Early post-operative outcome of pre-pectoral implant-based immediate total breast reconstruction with Polyglactin 910 (Vicryl™) mesh - low cost solution for a low-middle income country.

BACKGROUND: The incidence of breast cancer in Pakistan has been rising with approximately one third of these patients requiring mastectomy. Among breast reconstruction treatment options, the use of Acellular Dermal Matrix (ADM) for pre-pectoral breast implant surgery has proven effective with improved cosmetic outcome. However, due to high cost it cannot be regularly implemented in a developing country like Pakistan. An alternative to ADM, Polyglactin 910 (Vicryl™, Ethicon) mesh has been introduced in pre-pectoral breast reconstructive surgery which has shown to be almost 10 times lower in cost. We set out to determine the frequency of early postoperative complications when using Polyglactin 910 mesh for pre-pectoral implant-based breast reconstruction surgery. METHODS: A single centre, retrospective, chart review was conducted, and a total 28 women were included in the study. Thirty-two pre-pectoral implant-based mastectomies with Polyglactin 910 mesh were performed. Early post-operative outcomes (within 12 months of procedure) including duration of antibiotic use, post-operative infection, implant displacement, flap necrosis, seroma formation, wound dehiscence, hematoma formation, capsular contracture and reconstruction failure, were recorded. RESULTS: Only 4 (12.5%) women experienced early post-operative morbidity. One patient developed a wound dehiscence, which eventually led to reconstruction failure and removal of the implant. Another patient had seroma formation and flap necrosis. None of the patients developed postoperative implant displacement, hematoma formation or capsular contracture in the early post-operative period. CONCLUSION: This study reveals that early post-operative outcomes with Polyglactin 910 mesh in breast reconstructive surgery are few, thus making it a cost effective, reliable, and safe treatment option, especially in developing countries like Pakistan.

Cost-benefit analysis of 3D-printed vascular models in abdominal free flap breast reconstruction.

3D-printed vascular models can enhance flap harvesting efficiency in abdominal free flap breast reconstruction, reducing the use of operating room time. However, no economic analyses with respect to model use in this context have been conducted to date. As such, this study examines model cost-benefit tradeoffs for use in abdominal free flap breast reconstruction.

Post-Mastectomy Breast Reconstruction Disparities: A Systematic Review of Sociodemographic and Economic Barriers.

Background: Breast reconstruction (BR) following mastectomy is a well-established beneficial medical intervention for patient physical and psychological well-being. Previous studies have emphasized BR as the gold standard of care for breast cancer patients requiring surgery. Multiple policies have improved BR access, but there remain social, economic, and geographical barriers to receiving reconstruction. Threats to equitable healthcare for all breast cancer patients in America persist despite growing awareness and efforts to negate these disparities. While race/ethnicity has been correlated with differences in BR rates and outcomes, ongoing research outlines a multitude of issues underlying this variance. Understanding the current and continuous barriers will help to address and overcome gaps in access. Methods: A systematic review assessing three reference databases (PubMed, Web of Science, and Ovid Medline) was carried out in accordance with PRISMA 2020 guidelines. A keyword search was conducted on 3 February 2024, specifying results between 2004 and 2024. Studies were included based on content, peer-reviewed status, and publication type. Two independent reviewers screened results based on title/abstract appropriateness and relevance. Data were extracted, cached in an online reference collection, and input into a cloud-based database for analysis. Results: In total, 1756 references were populated from all databases (PubMed = 829, Ovid Medline = 594, and Web of Science = 333), and 461 duplicate records were removed, along with 1147 results deemed ineligible by study criteria. Then, 45 international or non-English results were excluded. The screening sample consisted of 103 publications. After screening, the systematic review produced 70 studies with satisfactory relevance to our study focus. Conclusions: Federal mandates have improved access to women undergoing postmastectomy BR, particularly for younger, White, privately insured, urban-located patients. Recently published studies had a stronger focus on disparities, particularly among races, and show continued disadvantages for minorities, lower-income, rural-community, and public insurance payers. The research remains limited beyond commonly reported metrics of disparity and lacks examination of additional contributing factors. Future investigations should elucidate the effect of these factors and propose measures to eliminate barriers to access to BR for all patients.

