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1.
Plast Reconstr Surg ; 145(2): 303-311, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985608

RESUMO

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.


Assuntos
Implante Mamário/métodos , Neoplasias da Mama/cirurgia , Mamoplastia/métodos , Adolescente , Adulto , Assistência Ambulatorial/economia , Assistência Ambulatorial/estatística & dados numéricos , Implante Mamário/economia , Implantes de Mama/economia , Implantes de Mama/estatística & dados numéricos , Neoplasias da Mama/economia , Custos e Análise de Custo , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Utilização de Instalações e Serviços , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Mamoplastia/economia , Pessoa de Meia-Idade , Estudos Retrospectivos , Transplante Autólogo/economia , Transplante Autólogo/estatística & dados numéricos , Estados Unidos , Adulto Jovem
2.
Plast Reconstr Surg ; 145(2): 333-339, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985616

RESUMO

BACKGROUND: Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction. METHODS: The Massachusetts All-Payer Claims Database was queried for women undergoing immediate autologous or implant breast reconstruction from 2010 to 2014. Univariate analyses compared demographic and clinical characteristics between different reconstructive approaches. Logistic regression explored the relative impact of insurance type and physician payments on breast reconstruction modality. RESULTS: Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001). CONCLUSIONS: Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.


Assuntos
Reembolso de Seguro de Saúde/economia , Mamoplastia/economia , Microcirurgia/economia , Adulto , Implante Mamário/economia , Implante Mamário/estatística & dados numéricos , Implantes de Mama/economia , Implantes de Mama/estatística & dados numéricos , Neoplasias da Mama/economia , Neoplasias da Mama/cirurgia , Feminino , Retalhos de Tecido Biológico/economia , Humanos , Mamoplastia/estatística & dados numéricos , Massachusetts , Mastectomia/economia , Mastectomia/métodos , Medicaid/economia , Medicaid/estatística & dados numéricos , Microcirurgia/estatística & dados numéricos , Microvasos , Pessoa de Meia-Idade , Reoperação/economia , Reoperação/estatística & dados numéricos , Transplante Autólogo/economia , Estados Unidos
3.
Handchir Mikrochir Plast Chir ; 51(6): 418-423, 2019 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-31698485

RESUMO

The profitability of medical treatment has gained increasing importance in health politics and likewise has become a considerable part of a microsurgeon's daily practice. The resulting cost pressure leads to microsurgeons having to justify their often complex and expensive treatments against hospital providers and health insurances. In this position paper of the German Speaking Group for Microsurgery of Peripheral Nerves and Vessels, we analyze the current status of profitability of microsurgical extremity and breast reconstruction, and its impact on choice of therapy and residency training. We specifically highlight the available literature, that shows often reduced long-term treatment costs after microsurgical reconstruction in comparison to cheaper initial treatments. The statements are based on a consensus workshop on the 40th meeting of the DAM in Lugano, Switzerland.


Assuntos
Microcirurgia , Procedimentos Cirúrgicos Reconstrutivos , Cirurgia Plástica , Internato e Residência , Mamoplastia/economia , Microcirurgia/economia , Microcirurgia/métodos , Nervos Periféricos/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/economia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Suíça
4.
Plast Reconstr Surg ; 144(4): 540e-549e, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31568278

RESUMO

BACKGROUND: The number of free flap take-backs and successful salvages following microsurgical breast reconstruction decreases as time from surgery increases. As a result, the cost of extended inpatient monitoring to achieve a successful flap salvage rises rapidly with each postoperative day. This study introduces a simplified cost-utility model of inpatient flap monitoring and identifies when cost-utility exceeds the thresholds established for other medical treatments. METHODS: A retrospective review of a prospectively maintained database was performed of patients who underwent microsurgical breast reconstruction to identify flap take-back and salvage rates by postoperative day. The number of patients and flaps that needed to be kept on an inpatient basis each day for monitoring to salvage a single failing flap was determined. Quality-of-life measures and incremental cost-effectiveness ratios for inpatient flap monitoring following microsurgical breast reconstruction were calculated and plotted against a $100,000/quality-adjusted life-year threshold. RESULTS: A total of 1813 patients (2847 flaps) were included. Overall flap take-back and salvage rates were 2.4 percent and 52.3 percent, respectively. Of the flaps taken back, the daily take-back and salvage rates were 56.8 and 60.0 percent (postoperative day 0 to 1), 13.6 and 83.3 percent (postoperative day 2), 11.4 and 40.0 percent (postoperative day 3), 9.1 and 25.0 percent (postoperative day 4), and 9.1 and 0.0 percent (>postoperative day 4), respectively. To salvage a single failing flap each day, the number of flaps that needed to be monitored were 121 (postoperative day 0 to 1), 363 (postoperative day 2), 907 (postoperative day 3), 1813 (postoperative day 4), and innumerable for days beyond postoperative day 4. The incremental cost-effectiveness ratio of inpatient flap monitoring begins to exceed a willingness-to-pay threshold of $100,000/quality-adjusted life-year by postoperative day 2. CONCLUSION: The health care cost associated with inpatient flap monitoring following microsurgical breast reconstruction begins to rise rapidly after postoperative day 2.


