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

Results

During the study period, 12,296 women undergoing mastectomy and immediate breast reconstruction were identified: 8039 women (65.4 percent) underwent implant-based breast reconstruction and 4257 (34.6 percent) underwent autologous breast reconstruction. Table 1 shows the patient characteristics of the cohort. Women undergoing implant-based breast reconstruction were younger than those undergoing autologous reconstruction (average age, 48.6 years versus 49.6 years; p < 0.0001). Comorbidity burden, measured using the modified Charlson-Deyo method, was no different between women undergoing implant-based and autologous breast reconstruction, at a mean of 0.4 in both groups (p = 0.08).

Over the 11 years of the study period, there was a gradual increase in the proportion of reconstructions performed as implant-based breast reconstructions, whereas autologous breast reconstructions were more frequently used in the earlier years. In 2004, 52.8 percent of the breast reconstructions were implant-based and 47.2 percent were autologous; however, in the more recent years, 67.3 percent of the breast reconstructions were implant-based compared with 32.7 percent autologous (Figure 1).

Figure 1.

Immediate breast reconstruction (IBBR) trends and reconstructive method in the United States among privately insured women from 2004 to 2014.

At the initial surgery, the mean length of hospital stay was 3.6 days for women undergoing autologous reconstruction compared with 1.9 days for those undergoing implant-based reconstruction (p < 0.0001). After the index surgery, the rate of subsequent inpatient hospital admissions over the following 2 years was significantly higher for women undergoing implant-based reconstruction, at 29.3 admissions per 100 women, compared with autologous reconstruction, at 25.3 admissions per 100 women (p < 0.0001). The most common indication for hospital admissions for implant-based reconstruction was coded as device complication (15.3 percent), whereas for autologous reconstruction, it was a procedure complication (16.9 percent). Within 2 years of the initial operation, the rate of conversion from implant-based to autologous breast reconstruction after implant failure, or as a planned second stage, was 11 percent.

Health care use data are shown in Table 2, stratified by procedure. The rates of office visits were significantly higher for implant-based compared with autologous breast reconstruction in the 2-year period following the index surgery [unilateral, 2445.1 versus 2283.6 per 100 women (p = 0.0002); bilateral, 2395.1 versus 2296.7 per 100 women (p = 0.0001)]. Likewise, those undergoing implant-based reconstruction had higher rates of hospitalization than those undergoing autologous reconstruction [unilateral, 30.3 versus 23.1 per 100 women (p < 0.0001); bilateral, 29.0 versus 26.8 per 100 women (p = 0.04)]. The rate of emergency room visits did not differ between both methods, at 30 per 100 women for unilateral implant-based breast reconstruction compared with 31 per 100 women for autologous breast reconstruction (p = 0.44). The most common reason for emergency room visit was abdominal pain (6.2 percent), followed by chest pain (6.0 percent), procedure complication (5.1 percent), fever of unknown origin (4.2 percent), headache/migraine (3.8 percent), and skin infection (3.7 percent).

Nearly 75 percent of implant-based breast reconstructions and 59 percent of autologous breast reconstructions were bilateral procedures over the study period. When resource use was broken down by laterality (Table 3), the rate of office visits did not differ significantly between unilateral and bilateral procedures, irrespective of the method of reconstruction. However, the rate of emergency room visits was significantly higher for women undergoing bilateral procedures, both for implant-based and for autologous breast reconstruction. Furthermore, subsequent in-patient admissions were significantly more common in women undergoing bilateral autologous reconstruction when compared to unilateral autologous reconstruction but did not differ among women undergoing unilateral or bilateral implant-based reconstruction.

Mean predicted costs and associated 95 percent confidence intervals comparing autologous and implant-based breast reconstruction stratified by laterality are presented in Table 4 (unilateral and bilateral). For unilateral reconstructions, when the total cost of care was broken down into reconstruction costs and 2-year postreconstruction costs, significant differences were noted. The mean predicted reconstruction cost of autologous reconstruction was higher than that of implant-based reconstruction, with an autologous reconstruction cost of $27,886 compared with an implant-based reconstruction cost of $19,478 (p < 0.0001). However, the aftercare surgical mean predicted cost was significantly higher for implant-based reconstruction at $79,447 compared with autologous reconstruction at $62,176 (p < 0.0001). When focusing on bilateral reconstructions, the mean predicted reconstruction cost of autologous reconstruction was nearly double that of implant-based reconstruction ($45,063 versus $23,399; p < 0.0001). As with unilateral costs, 2-year postsurgical costs were higher for implant-based reconstruction compared with autologous reconstruction ($81,599 versus $73,138; p < 0.0001). However, because of the higher mean predicted cost of bilateral autologous breast reconstruction, the total cost was higher than for bilateral implant-based reconstruction.

Looking at the longitudinal variation in costs of breast reconstruction over the 11 years of this study (Figure 2), gradual increases in mean predicted costs were observed, for both unilateral and bilateral autologous and implant-based breast reconstruction. In 2004, the mean predicted cost of unilateral autologous reconstruction was $19,332 compared with $45,258 in 2014. Implant-based reconstruction followed the same trend, with a mean predicted cost of $9333 in 2004, increasing to $34,920 in 2014. Similar increases were seen in bilateral costs and 2-year postreconstruction costs for both unilateral and bilateral reconstructions.

Figure 2.

Immediate breast reconstruction cost trends and reconstructive method in the United States among privately insured women from 2004 to 2014. ABR, autologous breast reconstruction; IBBR, implant-based breast reconstruction.

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