Increased Time Interval of Postoperative Flap Monitoring After Autologous Breast Reconstruction.

BACKGROUND: Hourly flap checks are the most common means of flap monitoring during the first 24 hours following autologous breast reconstruction (ABR). This practice often requires intensive care unit (ICU) admission, which is a key driver of health care costs and decreased patient satisfaction. This study addresses these issues by demonstrating decreased cost and length of admission associated with a 4-hour interval between flap checks during the first 24 hours following ABR. METHODS: This is a retrospective review of ABR surgeries performed by multiple surgeons from 2017 to 2020. Two cohorts were identified, one that underwent flap checks every hour in the ICU (Q1 cohort) and the other that underwent flap checks every 4 hours on the hospital floor (Q4 cohort). Our primary outcome measures were length of stay (LOS), flap takebacks, flap loss, and encounter cost. RESULTS: Rates of flap takeback and loss did not differ between cohorts (P = 0.18, P = 0.21). The Q4 cohort's average LOS was shorter than the Q1 cohort (P = 0.002). The Q4 cohort's average cost was also $25,554.80 less than the Q1 cohort (P < 0.001). This association persisted after controlling for LOS, operating room takeback, timing and laterality of reconstruction, and flap configuration (hazard ratio = 0.65, P = 0.0007). CONCLUSION: This study demonstrates the benefits of lengthened flap check intervals during the first 24 hours following ABR. These intervals decrease the cost of ABR while also maintaining safety, making ABR a more accessible option for breast reconstruction patients.

Local practice variations and payer differences underlie state-wide disparities in oncoplastic breast surgery.

BACKGROUND: Little is known about disparities in oncoplastic breast surgery delivery. METHODS: The Massachusetts All-Payer Claims Database was queried for patients who received lumpectomy for a diagnosis of breast cancer. Oncoplastic surgery was defined as adjacent tissue transfer, complex trunk repair, reduction mammoplasty, mastopexy, flap-based reconstruction, prosthesis insertion, or unspecified breast reconstruction after lumpectomy. RESULTS: We identified 18 748 patients who underwent lumpectomy between 2016 and 2020. Among those, 3140 patients underwent immediate oncoplastic surgery and 436 patients underwent delayed oncoplastic surgery. Eighty-one percent of patients who underwent oncoplastic surgery did so in the same county as they underwent a lumpectomy. However, the relative frequency of oncoplastic surgery varied significantly among counties. In multivariable regression, public insurance status (odds ratio: 0.87, 95% confidence interval: 0.80-0.95, p = 0.002) was associated with lower odds of undergoing oncoplastic surgery, even after adjusting for macromastia, other comorbidities, and county of lumpectomy. Average payments for lumpectomy with oncoplastic surgery were more than twice as high from private insurers ($840 vs. $1942, p < 0.001). CONCLUSION: Disparities in the receipt of oncoplastic surgery were related to differences in local practice patterns and the type of insurance patients held. Expanding services across counties and considering billing reform may help reduce these disparities.

Trends of medicare reimbursement for breast cancer and reconstructive surgery.

This study evaluated trends in Medicare reimbursement for commonly performed breast oncologic and reconstructive procedures. Average national relative value units (RVUs) for physician-based work, facilities, and malpractice were collected along with the corresponding conversion factors for each year. From 2010 to 2021, there was an overall average decrease of 15% in Medicare reimbursement for both breast oncology (-11%) and reconstructive procedures (-16%). Based on these findings, breast and reconstructive surgeons should advocate for reimbursement that better reflects the costs of their practice.

The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

One-stop autologous breast reconstruction: A safe and effective cost-saving pathway.