Assuntos
Análise Custo-Benefício , Retalhos de Tecido Biológico/economia , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Mamoplastia/economia , Mamoplastia/métodos , Microcirurgia , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Monitorização Fisiológica , Estudos Retrospectivos
5.
Plast Reconstr Surg ; 143(5): 1361-1368, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31033818

RESUMO

BACKGROUND: Gynecomastia is a common condition that can be corrected with surgical excision of the breast tissue. Unlike the policies available for reduction mammaplasty in women, gynecomastia policies are variable and not based on strong scientific evidence. This study reviews U.S. insurance policies for coverage of gynecomastia surgery and compares these policies to the guidelines put forth by the American Society of Plastic Surgeons. METHODS: Sixty U.S. insurance companies were selected based on their market share value. Medicare was also evaluated. The policy for each company was identified using a Web-based search or by contacting the company directly. Policies were reviewed to abstract coverage criteria. All information gathered was compared to national recommendations. RESULTS: Of the 61 companies evaluated, 38% did not have a well-defined policy for gynecomastia surgery and assessed each request on a case-by-case basis with no defined criteria. The remaining 62% of providers held a defined policy. Companies often required thorough documentation of breast size, body mass index, extent and duration of symptoms, and prior treatments, but requirements varied between insurers. Many of these policies were limited in their coverage, e.g. they would cover tissue excision but not liposuction. Fourteen companies would consider of coverage for patients younger than 18 years. CONCLUSIONS: Coverage of gynecomastia surgery varies across insurers. Insurance company considerations do not often align with patient concerns and physician recommendations on gynecomastia and its treatment options. Coverage criteria should be reevaluated and universally established, to expand access to care and improve treatment efficiency.


Assuntos
Ginecomastia/cirurgia , Política de Saúde/economia , Acesso aos Serviços de Saúde/economia , Cobertura do Seguro/estatística & dados numéricos , Mamoplastia/economia , Ginecomastia/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/normas , Masculino , Mamoplastia/normas , Medicare/economia , Medicare/estatística & dados numéricos , Sociedades Médicas/normas , Cirurgia Plástica/normas , Estados Unidos
6.
Breast J ; 25(3): 488-492, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30983100

RESUMO

BACKGROUND: Persistent socioeconomic disparities are evident in the delivery of health care. Despite previous research into health disparities, the extent of the effect of economic inequalities in the management of breast cancer is not well understood. The purpose of our study is to perform a national assessment of the impact of economic factors on key aspects of breast cancer management. METHODS: This is a retrospective study using data from the National Cancer Database. The population consisted of female patients with primary breast cancer diagnosed between 2011 and 2015. Patients were categorized based on household income and insurance status. Outcomes investigated were stage at diagnosis, rate of breast conservation therapy, use of immediate reconstruction following mastectomy, and administration of systemic therapy for stage 3 and 4 disease. Multivariable logistic regression analyses were performed to determine significant associations between economic factors and clinical outcomes. Survival analysis was performed to evaluate the influence of income and insurance on survival. RESULTS: In total, 666 487 women were evaluated. Multivariable regression analyses revealed that patients with lower income (OR, 1.23) and no insurance (OR, 1.64) were more often diagnosed with later stage disease. Patients with lower income (OR, 1.08) and no insurance (OR, 1.05) had a higher likelihood of undergoing mastectomy instead of breast conserving therapy. Patients with lower income (OR, 0.51) and no insurance (OR, 0.27) were less likely to receive immediate breast reconstruction. Administration of systemic therapy was less frequent in patients with lower income (OR, 0.90) and no insurance (OR, 0.52). A survival benefit was demonstrated in patients with high income and insurance. CONCLUSION: Our findings demonstrate prevailing disparities in the delivery of care among patients with limited economic resources, which pertains to some of the most important aspects of breast cancer care. The full etiology of the observed disparities is complex and multifactorial, and a better understanding of these issues offers the potential to close the existing gap in quality of care.


