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Breast: Original Articles

Autologous Breast Reconstruction versus Implant-Based Reconstruction: How Do Long-Term Costs and Health Care Use Compare?

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

Author Information
Plastic and Reconstructive Surgery: February 2020 - Volume 145 - Issue 2 - p 303-311
doi: 10.1097/PRS.0000000000006422

Abstract

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

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

PATIENTS AND METHODS

Data Source

We conducted a retrospective analysis of data from OptumLabs Data Warehouse, which includes deidentified claims data for privately insured and Medicare Advantage enrollees in a large, private, U.S. health plan.5 The database contains longitudinal health information on enrollees, representing a diverse mixture of ages, ethnicities, and geographic regions across the United States.6 The health plan provides comprehensive full insurance coverage for physician, hospital, and prescription drug services.

Study Population

We identified all women (aged 18 to 64 years) with a diagnosis of breast cancer who underwent immediate breast reconstruction between January of 2004 and December of 2014. (See Table, Supplemental Digital Content 1, which shows the CPT codes used for cohort creation for mastectomy and for reconstruction, http://links.lww.com/PRS/D879.) The date of the mastectomy and immediate breast reconstruction hospitalization was defined as the index date. Patients were required to have at least 12 months of continuous medical coverage before the index surgery date (baseline period) and 2 years after the discharge date.

Independent Variables

Baseline characteristics included age, race (i.e., white, black, Hispanic, Asian, unknown), geographic region (i.e., Midwest, Northeast, South, West, other), Charlson-Deyo comorbidity index (modified), year of reconstruction, type of reconstruction (i.e., autologous or implant), hospital length of stay, and laterality. Age was stratified into four categories (i.e., 18 to 34 years, 35 to 44 years, 45 to 54 years, and 55 to 64 years). The Charlson-Deyo index was modified using only non–breast cancer baseline comorbidities captured by International Classification of Diseases, Ninth Revision, codes in any position on claims occurring within 12 months before the index reconstruction date.7 For analysis, the index was stratified into four categories (i.e., 0, 1, 2, and ≥3).

Outcomes

The primary outcomes were 2-year use and cost of care. Use measures included rates of subsequent hospitalizations, emergency room visits, and office visits during the 2 years after discharge of reconstruction hospitalization. Rates were presented per 100 women. OptumLabs data contain total paid amounts, which is the sum of out-of-pocket (patient) and health plan (insurer) spending associated with all medical claims (i.e., ambulatory visits, emergency room visits, inpatient hospitalizations, and other services). Costs were reported for the 2-year follow-up period from reconstruction hospitalization discharge and include professional services. All costs were adjusted to 2015 U.S. dollars using the Consumer Price Index.8 Reconstruction costs included all professional services from admission to discharge date of reconstruction hospitalization. The postreconstruction costs refer to all costs incurred over the subsequent 2 years after reconstruction hospitalization including inpatient, outpatient, and clinical services costs (including imaging) and any subsequent reconstruction costs. Of note, office visits during the global period were captured by CPT codes but have zero cost.

Statistical Analysis

Patient characteristics (i.e., age, race, region, modified Charlson-Deyo comorbidity, year of reconstruction, type of immediate reconstruction, length of stay, and laterality) were described using mean (standard deviation) or count (percentage) as appropriate. Furthermore, we examined differences in patient characteristics among patients with autologous breast reconstruction versus implant-based breast reconstruction using chi-square and t tests to assess univariate differences. Unadjusted use rates were compared between the autologous and implant-based breast reconstruction patients using t tests. A generalized linear model was used to adjust for patient characteristics and calculate predicted costs. Statistical differences in incremental costs were determined using 95 percent confidence intervals. A value of p < 0.05 was considered statistically significant. All statistical analyses were performed using SAS software version 9.4 (SAS Institute, Inc., Cary, N.C.).

