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.

A low cost training phantom model for radio-guided localization techniques in occult breast lesions.

Radio-guided localization (RGL) for identifying occult breast lesions has been widely accepted as an alternative technique to other localization methods, including those using wire guidance. An appropriate phantom model would be an invaluable tool for practitioners interested in learning the technique of RGL prior to clinical application. The aim of this study was to devise an inexpensive and reproducible training phantom model for RGL. We developed a simple RGL phantom model imitating an occult breast lesion from inexpensive supplies including a pimento olive, a green pea and a turkey breast. The phantom was constructed for a total cost of less than $20 and prepared in approximately 10 min. After the first model's construction, we constructed approximately 25 additional models and demonstrated that the model design was easily reproducible. The RGL phantom is a time- and cost-effective model that accurately simulates the RGL technique for non-palpable breast lesions. Future studies are warranted to further validate this model as an effective teaching tool.

Nurse practitioner-staffed clinic at Virginia Mason improves care and lowers costs for women with benign breast conditions.

The implementation of a breast clinic based on the use of an advanced registered nurse practitioner at Virginia Mason Medical Center in Seattle, Washington, substantially improved care timeliness and efficiency for women with symptomatic benign breast conditions. Women received their final benign diagnosis in an average of four rather than sixteen days, with fewer imaging studies and physician visits, when compared to a control group. Savings to the employer were estimated at $316 per woman, primarily from increased work productivity. Direct care costs decreased an estimated 19 percent, to $213 per woman. By decreasing both direct medical costs and indirect costs such as work absenteeism and presenteeism, the Virginia Mason Breast Clinic has created substantial savings for providers and employers while delivering care that patients rate highly. This model demonstrates the feasibility of achieving higher quality at lower cost through integrated care.

A European comparison of reimbursement in breast reconstruction.

AIMS: Case payment mechanisms have become the principal means of remunerating hospitals in most developed countries. The purpose of this study was to make an international comparison of reimbursement for breast reconstructive surgery. METHODS: We analysed remuneration for unilateral and bilateral female breast reconstruction (pedicled flaps, free flaps, alloplastic procedures) across five different European countries. National grouper software was used to identify Diagnosis Related Groups from which the proceeds were derived. RESULTS: The mean reimbursement was € 5593 for pedicled flaps, € 9149 for free flaps and € 4037 for implant-based reconstructions. The highest payments were in Sweden and the lowest in Italy. When adjusting payments by purchasing power parities, the relation among the countries did not change. The Austrian system makes a clear distinction between one-stage and two-stage delayed reconstructive interventions whereas reimbursement in other countries favoured a two-stage approach. Only one of five national reimbursement systems distinguishes between unilateral and bilateral reconstructions. CONCLUSIONS: Across a spectrum of European countries, reimbursement for breast reconstruction was based on similar procedure-specific systems, although there was a wide variation in tariffs and consideration of other factors such as underlying diagnosis. As delivery of healthcare becomes more rationalised, there is a need for individualised reimbursement which correlates directly with activity. Drawing on the experience of different healthcare systems may lead to development of a more robust and fair system of reimbursement.

Economic analysis of screening strategies for rupture of silicone gel breast implants.

BACKGROUND: In 2006, the U.S. Food and Drug Administration recommended screening of all women with silicone gel breast implants with magnetic resonance imaging 3 years after implantation and every 2 years thereafter to assess their integrity. The cost for these serial examinations over the lifetime of the breast implants is an added burden to insurance payers and to women. The authors performed an economic analysis to determine optimal screening strategies by considering the diagnostic accuracy of the screening tests, costs of the tests, and subsequent implant removal. METHODS: The authors determined aggregate/pooled values for sensitivity and specificity of the screening tests of ultrasound and magnetic resonance imaging in detecting silicone breast implant ruptures from the data obtained from published literature. They compiled costs, based on Medicare reimbursements for 2011, for the following elements: imaging modalities, anesthesia, and three surgical treatment options for detected ruptures. A decision tree was used to compare three alternate screening strategies of ultrasound only, magnetic resonance imaging only, and ultrasound followed by magnetic resonance in asymptomatic and symptomatic women. RESULTS: The cost per rupture of screening and management of rupture with ultrasound in asymptomatic women was $1090; in symptomatic women, it was $1622. A similar cost for magnetic resonance imaging in asymptomatic women was $2067; in symptomatic women it was $2143. A similar cost for ultrasound followed by imaging in asymptomatic women was $637; in symptomatic women, it was $2908. CONCLUSION: Screening with ultrasound followed by magnetic resonance imaging was optimal for asymptomatic women, and screening with ultrasound was optimal for symptomatic women.