Assuntos
Neoplasias da Mama/terapia , Renda/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Mamoplastia/estatística & dados numéricos , Mastectomia Segmentar/estatística & dados numéricos , Neoplasias da Mama/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Mamoplastia/economia , Mastectomia Segmentar/economia , Estudos Retrospectivos , Fatores Socioeconômicos , Estados Unidos
7.
Br J Surg ; 106(5): 586-595, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30835827

RESUMO

BACKGROUND: Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure and its economic impact is significant. This study aimed to analyse whether a direct one-stage IBBR with use of an acellular dermal matrix (ADM) is more cost-effective than two-stage (expander-implant) breast reconstruction. METHODS: The BRIOS (Breast Reconstruction In One Stage) study was an open-label multicentre RCT in which women scheduled for skin-sparing mastectomy and immediate IBBR were randomized between one-stage IBBR with ADM or two-stage IBBR. Duration of surgery and hospital stay, and visits for the primary surgery, unplanned and cosmetic procedures were recorded. Costs were estimated at an institutional level. Health status was assessed by means of the EuroQol Five Dimensions 5L questionnaire. RESULTS: Fifty-nine patients (91 breasts) underwent one-stage IBBR with ADM and 62 patients (92 breasts) two-stage IBBR. The mean(s.d.) duration of surgery in the one-stage group was significantly longer than that for two-stage IBBR for unilateral (2·52(0·55) versus 2·02(0·35) h; P < 0·001) and bilateral (4·03(1·00) versus 3·25(0·58) h; P = 0·017) reconstructions. Costs were higher for one-stage compared with two-stage IBBR for both unilateral (€12 448 (95 per cent c.i. 10 722 to 14 387) versus €9871 (9373 to 10 445) respectively; P = 0·025) and bilateral (€16 939 (14 887 to 19 360) versus €13 383 (12 414 to 14 669); P = 0·002) reconstructions. This was partly related to the use of relatively expensive ADM. There was no difference in postoperative health status between the groups. CONCLUSION: One-stage IBBR with ADM was associated with higher costs, but similar health status, compared with conventional two-stage IBBR. Registration number: NTR5446 ( http://www.trialregister.nl).


Assuntos
Derme Acelular , Implantes de Mama , Análise Custo-Benefício , Mamoplastia/economia , Mamoplastia/métodos , Expansão de Tecido , Neoplasias da Mama/cirurgia , Feminino , Humanos , Tempo de Internação , Mamoplastia/efeitos adversos , Mastectomia , Duração da Cirurgia , Medidas de Resultados Relatados pelo Paciente , Complicações Pós-Operatórias , Estudos Prospectivos , Reoperação , Resultado do Tratamento
8.
Plast Reconstr Surg ; 143(3): 465e-476e, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30817637

RESUMO

BACKGROUND: The purpose of this systematic review was to comprehensively summarize barriers of access to breast reconstruction and evaluate access using the Penchansky and Thomas conceptual framework based on the six dimensions of access to care. METHODS: The authors performed a systematic review that focused on (1) breast reconstruction, (2) barriers, and (3) breast cancer. Eight databases (i.e., EMBASE, MEDLINE, PsycINFO, CINHAL, ePub MEDLINE, ProQuest, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials) were searched. English peer-reviewed articles published between 1996 and 2016 were included. RESULTS: The authors' search retrieved 4282 unique articles. Two independent reviewers screened texts, selecting 99 articles for inclusion. All studies were observational and qualitative in nature. The availability of breast reconstruction was highest in teaching hospitals, private hospitals, and national cancer institutions. Accessibility affected access, with lower likelihood of breast reconstruction in rural geographic locations. Affordability also impacted access; high costs of the procedure or poor reimbursement by insurance companies negatively influenced access to breast reconstruction. Acceptability of the procedure was not universal, with unfavorable physician attitudes toward breast reconstruction and specific patient and tumor characteristics correlating with lower rates of breast reconstruction. Lastly, lack of patient awareness of breast reconstruction reduced the receipt of breast reconstruction. CONCLUSIONS: Using the access-to-care framework by Penchansky and Thomas, the authors found that barriers to breast reconstruction existed in all six domains and interplayed at many levels. The authors' systematic review analyzed this complex relationship and suggested multiprong interventions aimed at targeting breast reconstruction barriers, with the goal of promoting equitable access to breast reconstruction for all breast cancer patients.