RESULTS

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

Table 1. - Patient Characteristics of 12,296 Women Who Underwent Immediate Autologous or Implant-Based Breast Reconstruction following Mastectomy
ABR (%) IBBR (%) Total (%) p
No. 4257 8039 12,296
Mean age ± SD, yr 49.6 ± 7.6 48.6 ± 8.1 48.9 ± 7.9 <0.0001
Age group <0.0001
 18–34 years 120 (2.8) 362 (4.5) 482 (3.9)
 35–44 years 962 (22.6) 2132 (26.5) 3094 (25.2)
 45–54 years 1918 (45.1) 3496 (43.5) 5414 (44.0)
 55–64 years 1257 (29.5) 2049 (25.5) 3306 (26.9)
Race <0.0001
 White 2061 (48.4) 4328 (53.8) 6389 (52.0)
 Black 379 (8.9) 457 (5.7) 836 (6.8)
 Hispanic 251 (5.9) 438 (5.4) 689 (5.6)
 Asian 91 (2.1) 156 (1.9) 247 (2.0)
 Unknown/missing 1475 (34.6) 2660 (33.1) 4135 (33.6)
Census region <0.0001
 Midwest 742 (17.4) 1839 (22.9) 2581 (21.0)
 Northeast 724 (17.0) 1476 (18.4) 2200 (17.9)
 South 2355 (55.3) 3396 (42.2) 5751 (46.8)
 West 436 (10.2) 1328 (16.5) 1764 (14.3)
Mean modified Charlson Index ± SD 0.4 ± 0.8 0.4 ± 0.7 0.4 ± 0.7 0.0820
Modified Charlson group 0.3620
 0 2984 (70.1) 5750 (71.5) 8734 (71.0)
 1 966 (22.7) 1759 (21.9) 2725 (22.2)
 2 202 (4.7) 350 (4.4) 552 (4.5)
 ≥3 105 (2.5) 180 (2.2) 285 (2.3)
Year of reconstruction <0.0001
 2004 332 (7.8) 371 (4.6) 703 (5.7)
 2005 358 (8.4) 424 (5.3) 782 (6.4)
 2006 366 (8.6) 532 (6.6) 898 (7.3)
 2007 384 (9.0) 688 (8.6) 1072 (8.7)
 2008 392 (9.2) 719 (8.9) 1111 (9.0)
 2009 439 (10.3) 899 (11.2) 1338 (10.9)
 2010 393 (9.2) 947 (11.8) 1340 (10.9)
 2011 407 (9.6) 911 (11.3) 1318 (10.7)
 2012 378 (8.9) 927 (11.5) 1305 (10.6)
 2013 430 (10.1) 844 (10.5) 1274 (10.4)
 2014 378 (8.9) 777 (9.7) 1155 (9.4)
Mean mastectomy plus IBR length of stay ± SD, days 3.6 ± 2.1 1.9 ± 1.6 2.5 ± 1.9 <0.0001
Laterality <0.0001
 Bilateral 2508 (58.9) 6015 (74.8) 8523 (69.3)
 Unilateral 1749 (41.1) 2024 (25.2) 3773 (30.7)
IBR, immediate breast reconstruction; ABR, immediate autologous breast reconstruction; IBBR, immediate implant-based breast reconstruction.

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

Fig. 1.
Fig. 1.:
Immediate breast reconstruction (IBBR) trends and reconstructive method in the United States among privately insured women from 2004 to 2014.

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

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

Table 2. - Comparison of 2-Year Use Rates per 100 Women, Stratified by Procedure
Variable No. ABR IBBR p
Unilateral 3773
 Inpatient admissions 23.1 30.3 <0.0001
 Office visits 2283.6 2445.1 0.0002
 ER visits 31.0 29.9 0.442
Bilateral 8523
 Inpatient admissions 26.8 29.0 0.0372
 Office visits 2296.7 2395.1 0.0001
 ER visits 35.2 34.8 0.7211
ABR, immediate autologous breast reconstruction; IBBR, immediate implant-based breast reconstruction; ER, emergency room.

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

Table 3. - Comparison of 2-Year Use Rates per 100 Women, Stratified by Laterality
Variable No. Unilateral Bilateral p
ABR 4257
 Inpatient admissions 23.1 26.8 0.0063
 Office visits 2283.6 2296.7 0.6165
 ER visits 31.0 35.2 0.0051
IBBR 8039
 Inpatient admissions 30.3 29.0 0.2815
 Office visits 2445.1 2395.1 0.1004
 ER visits 29.9 34.8 0.0001
ABR, immediate autologous breast reconstruction; IBBR, immediate implant-based breast reconstruction; ER, emergency room.

