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Nationwide Cost Comparison of Autologous vs Implant-based Postmastectomy Reconstruction
Stephanie Scurci, M.D.1, Joshua Parecco, MD1, Lucy De La Cruz, MD1, Abhishek Chatterjee, MD2.
1University of Miami - Palm Beach, Boynton Beach, FL, USA, 2Tufts Medical Center, Boston, MA, USA.

Nationwide Cost Comparison of Autologous vs. Implant-Based Post-Mastectomy Reconstruction
PURPOSE: Cost is one of many factors that motivate breast reconstruction decisions. Over the past several years, the number of post-mastectomy reconstructions performed have rapidly increased and a shift from autologous to implant-based reconstructions has occurred. There is a federal mandate for breast reconstruction since the passage of the Women’s Health and Cancer Right Acts in 1998, however access to all types of reconstructive options is not ubiquitous. This study compared both charge and cost for autologous and implant-based reconstructions. We also assessed whether patients’ financial factors, including insurance type and median income, were associated with either type of reconstruction.
METHODS: The Nationwide Readmission Database (NRD) for 2013 was queried for all patients undergoing mastectomy for ductal carcinoma in situ (DCIS) or invasive breast cancer with reconstruction. Patients with autologous reconstruction were compared to patients reconstructed with a tissue expander or implant. Various patient characteristics were compared using Chi-squared for categorical variables or student’s t-test for continuous variables.
RESULTS: A total of 13,728 patients underwent post-mastectomy reconstruction, 4,175 (30.4%) autologous and 9,554 (69.5%) implant-based reconstructions. Both the mean hospital cost ($22,827 vs $19,296) and charge ($83,927 vs $73,263) were greater for autologous compared to implant-based reconstructions. The mean cost-charge ratio for autologous reconstructions was 3.68 vs 3.79 for implant-based reconstruction. Neither insurance type nor median income quartile was independently associated with either type of breast reconstruction. Regarding outcomes, implant-based reconstruction was associated with a lower readmission rate (1.1% versus 2.9%, p=0.01). Increased age and comorbidities were found to be associated with autologous reconstructions.
CONCLUSIONS:
Autologous reconstructions were more expensive than implant-based reconstructions. Despite this difference in cost, neither insurance type nor median household income was independently associated with either reconstruction type. This is unlike older studies from the 1990s-2000s, which found that private insurance and higher median income were predictors for autologous reconstruction. Although median cost and charge was greater for autologous breast reconstruction, the cost-charge ratio for implant-based reconstructions was greater than autologous. This corresponds with the decreased Medicare reimbursement for autologous reconstructions compared to implant-based, despite the longer operating room time and increased technical difficulty associated with autologous reconstruction. This difference in cost-charge ratio across insurance types may drive reconstruction type moreso than patients’ personal financial factors.

Table 1. Cost, socioeconomic, and demographic characteristics of autologous vs implant-based breast reconstruction.
CharacteristicsAutologous(n=4,175)Tissue expander or implant(n=9,554)p-value
Mean Charges$83,927$73,263<0.01
Mean Cost$22,827$19,296<0.01
Primary Payer0.07
Private insurance3040 (73)6876 (72)
Medicare602 (14)1396 (15)
Medicaid354 (9)925 (10)
Other179 (4)357 (4)
Median household income0.32
Unknown57 (1)161 (2)
$1 - $37,999604 (15)1283 (13)
$38,000 - $47,999782 (19)1800 (19)
$48,000 - $63,9991051 (25)2470 (26)
$64,000 or more1681 (40)3840 (40)
Readmission (within 30 days)204 (5)353 (4)<0.01
Median Age (years)53.452.1<0.01
Median Comorbidities1.10.9<0.01


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