Economic Implications of Recent Trends in U. S. Immediate Autologous Breast Reconstruction

Background: Recent trends in U.S. breast oncology and autologous reconstruction, such as greater use of contralateral prophylactic mastectomies and microsurgery, may have increased reconstructive complication rates and costs. Simultaneously, with the increased complexity of autologous reconstruction in the setting of declining reimbursement, there may be market concentration of these procedures to specialized high-volume centers. This study aimed to (1) measure cost of autologous reconstruction in the setting of microsurgical technique, contralateral prophylactic mastectomies, and high-volume centers; and (2) analyze trends in market share of these procedures. Methods: Inflation-adjusted hospital charges were analyzed for autologous procedures using the Nationwide Inpatient Sample database (1998 to 2010), including a subgroup of microsurgical cases. Median charges were adjusted by patient case mix and analyzed by outcome, procedure type, and hospital volume using the Mann-Whitney test. Market share was evaluated through examination of trends in hospitals performing autologous reconstruction and procedures at high-volume centers. Results: Median charges for 21,016 autologous reconstructions were $22,198. Costs were higher for bilateral reconstruction ($34,202) and microsurgical cases ($57,449). Hospital charges increased from $20,315 (no complications) to $42,210 when both surgery-specific and systemic complications were present (p < 0.01). High-volume hospitals reduced charges by 7.5 percent and had lower costs in the setting of complications (p < 0.01). The number of hospitals performing autologous reconstructions decreased 35 percent, with increasing annual procedures in high-volume centers (48.3 to 73.3, p < 0.01). Conclusions: Bilateral reconstructions and microsurgical technique are associated with greater health care costs. The market concentration of autologous reconstruction to high-volume centers is associated with reduced charges. The long-term implications of this trend are unknown.