[Cost analysis of conservative versus operative therapy of macromastia]. / Kostenanalyse der konservativen versus operativen therapie der makromastie.

Macromastia causes back and neck pain, scaphodynia, intertrigo of the inframammary crease up to dysaesthesia. Typical complaints of patients with macromastia are physical burden, psychological irritation and aesthetic deformity, often resulting in social isolation. Despite the demonstrable success of reduction mammaplasty to eliminate not only the symptoms of macromastia but the cause of the ailment, conservative therapy is still favoured by insurance companies and bearing of costs for surgical therapy therefore is rejected. Expenses of conservative treatment as well as costs related to appeal and lawsuits against insurance decisions exceed the case-based lump sum of reduction mammaplasty manifold. Conservative treatments do not eliminate the causes of the illness. Therefore the rejection of a medically indicated reduction mammaplasty has to be regarded as unfavourable and economically inefficient.

Hypertrophy of the breast: a problem of beauty or health?

BACKGROUND: Despite the complex health burden for women with breast hypertrophy, medical directors of health insurance companies are not convinced that this procedure is of medical benefit for patients. Therefore, coverage of cost by the health insurance companies is no longer guaranteed. The purpose of this study is to evaluate the influence of breast weight on the physical and psychological morbidity of women and to prove the medical necessity of reduction mammaplasty. METHODS: We performed a cohort study of 50 women with various breast sizes, a mean age of 28 years (range 20-40 years), and a body mass index (BMI) <25. Breast weight was measured, the spine was investigated by magnetic resonance imaging (MRI), and a spine score of clinical symptoms was assessed. The Beck Depression Inventory (BDI) was used to evaluate psychological impairment. Pathological findings have been correlated with breast weight, and the risk of developing a morphological or psychological disorder independence of the breast weight was calculated. RESULTS: The incidence of degenerative spine disorders and the extent of depressive symptoms are correlated with increasing breast weight. CONCLUSIONS: The data show that high breast weight has a negative influence on the physical and psychological morbidity of women. This objective evidence in support of the medical necessity of reduction mammaplasty should guide managed care organizations' methods for determining coverage for reduction mammaplasty.

Mammography coding and reimbursement.

This article describes mammography coding and reimbursement, coding responsibilities for personnel and the importance of coding accuracy. After completing this article, the reader will: Recognize basic terms associated with mammography coding and reimbursement. Explain reimbursement differences between screening and diagnostic mammography. Understand the responsibilities of mammography facility personnel in accurate coding. Recognize the impact of coding, reimbursement and regulation on the economics of mammography practice. Explain basic coding concepts for screening, diagnostic and follow-up mammographic studies. Describe some new breast imaging technologies reimbursed by Medicare.

New tools for cost-effective delivery of breast imaging.