INTRODUCTION: Patients undergoing autologous breast reconstruction usually require further operations as part of their reconstructive journey. This involves contralateral breast symmetrization and nipple-areola complex (NAC) reconstruction. Restrained access to elective operating space led us to implement a one-stop breast reconstruction pathway. METHODS: Patients undergoing contemporaneous contralateral breast symmetrization and immediate NAC reconstruction with free nipple grafts between July 2020 and June 2021 were identified. A retrospective review of our prospectively maintained database was conducted, to retrieve surgical notes, postoperative complications, and length of inpatient stay. A cost analysis was performed considering savings from contralateral symmetrization. RESULTS: A total of 50 eligible cases were identified, which had unilateral one-stop breast reconstructions. Complication rates and length of stay were not affected by this approach, with only one free flap being lost for this cohort. This approach resulted in £181,000 being saved for our service over a calendar year. DISCUSSION: A one-stop breast reconstruction pathway has proven to be safe and effective in our unit. During these uncertain times, it has streamlined the management of eligible patients, while releasing capacity for other elective operations. Patients avoid having to wait for secondary procedures, finishing their reconstructive pathway earlier. We plan to continue providing this service which has shown to be beneficial clinically and financially.

Co-surgeon versus Single-surgeon Outcomes in Free Tissue Breast Reconstruction: A Meta-analysis.

BACKGROUND: Autologous breast reconstruction offers superior long-term patient reported outcomes compared with implant-based reconstruction. Universal adoption of free tissue transfer has been hindered by procedural complexity and long operative time with microsurgery. In many specialties, co-surgeon (CS) approaches are reported to decrease operative time while improving surgical outcomes. This systematic review and meta-analysis synthesizes the available literature to evaluate the potential benefit of a CS approach in autologous free tissue breast reconstruction versus single-surgeon (SS). METHODS: A systematic review and meta-analysis was conducted using PubMed, Embase, and MEDLINE from inception to December 2022. Published reports comparing CS to SS approaches in uni- and bilateral autologous breast reconstruction were identified. Primary outcomes included operative time, postoperative outcomes, processes of care, and financial impact. Risk of bias was assessed and outcomes were characterized with effect sizes. RESULTS: Eight retrospective studies reporting on 9,425 patients were included. Compared with SS, CS approach was associated with a significantly shorter operative time (SMD -0.65, 95% confidence interval [CI] -1.01 to -0.29, p < 0.001), with the largest effect size in bilateral reconstructions (standardized mean difference [SMD] -1.02, 95% CI -1.37 to -0.67, p < 0.00001). CS was also associated with a significant decrease in length of hospitalization (SMD -0.39, 95% CI -0.71 to -0.07, p = 0.02). Odds of flap failure or surgical complications including surgical site infection, hematoma, fat necrosis, and reexploration were not significantly different. CONCLUSION: CS free tissue breast reconstruction significantly shortens operative time and length of hospitalization compared with SS approaches without compromising postoperative outcomes. Further research should model processes and financial viability of its adoption in a variety of health care models.

Post-mastectomy Breast Reconstruction With Gas vs Saline Tissue Expanders: Does the Fill Type Matter?

The most common reconstruction technique following mastectomy is a 2-stage technique that involves tissue expansion followed by definitive implant-based reconstruction (IBR). Tissue expanders (TEs) have classically used saline for initial fill; however, TEs with an initial gas fill (GTE)-including the CO2-based AeroForm (AirXpanders, San Francisco, CA) TE and TEs initially filled with atmospheric air-have been increasingly used in the past decade. We aimed to compare the outcomes in breast reconstruction for tissue expanders initially filled with saline vs gas. PubMed was queried for studies comparing gas- and saline-filled tissue expanders (STEs) used in IBR. A meta-analysis was performed on major postoperative outcomes and the required expansion and definitive reconstruction time. Eleven studies were selected and included in the analysis. No significant differences existed between tissue expansion with GTEs vs STEs for 11 of the 13 postoperative outcomes investigated. Out of the complications investigated, only the risk of infection/cellulitis/abscess formation was significantly lower in the GTE cohort (odds ratio 0.62; 95% CI, 0.47 to 0.82; P = .0009). The time to definitive reconstruction was also significantly lower in the GTE cohort (mean difference [MD], 45.85 days; 95% CI, -57.80 to -33.90; P < .00001). The total time to full expansion approached significance in the GTE cohort (MD, -20.33 days; 95% CI, -41.71 to 1.04; P = .06). A cost analysis considering TE cost and infection risk determined that GTE use saved a predicted $2055.34 in overall healthcare costs. Surgical outcomes for both fill types were predominantly similar; however, GTEs were associated with a significantly decreased risk of postoperative infection compared to saline-filled TEs. GTEs could also reduce healthcare expenditures and require less time until definitive reconstruction after placement.

