Autologous Breast Reconstruction Versus Implant-Based Reconstruction

How Do Long-Term Costs and Health Care Use Compare?

Valerie Lemaine, M.D., M.P.H.; Stephanie R. Schilz, B.A.; Holly K. Van Houten, B.A.; Lin Zhu, M.D.; Elizabeth B. Habermann, Ph.D.; Judy C. Boughey, M.D.

Disclosures

Plast Reconstr Surg. 2020;145(2):303-311. 

In This Article

Abstract and Introduction

Abstract

Background: The authors compared long-term health care use and cost in women undergoing immediate autologous breast reconstruction and implant-based breast reconstruction.

Methods: This study was conducted using the OptumLabs Data Warehouse, which contains deidentified retrospective administrative claims data, including medical claims and eligibility information from a large U.S. health insurance plan. Women who underwent autologous or implant-based breast reconstruction between January of 2004 and December of 2014 were included. The authors compared 2-year use rates and predicted costs of care. Comparisons were tested using the t test.

Results: Overall, 12,296 women with immediate breast reconstruction were identified; 4257 with autologous (35 percent) and 8039 with implant-based (65 percent) breast reconstruction. The proportion of autologous breast reconstruction decreased from 47.2 percent in 2004 to 32.7 percent in 2014. The mean predicted reconstruction cost of autologous reconstruction was higher than that of implant-based reconstruction in both unilateral and bilateral surgery. Similar results for mean predicted 2-year cost of care were seen in bilateral procedures. However, in unilateral procedures, the 2-year total costs were higher for implant-based than for autologous reconstruction. Two-year health care use rates were higher for implant-based reconstruction than for autologous reconstruction for both unilateral and bilateral procedures. Women undergoing unilateral implant-based reconstruction had higher rates of hospital admissions (30.3 versus 23.1 per 100; p < 0.01) and office visits (2445.1 versus 2283.6 per 100; p < 0.01) than those who underwent autologous reconstruction. Emergency room visit rates were similar between the two methods. Bilateral procedures yielded similar results.

Conclusion: Although implant-based breast reconstruction is a less expensive index operation than autologous breast reconstruction, it was associated with higher health care use, resulting in similar total cost of care over 2 years.

Introduction

In 2017, members of the American Society of Plastic Surgeons performed over 106,000 breast reconstruction procedures.[1] Under the Women's Health and Cancer Rights Act of 1998, group insurance plans that cover mastectomies must also cover breast reconstruction and necessary symmetry procedures.[2] Between 1998 and 2008, on average, immediate breast reconstruction has been increasing by 5 percent per year in the United States, based on data from the Nationwide Inpatient Sample database.[3]

In the current and future health care environment, health care redesign is widespread, as there is mounting pressure to improve value of health care with financially sustainable models while incentivizing quality improvement. As bundled care becomes more widespread, applying these concepts to breast reconstruction following mastectomy poses several challenges, as the process of care for breast reconstruction is composed of a variety of ever-evolving pathways influenced by innovations in surgical techniques and technologies.[4] Depending on the selected surgical approach for a given patient, breast reconstruction can involve a variable number of stages spanning over months or years, with variable numbers of physician visits and surgical procedures. At present, it is unknown whether and how bundled care might impact breast reconstruction. In this study, two of the most commonly performed immediate breast reconstruction procedures were compared through a longitudinal analysis of health care use and total costs over 2 years following mastectomy: implant-based breast reconstruction and autologous breast reconstruction. This study's purpose was to provide comparative long-term cost information that may help guide patients, physicians, and payers in the decision-making process of breast reconstruction in the current landscape where bundled care becomes more widely implemented.

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