Breast imaging has a deserved reputation as a very difficult financial proposition for hospitals. Regulation, low reimbursement, costly new technologies and staff shortages all combine to create an operational environment that is difficult, at best. While it may not be possible for every hospital to make breast imaging profitable, it is the obligation of every hospital to make this and all service lines as cost-effective as possible. While the typical care episode in a hospital will include several different services or procedures, the breast-imaging patient is typically in the department or breast center for a single procedure. Consequently, all of the administrative and facility costs of the patient encounter must be borne by the reimbursement for the single procedure. Breast imaging involves relatively expensive technology and highly-trained, and costly, technologists in its delivery. The costs of these inputs are relatively fixed; therefore material improvement can only be realized through the redesign of process. Analysis of the process of care delivery is critical to any discussion of the economics of breast imaging. Breast imaging can basically be divided into two categories: screening mammography and diagnostic procedures. This is a very important distinction, because screening mammography requires only general supervision, while the balance of breast imaging requires the direct supervision of the physician. Decoupling the physician from the examination allows the organization of screening delivery programs in highly efficient, high-throughput systems. On the diagnostic side of breast imaging, the primary economic enhancement that can be realized is from the delivery of more than one procedure during the patient visit. Mammography has high fixed costs (technology and technologist) and, where high fixed costs are found, profitability is determined by process and volume. Where process can be optimized to a level that will allow a positive return for each mammogram, volume becomes a multiplier. Responding to congressional pressure exerted in 2001, CMS increased the 2002 payment rate (global) for screening mammography from $69.23 (2001) to $81.81. The increase, however, was a mixed blessing, as it was all in the professional component ($22.18 to $35.48). In fact, the technical component was actually reduced by $0.74 from $47.07 to $46.33. While the reduction in payment for producing the screening mammogram is unjustified by the costs of producing that exam, the hardest blow was reserved for the payment rates for diagnostic mammography. As previously discussed, improving process and increasing volumes will improve the financial picture, but the problem of a single, low, procedure reimbursement remains. The implementation of CAD, however, has the ability to change that reality. CMS treats CAD as an add-on procedure. It cannot be billed as a stand-alone charge, but it is paid when billed in conjunction with a screening or diagnostic mammogram. The implications of the add-on character of CAD reimbursement are disproportionate to the amount of the payment, because it does not have to carry any costs other than those directly involved in its delivery. Breast imaging in general, and mammography specifically, will continue to present a challenge to the radiology administrator. With proper attention to process and volumes, and the very important contribution of CAD, however, breast imaging has the potential to not only pay its own way but to become profitable.

Disease management is the future: breast cancer is the model.

The breast care continuum is characterized by a wide variety of procedures and pathways leading to similar outcomes. This variation leads to very substantial differences in costs and patient experience, dependant upon physician choice of procedure or pathway. The breast center is uniquely positioned to develop disease management for the breast, including subspecialized care, the adoption of evidence-based protocols, and comprehensive management of outcome information. This approach to disease management focuses on physician excellence and is the key to increasing the quality of patient care, decreasing the overall cost of breast cancer, and increasing reimbursement and practice satisfaction for breast physicians.

Screening for breast cancer: time, travel, and out-of-pocket expenses.

BACKGROUND: We estimated the personal costs to women found to have a breast problem (either breast cancer or benign breast disease) in terms of time spent, miles traveled, and cash payments made for detection, diagnosis, initial treatment, and follow-up. METHODS: We analyzed data from personal interviews with 465 women from four communities in Florida. These women were randomly selected from those with a recent breast biopsy (within 6-8 months) that indicated either breast cancer (208 women) or benign breast disease (257 women). One community was the site of a multifaceted intervention to promote breast screening, and the other three communities were comparison sites for evaluation of that intervention. All P values are two-sided. RESULTS: In comparison with time spent and travel distance for women with benign breast disease (13 hours away from home and 56 miles traveled), time spent and travel distance were statistically significantly higher (P<.001) for treatment and follow-up of women with breast cancer (89 hours and 369 miles). Personal financial costs for treatment of women with breast cancer were also statistically significantly higher (breast cancer = $604; benign breast disease = $76; P < .001) but were statistically significantly lower for detection and diagnosis (breast cancer = $170; benign breast disease = $310; P < .001). Among women with breast cancer, time spent for treatment was statistically significantly lower (P = .013) when their breast cancer was detected by screening (68.9 hours) than when it was detected because of symptoms (84.2 hours). Personal cash payments for detection, diagnosis, and treatment were statistically significantly lower among women whose breast problems were detected by screening than among women whose breast problems were detected because of symptoms (screening detected = $453; symptom detected = $749; P = .045). CONCLUSION: There are substantial personal costs for women who are found to have a breast problem, whether the costs are associated with problems identified through screening or because of symptoms.

US-guided core breast biopsy: use and cost-effectiveness.