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

Table 4. - Comparison of 2-Year Costs of Autologous and Implant-Based Breast Reconstruction for Unilateral and Bilateral Patients*
Procedure Predicted Cost
ABR (95% CI) IBBR (95% CI) Difference (95% CI)
Unilateral
 Reconstruction cost
  Mean $27,886 $19,478 $8408
  95% CI $27,429–$28,344 $19,118–$19,839 $7826–$8990
 Postreconstruction cost
  Mean $62,176 $79,447 −$17,272
  95% CI $61,417–$62,934 $78,744–$80,150 −$18,306 to −$16,238
 Total cost
  Mean $90,062 $98,926 −$8864
  95% CI $88,939–$91,185 $97,938–$99,913 −$10,359 to −$7369
Bilateral
 Reconstruction cost
  Mean $45,063 $23,399 $16,665
  95% CI $44,608–$45,518 $28,140–$28,657 $16,141–$17,188
 Postreconstruction cost
  Mean $73,138 $81,599 −$8461
  95% CI $72,437–$73,839 $81,161–$82,038 −$9277 to −$7646)
 Total cost
  Mean $118,201 $109,998 $8203
  95% CI $117,106–$119,297 $109,337–$110,659 $6924–$9483
ABR, autologous breast reconstruction; IBBR, implant-based breast reconstruction.
*All cost predictions were controlled for age, race, region, Charlson index, year of reconstruction, and length of stay.

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

Fig. 2.
Fig. 2.:
Immediate breast reconstruction cost trends and reconstructive method in the United States among privately insured women from 2004 to 2014. ABR, autologous breast reconstruction; IBBR, implant-based breast reconstruction.

DISCUSSION

In this analysis of 12,296 women undergoing immediate breast reconstruction following mastectomy in a large private insurer claims database, we aimed to characterize the 2-year health care use and total cost of care in women undergoing immediate implant-based and autologous reconstruction following mastectomy. Although the cost of the index surgery was lower for implant-based reconstruction, it was associated with higher aftercare costs than autologous reconstruction, resulting in similar 2-year total cost of care. We found that after the index surgery, implant-based reconstruction was associated with higher health care use than autologous reconstruction, specifically because of more subsequent inpatient admissions and office visits. In this study, more than two-thirds of all immediate breast reconstructions were bilateral. When analyzing health care use by laterality of the reconstructive surgery, we found that there were higher requirements for emergency room visits for bilateral breast reconstruction procedures, higher inpatient admissions for bilateral autologous reconstruction when compared to unilateral autologous reconstruction, but similar inpatient admissions for unilateral and bilateral implant-based reconstruction. Predictably, 2-year total cost of care was higher for bilateral breast reconstruction procedures, mostly because of higher reconstruction costs. Postreconstruction costs did not differ for unilateral and bilateral implant-based reconstruction. However, bilateral autologous breast reconstruction was associated with higher postreconstruction costs than unilateral autologous reconstruction.

To our knowledge, Fischer et al. published the only two published studies comparing longitudinal cost between implant-based breast reconstruction and autologous breast reconstruction.9,10 In the 2013 study, it is important to note that institutional financial data were used to derive cost associated with the completion of breast reconstruction over a 4-year period. These data did not include professional service fees or charges and did not include information on laterality of the reconstruction. Despite these limitations, the authors found that, compared with autologous reconstruction, implant-based reconstruction was associated with higher office visits, higher readmissions, higher number of surgical procedures, and an overall higher complication rate, which is in line with our study findings. Although the authors saw a trend toward lower cost for autologous reconstruction, no significant cost difference was found between autologous and implant-based breast reconstruction in their study. In the 2015 study, the authors found that initial health care charges were significantly lower in tissue expander breast reconstruction, when compared to autologous or direct-to-implant reconstruction.

One important finding of our study is that implant-based breast reconstruction is associated with more inpatient admissions and office visits. When patients were readmitted to the hospital, prosthetic device complication was the most common International Classification of Diseases, Ninth Revision, used to capture the diagnosis at admission. This diagnostic code encompasses a variety of complications, such as mechanical breakdown, displacement, and leakage, in addition to surgical-site infection. As for office visits, one could hypothesize that the higher frequency in implant-based reconstruction could be associated with required tissue expansions in two-stage implant-based reconstruction, and later unplanned office visits to discuss unplanned elective breast revision procedures.

The results of our study demonstrate that, at 2 years, total cost of care is similar between implant-based and autologous breast reconstruction, despite significant differences in index surgery and aftercare costs. These findings are supported by previously published work by Fischer et al.10 We found that the index surgery cost for implant-based reconstruction was significantly lower than for autologous reconstruction. This difference could be explained by the shorter length of hospital stay for implant-based reconstruction (1.9 days and 3.6 days, respectively), and by lower complication rates in the early postoperative period. In fact, several studies have demonstrated that autologous reconstruction is associated with a higher risk of 30-day complications when compared to implant-based reconstruction. In their 2015 study, Fischer et al. used data from four states’ inpatient and ambulatory surgery databases available through the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project to perform their analysis of women who underwent immediate breast reconstruction following mastectomy. In line with our study’s results, they found that initial health care charges were lower in women undergoing tissue expander breast reconstruction, when compared to those undergoing autologous or direct-to-implant reconstruction. Within 3 years from the index surgery, the authors report substantial rates of subsequent surgical procedures, narrowing the differences in health care charges when comparing the different reconstructive modalities. These findings also support our study’s observations.