Assuntos
Neoplasias da Mama/cirurgia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Mamoplastia/estatística & dados numéricos , Mastectomia/efeitos adversos , Austrália , Mama/cirurgia , Canadá , Feminino , Acesso aos Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde , Disparidades em Assistência à Saúde/economia , Humanos , Mamoplastia/economia , Reino Unido , Estados Unidos
9.
World J Surg ; 43(6): 1546-1553, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30719555

RESUMO

BACKGROUND: This study aimed to measure the use of pathology evaluation of breast specimens among patients undergoing reduction mammaplasty and assess rates of new diagnoses of breast disease and associated cost. METHODS: We analyzed the Truven MarketScan Databases from 2009 to 2015 to identify adult female patients undergoing reduction mammaplasty for macromastia. We recorded patient age, rates of obtaining pathology evaluation, new diagnoses of benign or malignant breast disease after pathology evaluation, and total cost for the surgery encounter. RESULTS: Among 17,738 macromastia patients undergoing reduction mammaplasty, 91.3% (n = 16,193) received pathology evaluation. Pathology evaluation rates were clinically similar across age groups <70 years (90.8-92.1%) and slightly lower for patients ≥70 (85.0%). Among 6987 patients less than 40 years who received pathology evaluation, 0.06% (n = 4) were subsequently diagnosed with malignant breast disease within 3 months, compared to 0.23% in the entire cohort (n = 37/16,193). Pathology claims resulted in an added $307 (SD 251) on average for the breast reduction surgery encounters. CONCLUSIONS: Breast tissue after reduction mammaplasty is routinely submitted for pathology evaluation, without consideration of age-based risk for breast cancer. Routine pathology evaluation of breast tissue in patients in lower risk age groups (less than 40 years) required an additional $536,000 on average to detect a single occult breast cancer compared to an added $85,600 to detect a new malignancy in patients 40 years and older. Clinicians and policy makers should consider whether routine pathology evaluation of breast tissue should be individualized based on risk factors for breast cancer.


Assuntos
Neoplasias da Mama/diagnóstico , Mama/anormalidades , Mama/patologia , Hipertrofia/cirurgia , Mamoplastia , Adolescente , Adulto , Idoso , Mama/cirurgia , Estudos de Coortes , Feminino , Humanos , Mamoplastia/economia , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
10.
Plast Reconstr Surg ; 143(4): 1269-1274, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30730499

RESUMO

BACKGROUND: Postsurgical pain management is critical to patient satisfaction and value. Several studies have evaluated liposomal bupivacaine in postoperative pain management protocols; however, its economic feasibility remains undefined. This study analyzes the economic impact of liposomal bupivacaine using a national claims database to assess postoperative clinical and financial outcomes in plastic and reconstructive procedures. METHODS: The Vizient Clinical Data Base/Resource Manager electronic database was reviewed for plastic surgery procedures (i.e., abdominoplasty, abdominal wall reconstruction, mastectomy with immediate tissue expander placement, mastectomy with direct-to-implant reconstruction, autologous breast reconstruction, and augmentation mammaplasty) at participating hospitals from July 1, 2016, to July 1, 2017. The main outcome measures were the length of stay; 7-, 14-, and 30-day readmission rates; and direct and total costs observed. RESULTS: During the study period, 958 total cases met inclusion criteria. Liposomal bupivacaine was used in 239 cases (25 percent). Compared with cases that did not use liposomal bupivacaine, liposomal bupivacaine cases had a decreased length of stay (9.2 days versus 5.8 days), decreased cost (total cost, $39,531 versus $28,021; direct cost, $23,960 versus $17,561), and lower 30-day readmission rates (4 percent versus 0 percent). The 14- and 7-day readmission rates were similar between the two groups. CONCLUSIONS: The use of liposomal bupivacaine may contribute to a reduction in length of stay, hospital costs, and 30-day readmission rates for abdominal and breast reconstructive procedures, which could contribute to a favorable economic profile from a system view. Focusing on the measurement and improvement of value in the context of whole, definable, patient processes will be important as we transition to value-based payments.


Assuntos
Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Procedimentos Cirúrgicos Reconstrutivos/economia , Parede Abdominal/cirurgia , Abdominoplastia/economia , Abdominoplastia/estatística & dados numéricos , Anestésicos Locais/economia , Bupivacaína/economia , Custos e Análise de Custo , Feminino , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Lipossomos , Mamoplastia/economia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
11.
Am J Surg ; 218(3): 597-604, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30739739

RESUMO

PURPOSE: Breast cancer surgical treatment may include large volume displacement oncoplastic surgery (LVOS) or mastectomy with free flap reconstruction (MFFR). We investigated the cost-utility between LVOS versus MFFR to determine which approach was most cost-effective. METHODS: A literature review was performed to calculate probabilities for clinical outcomes for each surgical option (LVOS versus MFFR), and to obtain utility scores that were converted into quality adjusted life years (QALYs) as measures for clinical effectiveness. Average Medicare payments were surrogates for cost. A decision tree was constructed and an incremental cost-utility ratio (ICUR) was used to calculate cost-effectiveness. RESULTS: The decision tree demonstrates associated QALYs and costs with probabilities used to calculate the ICUR of $3699/QALY with gain of 2.7 QALY at an additional cost of $9987 proving that LVOS is a cost-effective surgical option. One-way sensitivity analysis showed that LVOS became cost-ineffective when its clinical effectiveness had a QALY of less than 30.187. Tornado Diagram Analysis and Monte-Carlo simulation supported our conclusion. CONCLUSION: LVOS is cost-effective when compared to MFFR for the appropriate breast cancer patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: II.