Racial Disparities in the Cost of Unplanned Hospitalizations after Breast Reconstruction.

BACKGROUND: Given the national attention to disparities in health care, understanding variation provided to minorities becomes increasingly important. This study will examine the effect of race on the rate and cost of unplanned hospitalizations after breast reconstruction procedures. METHODS: The authors performed an analysis comparing patients undergoing implant-based and autologous breast reconstruction in the Healthcare Cost and Utilization Project. The authors evaluated the rate of unplanned hospitalizations and associated expenditures among patients of different races. Multivariable analyses were performed to determine the association among race and readmissions and health care expenditures. RESULTS: The cohort included 17,042 patients. The rate of an unplanned visit was 5%. The rates of readmissions among black patients (6%) and Hispanic patients (7%) in this study are higher compared with white patients (5%). However, after controlling for patient-level characteristics, race was not an independent predictor of an unplanned visit. In our expenditure model, black patients [adjusted cost ratio, 1.35 (95% CI, 1.11 to 1.66)] and Hispanic patients [adjusted cost ratio, 1.34 (95% CI, 1.08 to 1.65)] experienced greater cost for their readmission compared with white patients. CONCLUSIONS: Although race is not an independent predictor of an unplanned hospital visit after surgery, racial minorities bear a higher cost burden after controlling for insurance status, further stimulating health care disparities. Adjusted payment models may be a strategy to reduce disparities in surgical care. In addition, direct and indirect measures of disparities should be used when examining health care disparities to identify consequences of inequities more robustly.

Financial Implications of Enhanced Recovery After Surgery Protocols in Microsurgical Breast Reconstruction.

INTRODUCTION: Surgical advancements in breast reconstruction have allowed a shift toward optimizing patient-reported outcomes and efficiency measures. The enhanced recovery after surgery (ERAS) protocol has been instrumental in improving outcomes, but the effect of these protocols on health care spending has not been examined. This study aims to assess the effect of ERAS protocols on the length of hospital stay and costs associated with microsurgical breast reconstruction. METHODS: In 2018, the authors implemented an ERAS protocol for patients undergoing microsurgical breast reconstruction that included perioperative procedures involving patient education and care. Subjects included patients who underwent deep inferior epigastric perforator flap breast reconstruction at the authors' institution between 2016 and 2019. Data were gathered from the electronic medical record and the hospital system's finance department, and patients were divided into pre-ERAS and ERAS cohorts. A 2-sample t test was used for statistical analysis. RESULTS: The study included 269 patients with no statistically significant differences in demographic data between the cohorts. The average length of hospitalization was 3.46 days for the pre-ERAS group and 2.45 days for the ERAS group ( P = 0.000). In a linear regression, the ERAS protocol predicted a 1.04-day decrease in the length of stay ( P = 0.000). Overall, total direct cost decreased by 7.5% with the ERAS protocol. CONCLUSION: The rising cost of health care presents a challenge for providers to reduce the cost burden placed on our health system while providing the highest-quality care. This study demonstrates that the use of standardized ERAS protocols can achieve this 2-fold goal.

Microvascular Breast Reconstruction in the Era of Value-Based Care: Use of a Cosurgeon Is Associated with Reduced Costs, Improved Outcomes, and Added Value.