PURPOSE: To determine the frequency with which ultrasonographically (US) guided core biopsy obviated diagnostic surgical biopsy of nonpalpable breast masses, to calculate the cost savings of diagnosis attributable to US-guided core biopsy, and to compare the costs of US-guided versus stereotactically guided core biopsy. MATERIALS AND METHODS: US-guided core biopsy was performed in 151 consecutive solitary, nonpalpable breast masses in 151 women (age range, 23-80 years) by using a 14-gauge automated gun and needle. Clinical follow-up data were obtained. Cost savings were assessed by using national Medicare reimbursement costs of +385 for US-guided core biopsy, +610 for stereotactic core biopsy, and +1,332 for needle localization and surgical biopsy. RESULTS: US-guided core biopsy obviated a surgical procedure in 128 (85%) of 151 women. The mean adjusted direct cost saving per US-guided core biopsy was +744 per case. Use of US-guided biopsy decreased the cost of diagnosis by 56% (+744/+1,332) over the cost of surgical biopsy. If biopsy had been performed with stereotactic rather than with US guidance, the mean adjusted direct cost saving would have been +519 per case, a 39% (+519/1,332) decrease in the cost of diagnosis compared with the cost of surgical biopsy. CONCLUSION: Percutaneous biopsy of a nonpalpable breast mass with either US or stereotactic guidance is less expensive than surgery, but cost savings are greater with US-guided biopsy.

Surveillance mammography and stereotactic core breast biopsy for probably benign lesions: a cost comparison analysis.

RATIONALE AND OBJECTIVES: The authors compared the economic effect of stereotactic core needle biopsy (CNB) with that of short-term unilateral surveillance mammography in the management of probably benign breast lesions detected during routine screening mammography. METHODS: Published data with regard to the cost of stereotactic CNB and unilateral mammography were applied to 3,184 patients who underwent surveillance mammography; including 161 patients who underwent biopsy. Costs of immediate tissue diagnosis were compared with costs of surveillance with use of ratios of published reimbursement scales to minimize geographic variations. Sensitivity analyses were applied to this ratio. RESULTS: The cost of managing probably benign breast lesions with surveillance mammography was $3,307,575 less than if all lesions had been managed with CNB. The ratio of the cost of CNB to the cost of surveillance mammography was 8:1. This ratio is more sensitive to the frequency of use of CNB than to reimbursement schedules. CONCLUSION: With similar false-negative rates, CNB is more costly than surveillance and has a negative effect in the management of probably benign breast lesions, unless interval change during surveillance prompts tissue diagnosis.

Socioeconomic variation in admission for diseases of female genital system and breast in a national cohort aged 15-43.

OBJECTIVE: To investigate socioeconomic variation among young women in the risk of hospital admission for diseases (including neoplasms) of the female genital system and breast and for the common surgical procedures of dilatation and curettage and hysterectomy. DESIGN: Large nationally representative cohort study with individual records of confirmed admissions to NHS and private hospitals since birth and data on occupational and educational experience. SETTING: England, Scotland, and Wales. PATIENTS: General population sample of 1628 women, 1549 of whom had a complete admissions record for the ages of 15-43 years. MAIN OUTCOME MEASURES: The percentage of women admitted for neoplasms or other diseases of the female genital system and breast or who had dilatation and curettage or hysterectomy between the ages of 15 and 43 years. RESULTS: By the age of 43, 35% of women had been admitted, 17% had undergone dilatation and curettage at least once, and 10% had had a hysterectomy. There were significant inverse educational gradients, the risk of admission increasing more than twofold between the most and least educated women. The differential risk was most striking for disorders of menstruation, in which only 1% of those with the highest educational qualifications and 19% of those with minimal qualifications had been admitted to hospital. There was a significant educational gradient in the hysterectomy rate (from 1% to 15%) and a twofold difference in the risk of dilatation and curettage. There were also significant gradients in risk of admission and of hysterectomy according to partner's social class. CONCLUSIONS: Socioeconomic variations in the risk of dilatation and curettage and of hysterectomy were large. Lessening the socioeconomic gradient in risks of admissions and surgery for diseases of the female genital system and breast, particularly for menstrual disorders, could have important resource implications.

Benign breast disease: the cost of the service and the cost to the patient.

The patients attending a hospital breast clinic during 1 year have been reviewed to assess the impact and cost of benign conditions. Four of 5 patients referred do not have cancer. The cost to the patient lies predominantly in anxiety related to the possibility of cancer and, to a lesser extent, in cosmetic damage due to multiple biopsies. Benign breast disease is a common problem that creates severe anxiety in many women and a heavy burden on an overstretched National Health Service. A policy of reeducating general practitioners when it is safe not to refer may reduce this problem. Cyst aspiration or needle aspiration cytology may reduce the burden to both the patient and the health service, while desensitization of women's groups and women themselves to the needs for breast self-examination can also reduce this burden.