Several factors may contribute to the rising costs of breast reconstruction care observed in our study. First, in the earlier years of the study period, acellular dermal matrix was introduced to the market, and there has been a steep rise in its use in breast reconstruction, which dramatically increased the costs of implant-based reconstruction. The use of other adjunct technologies, such as preoperative perforator imaging and intraoperative fluorescent angiography, may also contribute to the rising costs. Second, in 2006, the U.S. Food and Drug Administration lifted the moratorium on silicone breast implants, which quickly supplanted saline implants in implant-based reconstruction because of their superior characteristics. Third, fat grafting has become an increasingly popular adjunct procedure to improve the aesthetic outcomes of breast reconstruction. The American Society of Plastic Surgeons Fat Grafting Task Force first examined the literature on fat grafting to the breasts in 2009,11 and by 2013, a survey showed that 62 percent of plastic surgeons who responded to the questionnaire performed fat grafting in reconstructive breast surgery.12 Fourth, with the Women’s Health and Cancer Right Act of 1998, are women and/or plastic surgeons increasingly using health care resources for secondary breast reconstruction revision procedures to obtain the desired aesthetic result? Lastly, changing patterns in oncologic care may also play a role: our study’s findings highlighted the observed rising rates of contralateral prophylactic mastectomy in women diagnosed with unilateral breast cancer in the United States.13–17 In Boughey et al.’s study comparing 2-year unadjusted health care use rates and total cost of care between unilateral and bilateral mastectomy with immediate breast reconstruction, the 2-year total cost of care was higher in bilateral cases. Furthermore, women undergoing bilateral mastectomies and immediate breast reconstruction had increased rates of emergency room visits secondary to surgical-site complications.18 Bilateral mastectomies, with or without immediate breast reconstruction, have been associated with higher rates of postoperative complications.19–21 In our study, bilateral autologous reconstruction was associated with higher reconstruction costs and higher postreconstruction costs; interestingly, bilateral implant-based reconstruction was associated with higher reconstruction costs, but postreconstruction costs did not differ between unilateral and bilateral implant-based reconstruction. This finding could provide arguments in favor of immediate implant-based reconstruction as a preferred reconstructive modality in the context of contralateral prophylactic mastectomy, in light of the absence of postreconstruction cost differential between unilateral and bilateral implant-based reconstruction.

It is important to recognize certain limitations of administrative claims studies. First, claims data alone cannot guarantee that complete and accurate health data are provided. Second, our study design relied on billing codes to define our cohort, its baseline characteristics, and its outcomes. Although billing codes are prone to inaccuracies, these methods have been used extensively in the scientific literature. Third, our cohort includes only women with commercial health insurance and excludes those covered by government payers. Other limitations of our study include its observational nature, with absence of information on patient and provider decision-making for selection of a particular breast reconstruction technique. This may have resulted in a selection bias for autologous reconstruction when compared to implant-based reconstruction, and the two groups may be dissimilar for associated treatment factors such as radiation therapy and chemotherapy. Furthermore, no information on tumor stage or radiation exposure is available. In addition, this study examines only a 2-year period after the index procedure, because of a lack of sufficient available data to make comparisons beyond that period. One could hypothesize that this lack of available data may be attributable to reduced numbers of health insurance claims data beyond 2 years. To that effect, the study by Fischer et al. did demonstrate a limited number of complications and claims 2 years after the index operation.10 Lastly, this analysis is limited to immediate reconstruction, as it was not possible to obtain link mastectomy and delayed reconstruction codes to compare health care use and costs.

CONCLUSIONS

Health care reimbursement models are transitioning from volume-based to value-based models. Value-based health care measures health outcomes against the cost of delivering these outcomes. Assessing value of breast reconstruction approaches poses a unique challenge because of the inherent variability in breast reconstruction techniques that influences how we will define what constitutes an episode of care. Our analysis of a large series of women undergoing immediate breast reconstruction found that although index and subsequent costs varied between implant-based and autologous breast reconstruction, the total 2-year costs were similar. As the widespread adoption of a bundled care model is being considered in the United States to improve value of care, further research that incorporates comorbidities, outcomes data, health care use, and cost is needed to inform policy decisions in plastic surgery. Overall, our data provide an important addition to the literature as patients and their plastic surgeon often confront a difficult decision in choosing between breast reconstruction procedures.

ACKNOWLEDGMENT

This publication was made possible by funding from the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.

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