BACKGROUND: Reducing complications while controlling costs is a central tenet of value-based health care. Bilateral microvascular breast reconstruction is a long operation with a relatively high complication rate. Using a two-surgeon team has been shown to improve safety in bilateral microvascular breast reconstruction; however, its impact on cost and efficiency has not been robustly studied. The authors hypothesized that a cosurgeon for bilateral microvascular breast reconstruction is safe, effective, and associated with reduced costs. METHODS: The authors retrospectively reviewed all patients who underwent bilateral microvascular breast reconstruction with either a single surgeon or surgeon/cosurgeon team over an 18-month period. Charges were converted to costs using the authors' institutional cost-to-charge ratio. Surgeon opportunity costs were estimated using time-driven activity-based costing. Propensity scoring controlled for baseline characteristics between the two groups. A locally weighted logistic regression model analyzed the cosurgeon's impact on outcomes and costs. RESULTS: The authors included 150 bilateral microvascular breast reconstructions (60 single-surgeon and 90 surgeon/cosurgeon reconstructions) with a median follow-up of 15 months. After matching, the presence of a cosurgeon was associated with a significantly reduced mean operative duration (change in operative duration, -107 minutes; p < 0.001) and cost (change in total cost, -$1101.50; p < 0.001), which was even more pronounced when surgeon/cosurgeon teams worked together frequently (change in operative duration, -132 minutes; change in total cost, -$1389; p = 0.007). The weighted logistic regression models identified that a cosurgeon was protective against breast-site complications and trended toward reduced overall and major complication rates. CONCLUSION: The practice of using a of cosurgeon appears to be associated with reduced costs and improved outcomes, thereby potentially adding value to bilateral microvascular breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Cost-utility analysis of breast reduction surgery for women with symptomatic breast hypertrophy.

OBJECTIVE: To assess the cost-effectiveness of breast reduction surgery for women with symptomatic breast hypertrophy in Australia. DESIGN: Cost-utility analysis of data from a prospective cohort study. SETTING, PARTICIPANTS: Adult women with symptomatic breast hypertrophy assessed for bilateral breast reduction at the Flinders Medical Centre, a public tertiary hospital in Adelaide, April 2007 - February 2018. The control group included women with breast hypertrophy who had not undergone surgery. MAIN OUTCOME MEASURES: Health care costs (for the surgical admission and other related hospital costs within 12 months of surgery) and SF-6D utility scores (measure of health-related quality of life) were used to calculate incremental costs per quality-adjusted life-year (QALY) gained over 12 months, extrapolated to a 10-year time horizon. RESULTS: Of 251 women who underwent breast reduction, 209 completed the baseline and at least one post-operation assessment (83%; intervention group); 124 of 350 invited women waiting for breast reduction surgery completed the baseline and 12-month assessments (35%; control group). In the intervention group, the mean SF-6D utility score increased from 0.313 (SD, 0.263) at baseline to 0.626 (SD, 0.277) at 12 months; in the control group, it declined from 0.296 (SD, 0.267) to 0.270 (SD, 0.257). The mean QALY gain was consequently greater for the intervention group (adjusted difference, 1.519; 95% CI, 1.362-1.675). The mean hospital cost per patient was $11 857 (SD, $4322), and the incremental cost-effectiveness ratio (ICER) for the intervention was $7808 per QALY gained. The probability of breast reduction surgery being cost-effective was 100% at a willingness-to-pay threshold of $50 000 per QALY and 88% at $28 033 per QALY. CONCLUSIONS: Breast reduction surgery for women with symptomatic breast hypertrophy is cost-effective and should be available to women through the Australian public healthcare system.

Representation of African American Patients in Social Media for Breast Reconstruction.

