Is Direct-to-Implant Breast Reconstruction Cost Effective? A Cost Utility Analysis of Prosthetic Breast Reconstruction

PURPOSE:

Expander-implant breast reconstruction is the gold standard for prosthetic reconstruction today. The advent of skin-sparing mastectomy and the use of acellular dermal matrix have paved the way for safe single-stage prosthetic reconstruction. Prior studies have suggested that single-stage breast reconstruction is cheaper than expander-implant breast reconstruction although linked to more revisions^1-2. This is the first formal cost utility analysis to compare the cost and quality of life of both procedures in order to guide clinically efficacious treatment.

METHODS:

A comprehensive literature review was conducted using the MEDLINE, EMBASE, and COCHRANE databases to include studies directly comparing matched patient cohorts undergoing single-stage or staged prosthetic reconstruction. Six studies were selected examining 791 direct-to-implant reconstructions and 1142 expander-implant reconstructions with follow-up spanning 31.25 months and 37.6 months, respectively. Costs were derived adopting both societal and third-party payer perspectives. Utilities were derived from surveying an expert panel. Probabilities of clinically relevant complications were combined with cost and utility estimates to fit into a decision tree analysis (Figure 1).

RESULTS:

The overall complication rate was 35% for single-stage reconstruction and 34% for expander-implant reconstruction (Figure 2). Our baseline analysis using Medicare reimbursement revealed a cost decrease of $638.76 and a clinical benefit of 0.90 quality-adjusted life years when performing single-stage reconstructions yielding an incremental cost-utility ratio of -$712.9. When using societal costs, the incremental cost-utility ratio decreased to -$5395.94. Multivariate sensitivity analysis further reaffirmed the cost effectiveness of single-stage reconstruction.

CONCLUSIONS:

Direct-to-implant reconstructions are cost effective and should always be considered in non-obese, non-smoking patients with healthy mastectomy flaps who do not desire larger breasts following reconstruction.

Figure 1. Decision Tree Analysis comparing Single-stage reconstruction to Expander-implant reconstruction.

Figure 2. Complication Rates for Health States for Direct-to-implant (DTI) reconstructions and Expander-implant (EI) reconstructions. The overall complication rate is similar, mastectomy skin necrosis and capsular contracture are slightly higher for DTI reconstructions while seroma and hematoma are slightly higher for EI reconstructions, infection rates are the same.

Figure 1

Figure 2