Assuntos
Neoplasias da Mama/cirurgia , Análise Custo-Benefício , Retalhos de Tecido Biológico , Mamoplastia/economia , Mamoplastia/métodos , Mastectomia/economia , Mastectomia/métodos , Técnicas de Apoio para a Decisão , Feminino , Humanos
13.
Ann Surg Oncol ; 26(5): 1190-1201, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30673898

RESUMO

BACKGROUND: Surgery for breast cancer can have significant impact on patient quality-of-life. Cost-utility analysis provides a way to analyze the economic impact of a surgical procedure with the change in a patient's quality of life. Utility scores are used in these analyses to quantify the impact on quality of life. We undertook a systematic review of the literature on breast cancer surgical procedures to compile a repository of utility scores and to assess gaps in the current literature. METHODS: Following PRISMA guidelines, a systematic review was performed for studies reporting utility scores for breast surgery and breast reconstruction. The health states and utility scores were extracted and grouped into seven procedural categories based on oncologic and reconstructive methods. Mean utility score and ranges were calculated and reported for each procedural category. RESULTS: Nineteen articles met the inclusion criteria assessing 118 health states. Most utility scores were obtained from healthcare professionals. Breast-conserving therapy yielded the highest mean utility score at 0.79, whereas mastectomy yielded a mean utility score of 0.75. Among reconstruction health states, implant reconstruction had a lower score than autologous reconstruction (0.64 implant vs. latissimus dorsi 0.69 and TRAM/DIEP 0.71). No utility scores were found associated with oncoplasty or nipple-sparing mastectomy procedures. CONCLUSIONS: A reliable body of utility scores is important in enabling future cost-utility and value-based analysis comparisons for breast surgical oncology. Additional work is needed to obtain health state assessments from the patient perspective, as well as assessment of more modern surgical and reconstructive approaches.


Assuntos
Neoplasias da Mama/economia , Custos e Análise de Custo , Mamoplastia/economia , Mastectomia/economia , Qualidade de Vida , Neoplasias da Mama/cirurgia , Feminino , Humanos
14.
Plast Reconstr Surg ; 143(1S Management of Surgical Incisions Utilizing Closed-Incision Negative-Pressure Therapy): 36S-40S, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30586102

RESUMO

BACKGROUND: Breast cancer accounts for 30% of all new cancer diagnoses in women. Although more options are now available regarding breast reconstruction, the risk of complications (eg, infection, dehiscence, and expander exposure) is also prevalent and must be considered when choosing a reconstruction option because the cost for complications can be substantial. METHODS: A hypothetical cost model was applied to clinical outcomes of a previous retrospective study comparing the use of closed-incision negative-pressure therapy (ciNPT) and standard of care (SOC) over breast incisions after immediate reconstruction. The adjusted complication cost for a mastectomy with reconstruction was a mean of $10,402 and was calculated using a database of inpatient, outpatient, and carrier claims. RESULTS: The previous retrospective study included data on 665 breasts (ciNPT = 331, SOC = 334) and 356 female patients (ciNPT = 177, SOC = 179) and reported on complication rates at the breast level: 8.5% (28/331) for the ciNPT breast group versus 15.9% (53/334) for the SOC group (P = 0.0092). In the ciNPT group, 24/177 patients (13.6%) had a complication, whereas in the SOC group, 38/179 patients (21.2%) had a complication. Based on the adjusted mean complication cost of $10,402, total complication cost for the ciNPT group was $250,000 versus $395,000 for the SOC group with a per-patient cost savings of $218.00 with ciNPT. CONCLUSION: The authors' preliminary findings show potential cost savings with the use of ciNPT over breast incisions and warrant further study regarding the cost-effectiveness of ciNPT compared with standard of care after immediate breast reconstruction.