BACKGROUND: Social media use by plastic surgeons may contribute to the overall increase in breast reconstruction in the United States. However, recent data show a concerning decrease in breast reconstruction in African American women. The purpose of this study was to analyze the inclusion of African American women in social media posts for breast reconstruction, with the premise that this may be a possible contributing factor to decreasing rates of breast reconstruction in this population. METHODS: Data from several social media platforms were obtained manually on December 1, 2019. Each image was analyzed using the Fitzpatrick scale as a guide. RESULTS: A total of 2580 photographs were included that met the authors' criteria. Only 172 photographs (6.7 percent) were nonwhite. This study surveyed 543 surgeons, 5 percent of whom were nonwhite. The analysis of the results from the random sample of the top plastic surgery social media influencers showed that only 22 (5 percent) of the photographs uploaded were nonwhite patients. Furthermore, 30 percent of surgeons did not have any photographs of nonwhite patients uploaded. CONCLUSIONS: Numerous factors can contribute to the disparity between the growing trend of white patients seeking reconstructive surgery compared to the decreasing trend of African American patients, one of which may be the disparity in their representation in social media, particularly among common platforms and social media influencers. This study highlights the evolving factors that may impair African American breast cancer patients' access to safe, effective breast reconstruction, which must be identified and resolved.

Impact of insurance payer and socioeconomic status on type of autologous breast reconstruction.

INTRODUCTION: Autologous breast reconstruction has evolved from more morbid procedures that sacrificed the abdominal muscle (the TRAM or transverse rectus abdominus muscle flap) to "perforator" flaps. Commercial insurers recognized the higher technical demand of perforator flaps by creating procedural codes with higher professional fees. This study examined whether procedure code discrepancies between insurance payers disproportionally incentivize perforator flaps among the commercially insured. METHODS: Autologous breast reconstructions identified from the National Inpatient Sample (NIS) were subdivided into microvascular perforator (85.74, 85.75, 85.76), microvascular TRAM (85.73), and pedicled TRAM flaps (85.72). Demographics, comorbidities and access to care were compared. A logistic regression comparing microvascular reconstructions only was used to identify predictors for perforator flap reconstruction. RESULTS: A total of 66,968 cases of autologous breast reconstruction were identified. Perforator flaps were more likely among the commercially insured (p < 0.001) and higher insurance quartiles (p < 0.001).When comparing microvascular reconstruction, perforator flaps were 1.72 (p < 0.001) times more likely among the commercially insured. As compared to the lowest income quartile, the fourth quartile had an odds ratio of 1.36 (p < 0.001) for perforator flap reconstruction. CONCLUSION: The presence of a separate perforator flap billing code among the commercially insured may be exacerbating existing socioeconomic disparities in breast cancer reconstruction.

Factors Associated With State-Specific Medicaid Expansion and Receipt of Autologous Breast Reconstruction Among Patients Undergoing Mastectomy.

Importance: Despite demonstrated psychosocial benefits, autologous breast reconstruction remains underutilized. An analysis of the association between Medicaid expansion and autologous breast reconstruction has yet to be performed. Objective: To compare autologous breast reconstruction rates and determine the association between Medicaid expansion and breast reconstruction. Design, Setting, and Participants: A retrospective cross-sectional study was performed using the State Inpatient Database from January 1, 2012, through September 30, 2015, and included 51 340 patients. Patients were identified using the International Classification of Diseases, Ninth Revision, codes for breast cancer, mastectomy, and autologous breast reconstruction. Data from states that expanded Medicaid (New Jersey, New York, and Washington) were compared with states that did not expand Medicaid (Florida, North Carolina, and Wisconsin). Data were analyzed from June 1, 2020, through February 28, 2021. Exposures: The Patient Protection and Affordable Care Act's Medicaid expansion was implemented in 2014; the preexpansion period ranged from 2012 to 2013 (2 years), whereas the postexpansion period ranged from 2014 to 2015 quarter 3 (1.75 years). Main Outcomes and Measures: Primary outcomes included use of autologous breast reconstruction before and after expansion. Independent covariates included patient demographics, comorbidities, and state of residence. Results: Among 45 850 patients who underwent mastectomy and 9215 patients who received autologous breast reconstruction, 36 777 (67%) were White and 32 205 (59%) had private insurance. The use of immediate or delayed autologous reconstruction increased from 18.1% (4951 of 27 290) to 23.0% (4264 of 18 560) throughout the study period. Compared with 2012, the odds of reconstruction were 64% higher in 2015 (odds ratio [OR], 1.64; 95% CI, 1.48-1.80; P < .001). African American (OR, 1.43; 95% CI, 1.33-1.55; P < .001) and Hispanic (OR, 1.44; 95% CI, 1.31-1.60; P < .001) patients had higher odds of reconstruction compared with White patients regardless of state of residence. However, Medicaid expansion was associated with a 28% decrease in the odds of reconstruction (OR, 0.72; 95% CI, 0.61-0.87; P < .001) for African American patients, a 40% decrease (OR, 0.60; 95% CI, 0.50-0.74; P < .001) for Hispanic patients, and 20% decrease (OR, 0.80; 95% CI, 0.67-0.96; P = .01) for patients with Asian, Native American, or other minority race/ethnicity. Medicaid expansion was not associated with changes in the odds of reconstruction for White patients. Conclusions and Relevance: In this cross-sectional study, although the odds of receiving autologous breast reconstruction increased annually, Medicaid expansion was associated with decreased odds of reconstruction for African American patients, Hispanic patients, and other patients of color.

