Krishnan Naveen M, Fischer John P, Basta Marten N, Nahabedian Maurice Y
Washington, D.C.; and Philadelphia, Pa.
From the Department of Plastic Surgery, Georgetown University Hospital; and the Division of Plastic Surgery, Perleman School of Medicine, University of Pennsylvania.
Plast Reconstr Surg. 2016 Sep;138(3):537-547. doi: 10.1097/PRS.0000000000002428.
Prosthetic breast reconstruction is most commonly performed using the two-stage (expander-implant) technique. However, with the advent of skin-sparing mastectomy and the use of acellular dermal matrices, one-stage prosthetic reconstruction has become more feasible. Prior studies have suggested that one-stage reconstruction has economic advantages relative to two-stage reconstruction despite a higher revision rate. This is the first cost-utility analysis to compare the cost and quality of life of both procedures to guide patient care.
A comprehensive literature review was conducted using the MEDLINE, EMBASE, and Cochrane databases to include studies directly comparing matched patient cohorts undergoing single-stage or staged prosthetic reconstruction. Six studies were selected examining 791 direct-to-implant reconstructions and 1142 expander-implant reconstructions. Costs were derived adopting both patient and third-party payer perspectives. Utilities were derived by surveying an expert panel. Probabilities of clinically relevant complications were combined with cost and utility estimates to fit into a decision tree analysis.
The overall complication rate was 35 percent for single-stage reconstruction and 34 percent for expander-implant reconstruction. The authors' baseline analysis using Medicare reimbursement revealed a cost decrease of $525.25 and a clinical benefit of 0.89 quality-adjusted life-year when performing single-stage reconstructions, yielding a negative incremental cost-utility ratio. When using national billing, the incremental cost-utility further decreased, indicating that direct-to-implant breast reconstruction was the dominant strategy. Sensitivity analysis confirmed the robustness of the authors' conclusions.
Direct-to-implant breast reconstruction is the dominant strategy when used appropriately. Surgeons are encouraged to consider single-stage reconstruction when feasible in properly selected patients.
乳房假体再造最常用的方法是两阶段（扩张器 - 植入物）技术。然而，随着保乳皮肤切除术的出现以及脱细胞真皮基质的应用，单阶段假体再造变得更加可行。先前的研究表明，尽管单阶段再造的翻修率较高，但相对于两阶段再造，它具有经济优势。这是第一项比较两种手术的成本和生活质量以指导患者护理的成本效用分析。
使用MEDLINE、EMBASE和Cochrane数据库进行了全面的文献综述，以纳入直接比较接受单阶段或分期假体再造的匹配患者队列的研究。选择了六项研究，检查了791例直接植入式再造和1142例扩张器 - 植入物再造。成本从患者和第三方支付者两个角度得出。效用通过对一个专家小组进行调查得出。将临床相关并发症的概率与成本和效用估计相结合，以纳入决策树分析。
单阶段再造的总体并发症发生率为35%，扩张器 - 植入物再造为34%。作者使用医疗保险报销的基线分析显示，进行单阶段再造时成本降低了525.25美元，临床获益为0.89个质量调整生命年，产生了负的增量成本效用比。使用全国计费时，增量成本效用进一步降低，表明直接植入式乳房再造是主导策略。敏感性分析证实了作者结论的稳健性。
直接植入式乳房再造在适当使用时是主导策略。鼓励外科医生在适当选择的患者可行时考虑单阶段再造。