Assuntos
Análise Custo-Benefício , Custos de Cuidados de Saúde/estatística & dados numéricos , Mamoplastia/economia , Tratamento de Ferimentos com Pressão Negativa/economia , Cuidados Pós-Operatórios/economia , Complicações Pós-Operatórias/prevenção & controle , Ferida Cirúrgica/terapia , Neoplasias da Mama/economia , Neoplasias da Mama/cirurgia , Redução de Custos/estatística & dados numéricos , Feminino , Humanos , Mastectomia/economia , Modelos Econômicos , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/economia , Estudos Retrospectivos , Ferida Cirúrgica/economia , Estados Unidos
15.
Ann Surg Oncol ; 26(1): 62-70, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30327971

RESUMO

BACKGROUND: Prior work has shown that the competitiveness of the market in which hospitals operate is associated with use of surgical procedures. This study examined the association between regional market competition and use of breast reconstruction for women with breast cancer and ductal carcinoma in situ undergoing mastectomy. METHODS: Women who underwent mastectomy from 2010 to 2011 recorded in the National Inpatient Sample were selected. The competitive market environment for each hospital in which patients were treated was estimated using the Herfindahl-Hirschman Index. Multivariable models were developed to examine the association between regional market competition and breast reconstruction, with adjustment for other clinical, demographic, and structural variables. RESULTS: Immediate breast reconstruction was performed for 9902 (45%) of 22,011 women. The rate of immediate breast reconstruction was 34.5% at hospitals in non-competitive markets, 49% at hospitals in moderately competitive markets, and 56.4% at hospitals in highly competitive markets (P < 0.0001). In a multivariable model, women in moderately competitive markets were 24% (risk ratio [RR] 1.24; 95% confidence interval [CI] 1.10-1.41) more likely to undergo immediate breast reconstruction than women in noncompetitive markets, whereas those in competitive markets were 25% (RR 1.25; 95% CI 1.11-1.41) more likely to have reconstruction. Later year of treatment, higher census tract income level, and residence in an urban area were associated with an increased likelihood of reconstruction (P < 0.05 for all). In contrast, older age, non-white race, and non-commercial insurance were associated with a lower likelihood of reconstruction (P < 0.05 for all). CONCLUSION: Patients who undergo mastectomy at hospitals in competitive markets are more likely to undergo immediate breast reconstruction.


Assuntos
Neoplasias da Mama/cirurgia , Carcinoma Intraductal não Infiltrante/cirurgia , Assistência à Saúde/economia , Competição Econômica , Mamoplastia/estatística & dados numéricos , Marketing de Serviços de Saúde/economia , Mastectomia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/economia , Carcinoma Intraductal não Infiltrante/economia , Feminino , Seguimentos , Hospitais , Humanos , Mamoplastia/economia , Pessoa de Meia-Idade , Prognóstico
16.
J Plast Reconstr Aesthet Surg ; 72(1): 52-61, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30270015

RESUMO

BACKGROUND: The EuroQol EQ-5D-5L instrument is the most widely used quality of life (QoL) measure in health economic evaluations. It is unclear whether such a generic instrument is valid enough to estimate the benefits of breast reconstruction (BR), given the specific changes observed in QoL after BR. Hence, we aimed to evaluate the validity of the EQ-5D-5L in patients who had undergone postmastectomy BR. METHODS: In a 10-year cross-sectional cohort study, 463 mastectomy patients completed an online survey: 202 patients with autologous-BR (A-BR), 103 with implant-based-BR (I-BR), and 158 without BR (MAS). The results were used to evaluate the psychometric performance of the EQ-5D-5L with respect to the ceiling effect and to known-group, convergent, and discriminant validity, by comparing it with the Breast-Q, the cancer-specific (EORTC-QLQ-C30), and breast cancer-specific (EORTC-QLQ-BR23) questionnaires. RESULTS: The EQ-5D-5L was able to discriminate between patients with and without complications, MAS with or without BR and MAS versus the general population. It was, however, not able to discriminate between A-BR vs. I-BR as well as BR vs. general population. It is not clear whether this was due to the insensitivity of the instrument, insufficient sample sizes, or because there were no actual differences in QoL between these groups. Good convergent and discriminant validity of both the EQ-5D-5L and its individual dimensions were demonstrated. Additional support for the instrument's validity was revealed by moderate correlations between the generic EQ-5D-5L and specific QoL aspects of BR such as sexuality and body image. CONCLUSIONS: The results of this study support the validity of the EQ-5D-5L as an outcome measure in health economic evaluations of BR.


