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The Economic Implications of Changing Trends in Breast Flap Reconstruction in the United States
Sophia Caccavale, GED, Irene Pien, BS, Michael Cheung, MD, Parag Butala, MD, Duncan Hughes, MD, Cassandra Ligh, BS, Michael R. Zenn, MD, Scott T. Hollenbeck, MD.
Duke University Medical Center, Durham, NC, USA.
Enthusiasm for the Deep Inferior Epigastric artery Perforator (DIEP) flap for breast reconstruction has grown in recent years. However, this flap is not performed at all centers or by all plastic surgeons that engage in breast reconstruction. It is unclear how widespread the DIEP flap has become in the United States and how this has affected the charges and costs associated with breast flap surgery.
METHODS: We used 3 years (2009 - 2011) of the Nationwide Inpatient Sample (NIS) to identify the population of patients undergoing Latissimus dorsi (LD), pedicle TRAM (pTRAM), free TRAM (fTRAM) and DIEP flaps as principle procedures. Patient identification was based on ICD-9 procedure codes, including LD (85.71), pTRAM (85.72), fTRAM (85.73) and DIEP (85.74). This generated 19,182 hospital discharges for review. Charges were defined by the NIS as the amount the hospital billed for services. Costs were defined by the NIS as the actual cost of production (ie. the amount the hospital received) using hospital charge-to-cost ratios. Statistical comparisons were made using linear regression, t-test and ANOVA models.
RESULTS: Between 2009 and 2011 the total number of discharges did not change significantly. In regards to number of discharges per year for each flap, there was no significant trend for LD (p=0.99) or pTRAM (p=0.29) flaps. However, the rate of fTRAM’s dropped significantly (p<0.02) and the rate of DIEP’s increased significantly (p<0.03) (Figure 1). Over the 3 years evaluated, the average percentage of patients with private insurance and any of the 4 flaps increased at a rate of 4.26% per year. Overall, the group varied significantly in the rate of private insurance (ANOVA p<0.02), with DIEP flap patients having the highest overall rate of private insurance (80.3%) and LD flap patients having the lowest (67.4%). The average charge / flap was $40,704 (LD); $51,933 (pTRAM); $69,909 (fTRAM); and $82,320 (DIEP) and none of these increased significantly over the 3 years. The average costs / flap for each flap was $12,017 (LD); $15,538 (pTRAM); $20,756 (fTRAM); and $23,616 (DIEP) and only the fTRAM flap average cost increased significantly over the 3 years (p=0.03). The overall charges for all 4 flaps increased at a rate of 0.0057% while overall costs increased at a rate of 0.029%. This can be explained by the increased number of DIEP flaps performed and the decreasing charges and increasing costs per year associated with these flaps. Despite the increasing overall costs for breast flap surgery it remains 0.27% less than the rate of inflation within the United States.
CONCLUSION: Recent trends in breast reconstruction show that the DIEP flap is being performed more frequently at both higher charge and higher costs than LD, pTRAM and fTRAM flaps. This has resulted in a non-significant increase in the overall costs for these four breast flaps. This remains less than the rate of inflation in the United States.
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