Changes in Korean National Healthcare Insurance Policy and Breast Cancer Surgery Trend in Korea.

BACKGROUND: Since April 2015, the Korean National Health Insurance (NHI) has reimbursed breast cancer patients, approximately 50% of the cost of the breast reconstruction (BR) procedure. We aimed to investigate NHI reimbursement policy influence on the rate of immediate BR (IBR) following total mastectomy (TM). METHODS: We retrospectively analyzed breast cancer data between April 2011 and June 2016. We divided patients who underwent IBR following TM for primary breast cancer into "uninsured" and "insured" groups using their NHI statuses at the time of surgery. Univariate analyses determined the insurance influence on the decision to undergo IBR. RESULTS: Of 2,897 breast cancer patients, fewer uninsured patients (n = 625) underwent IBR compared with those insured (n = 325) (30.0% vs. 39.8%, P < 0.001). Uninsured patients were younger than those insured (median age [range], 43 [38-48] vs. 45 [40-50] years; P < 0.001). Pathologic breast cancer stage did not differ between the groups (P = 0.383). More insured patients underwent neoadjuvant chemotherapy (P = 0.011), adjuvant radiotherapy (P < 0.001), and IBR with tissue expander insertion (P = 0.005) compared with those uninsured. CONCLUSION: IBR rate in patients undergoing TM increased after NHI reimbursement.

Cost-Effectiveness of Vioptix versus Clinical Examination for Flap Monitoring of Autologous Free Tissue Breast Reconstruction.

BACKGROUND: Vioptix is a near-infrared spectroscopy tissue oximetry technology that allows for noninvasive monitoring of flap perfusion. Despite the reported benefits of Vioptix, the cost-effectiveness of this flap monitoring technology has not been compared to clinical examination alone. METHODS: A cost-effectiveness model, from the patient perspective, was constructed with two treatment arms: clinical examination versus clinical examination combined with Vioptix for flap monitoring after autologous, free flap breast reconstruction. Costs, utilities, and other model inputs were identified from the literature. One-way and probabilistic sensitivity analyses were performed. Gamma distributions were created for cost variables, and beta distributions were created for probability variables. An incremental cost-effectiveness ratio under $50,000 per quality-adjusted life-year (QALY) was considered cost-effective. All analyses were performed using TreeAge Pro (Williamstown, Mass.). RESULTS: Mean cost of autologous free tissue transfer breast reconstruction with clinical examination-based flap monitoring was found to be $37,561 with an effectiveness of 0.79, whereas the mean cost of clinical examination with Vioptix for flap monitoring was $39,361 with effectiveness of 0.82. This yielded an incremental cost-effectiveness ratio of $60,507 for clinical examination combined with Vioptix for flap monitoring. One-way sensitivity analysis revealed that clinical examination with Vioptix became cost-effective when the cost of Vioptix was less than $1487. Probabilistic sensitivity analysis found that clinical examination was cost-effective in 86.5 percent of cases. CONCLUSION: Although clinical examination combined with Vioptix is minimally more effective for flap monitoring after autologous, free flap breast reconstruction, clinical examination alone is the more cost-effective flap monitoring option.