Assuntos
Neoplasias da Mama/cirurgia , Mamoplastia/psicologia , Qualidade de Vida , Adulto , Distribuição por Idade , Idoso , Neoplasias da Mama/economia , Orçamentos , Análise Custo-Benefício , Estudos Transversais , Feminino , Nível de Saúde , Indicadores Básicos de Saúde , Humanos , Mamoplastia/economia , Mastectomia/economia , Mastectomia/psicologia , Pessoa de Meia-Idade , Países Baixos , Medidas de Resultados Relatados pelo Paciente , Pontuação de Propensão , Anos de Vida Ajustados por Qualidade de Vida , Inquéritos e Questionários
17.
J Reconstr Microsurg ; 35(1): 74-82, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30085346

RESUMO

BACKGROUND: The abdomen is the most common area from which tissue is harvested for autologous breast reconstruction. We sought to examine national data to determine the differences in total hospital charges, length of stay (LOS), and early postoperative complications following pedicled transverse rectus abdominis myocutaneous flap (pTRAM), free TRAM (fTRAM), deep-inferior epigastric perforator (DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps. METHODS: The 2009-2013 Nationwide Inpatient Sample Database was used to identify patients who underwent a unilateral mastectomy and only one type of abdominally based autologous flap (pTRAM, fTRAM, DIEP, and SIEA) during the same hospital admission. Outcomes of interest included total charges, LOS, and complications including revision of vascular anastomosis and hematoma. RESULTS: A total of 3,310 cases were identified, corresponding to 15,991 abdominally based unilateral immediate breast reconstructions after standard weighting was applied; 5,079 (31.8%) were pTRAM flaps, 4,461 (27.9%) were fTRAM flaps, 6,206 (38.8%) were DIEP flaps, and 245 (1.5%) were SIEA flaps. The mean total charges for pTRAM, fTRAM, DIEP, and SIEA flaps were $17,765.5, $22,637.6, $25,814.6, and $26,605.2, respectively (p < 0.0001). The mean LOS for pTRAM, fTRAM, DIEP, and SIEA flaps were 96.5, 106.5, 106.7, and 108.9 hours, respectively (p = 0.002). The rates for return to the OR for the revision of a vascular anastomosis for pTRAM, fTRAM, DIEP, and SIEA were 0.0%, 1.72%, 2.66%, and 5.64%, respectively (p < 0.0001). CONCLUSIONS: There is variation in the total charges, LOS, and early complications between pTRAM, fTRAM, DIEP, and SIEA flap-based breast reconstruction. fTRAM, DIEP, and SIEA flaps incur higher hospital total charges, have longer lengths of stay, and experience more immediate complications compared with pTRAM. Well-designed prospective trials are required to better understand the findings from this study with the inclusion of other critical outcomes such as patient satisfaction, aesthetic results, and long-term outcomes such as abdominal wall morbidity.


Assuntos
Neoplasias da Mama/cirurgia , Retalhos de Tecido Biológico/irrigação sanguínea , Mamoplastia , Mastectomia , Retalho Perfurante/irrigação sanguínea , Complicações Pós-Operatórias/cirurgia , Reto do Abdome/transplante , Neoplasias da Mama/economia , Estudos Transversais , Estética , Feminino , Preços Hospitalares , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Mamoplastia/economia , Mamoplastia/métodos , Mastectomia/economia , Mastectomia/métodos , Pessoa de Meia-Idade , Satisfação do Paciente , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Resultado do Tratamento
18.
J Surg Oncol ; 119(3): 388-396, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30562406

RESUMO

BACKGROUND AND OBJECTIVES: The deep inferior epigastric perforator (DIEP) flap may be associated with less long-term donor-site morbidity compared with free muscle-sparing transverse rectus abdominis myocutaneous flap (MS-TRAM) flap. However, DIEP flaps may have longer operative time and higher rates of acute postoperative complications. We performed a cost-effectiveness analysis (CEA) that compared the long-term costs and patient-reported outcomes between the two flaps. METHODS: A retrospective cohort of women who received free MS-TRAM or DIEP flap reconstruction between January 2008 and December 2012, with a minimum of 2-year follow-up, were recruited. Cost data of the primary reconstruction and any subsequent hospitalization due to complications from the reconstruction within 2 years were obtained. Each patient received a BREAST-Q questionnaire at 2 years post-reconstruction. RESULTS: In total, 227 patients (180 DIEP, 47 free MS-TRAM) were included. DIEP patients had significantly fewer abdominal hernia (P = 0.04). The adjusted-incremental cost-effectiveness ratios found that DIEP flap was more cost-effective to free MS-TRAM flap in the domains of "Physical Well-Being of the Abdomen" and "Satisfaction with Outcome." CONCLUSIONS: DIEP flap is the more cost-effective method of autologous breast reconstruction in the long-term compared with free MS-TRAM flap with respect to patient-reported abdominal well-being and overall satisfaction with the outcome.


