New York, N.Y. From the Plastic and Reconstructive Surgical Service, Memorial Sloan-Kettering Cancer Center.
Plast Reconstr Surg. 2014 Mar;133(3):463-470. doi: 10.1097/PRS.0000000000000039.
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.
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.
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).
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.
近年来，美国乳腺癌肿瘤学和自体重建领域的趋势发生了变化，例如更多地采用对侧预防性乳房切除术和微创手术，这可能会增加重建并发症的发生率和成本。与此同时，随着自体重建的复杂性增加，在报销金额下降的情况下，这些手术可能会集中到专门的高容量中心。本研究旨在：（1）测量在使用微创手术技术、对侧预防性乳房切除术和高容量中心的情况下自体重建的成本；（2）分析这些手术的市场份额趋势。
使用全国住院患者样本数据库（1998 年至 2010 年）分析了自体手术的通胀调整后医院收费，包括微创手术病例的亚组。通过患者病例组合对中位数收费进行调整，并使用曼-惠特尼检验按结果、手术类型和医院容量进行分析。通过检查进行自体重建和在高容量中心进行手术的医院的趋势来评估市场份额。
21016 例自体重建的中位数收费为 22198 美元。双侧重建（34202 美元）和微创手术病例（57449 美元）的费用更高。当出现特定于手术和全身性并发症时，医院收费从 20315 美元（无并发症）增加到 42210 美元（p < 0.01）。高容量医院的收费降低了 7.5%，并且在存在并发症的情况下费用更低（p < 0.01）。进行自体重建的医院数量减少了 35%，而高容量中心的年度手术数量增加了（48.3 到 73.3，p < 0.01）。
双侧重建和微创手术技术与更高的医疗保健成本相关。自体重建向高容量中心的市场集中与收费降低有关。这种趋势的长期影响尚不清楚。
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