis which may not be completely representive of all cases.

The article was also supplemented by a PRS Journal Club podcast featuring Drs. Liza Wu, Sammy Sinno (@sammysinnoMD), Raj Sawh-Martinez (@docrfsm), and Amanda Silva (@AmandaKSilvaMD), which helped to launch the discussion on Twitter.

Some Outstanding Tweets and Q&A:

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