Assuntos
Neoplasias da Mama/economia , Análise Custo-Benefício , Artérias Epigástricas/transplante , Retalhos de Tecido Biológico/transplante , Mamoplastia/economia , Complicações Pós-Operatórias/economia , Reto do Abdome/transplante , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Feminino , Seguimentos , Retalhos de Tecido Biológico/irrigação sanguínea , Humanos , Pessoa de Meia-Idade , Retalho Perfurante/irrigação sanguínea , Prognóstico , Reto do Abdome/irrigação sanguínea , Estudos Retrospectivos
19.
Plast Reconstr Surg ; 142(6): 836e-839e, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30489512

RESUMO

BACKGROUND: Routine histologic analysis of the mastectomy scar is well studied in the delayed breast construction population; no data regarding its utility in the immediate, staged reconstruction cohort have been published. METHODS: A retrospective review of all of the senior author's (C.D.C.) patients who underwent immediate, staged reconstruction was performed. The mastectomy scar was analyzed routinely at the time of expander-to-implant exchange. Six hundred forty-seven breasts were identified. The mastectomy scar, time between expander and permanent implant, average patient age, and mastectomy indication were calculated. A cost analysis was completed. RESULTS: All scar pathologic results were negative for in-scar recurrence. The majority, 353 breasts, underwent mastectomy for carcinoma, 94 for germline mutations, 15 for high-risk lesions, six for high family risk, and 179 for contralateral symmetry/risk reduction. The average age at mastectomy/expander placement was 47.7 ± 10.3 years, and the average time between expander placement and implant exchange was 254 ± 152 days. The total histologic charge per breast was $602. CONCLUSIONS: A clinically silent in-scar recurrence is, at most, a rare occurrence. Routine histologic analysis of the mastectomy scar can be safely avoided in the immediate, staged reconstruction cohort. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Neoplasias da Mama/economia , Cicatriz/economia , Mamoplastia/economia , Mastectomia/economia , Implante Mamário/economia , Implantes de Mama/economia , Neoplasias da Mama/cirurgia , Cicatriz/patologia , Análise Custo-Benefício , Feminino , Humanos , Mamoplastia/métodos , Mastectomia/métodos , Pessoa de Meia-Idade , Recidiva , Reoperação/economia , Estudos Retrospectivos , Expansão de Tecido/economia
20.
Plast Reconstr Surg ; 142(6): 1438-1446, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30489515

RESUMO

BACKGROUND: Market competition is believed to promote patient access and health care delivery. The authors examined the relationship between market competition and use of surgical services for cancer, using free flap immediate breast reconstruction as a model scenario. METHODS: This retrospective cross-sectional analysis of the 2008 to 2011 Nationwide Inpatient Sample identified female patients undergoing immediate breast reconstruction. The Herfindahl-Hirschman Index was used to describe hospital markets as competitive or consolidated. The relationship between market competition and free flap immediate breast reconstruction use was explored using a hierarchical model before and after race stratification. RESULTS: Seven thousand three hundred seventy-two (10.7 percent) of 68,966 patients underwent free flap immediate breast reconstruction. A consolidated market was associated with 35 percent lower odds of free flap immediate breast reconstruction (95 percent CI, 0.43 to 0.97). Undergoing an operation in a later year [OR, 1.40; 95 percent CI (per year), 1.21 to 1.63], nonwhite race (OR, 1.33; 95 percent CI, 1.10 to 1.60), private insurance (OR, 2.09; 95 percent CI, 1.59 to 2.76), and teaching hospital status (OR, 2.67; 95 percent CI, 1.73 to 4.13) were associated with higher rates of free flap reconstruction. Market consolidation was associated with 48 percent lower odds of undergoing free flap immediate breast reconstruction in nonwhite patients only (95 percent CI, 0.29 to 0.92). CONCLUSIONS: A hospital's willingness to provide surgical services may be subject to market pressures. Market competition is associated with increased odds of free flap immediate breast reconstruction and higher use by racial minorities.


Assuntos
Neoplasias da Mama/cirurgia , Retalhos de Tecido Biológico/estatística & dados numéricos , Mamoplastia/estatística & dados numéricos , Neoplasias da Mama/economia , Grupos de Populações Continentais/estatística & dados numéricos , Estudos Transversais , Assistência à Saúde/economia , Assistência à Saúde/estatística & dados numéricos , Competição Econômica , Economia Hospitalar , Utilização de Equipamentos e Suprimentos , Feminino , Retalhos de Tecido Biológico/economia , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Mamoplastia/economia , Marketing de Serviços de Saúde/economia , Marketing de Serviços de Saúde/estatística & dados numéricos , Mastectomia/economia , Mastectomia/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos
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