Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.
Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
J Am Coll Surg. 2020 May;230(5):784-794e3. doi: 10.1016/j.jamcollsurg.2020.01.035. Epub 2020 Mar 26.
Enhanced recovery after surgery (ERAS) programs are being used increasingly in microvascular breast reconstruction. However, it is unclear as to what extent the benefits outweigh the costs. We hypothesized that an ERAS pathway for microvascular breast reconstruction would be cost-effective relative to the standard of care.
A decision-analytic model was made incorporating clinically relevant health states after microvascular breast reconstruction with ERAS vs standard of care. Probabilities and utility scores were abstracted from published sources, and a third-party payer perspective was adopted. Time-driven activity-based costing was used to map and estimate costs attributed to ERAS. Sensitivity analyses were performed to examine the robustness of the results.
The results of 5 studies, totaling 986 patients, were pooled to generate health state probabilities. ERAS was found to be dominant, being both less expensive and more effective than standard of care. On sensitivity analysis, ERAS becomes cost-ineffective (incremental cost-utility ratio > $50,000/quality-adjusted life year) at an amount > $19,336.75. Length of stay would have to be reduced from 5.96 days to 3.36 days for standard of care to become cost-effective. Monte-Carlo analysis demonstrated ERAS to be the more cost-effective option across a range of willingness-to-pay values.
Despite the increased medication and personnel costs attributed to ERAS, it is less costly overall and associated with superior outcomes compared with standard of care. These findings lend additional support to the value of ERAS implementation in microvascular breast reconstruction. Time-driven activity-based costing provides granular estimates and are useful in quality-improvement initiatives.
加速康复外科（ERAS）方案越来越多地应用于微血管乳房重建。然而，尚不清楚其获益是否超过成本。我们假设微血管乳房重建的 ERAS 路径相对于常规护理是具有成本效益的。
我们建立了一个决策分析模型，纳入了 ERAS 与常规护理相比在微血管乳房重建后具有临床相关性的健康状态。概率和效用评分从已发表的来源中提取，并采用第三方支付者的观点。时间驱动的活动基础成本法用于映射和估计与 ERAS 相关的成本。进行了敏感性分析以检查结果的稳健性。
共纳入 5 项研究，总计 986 例患者，以生成健康状态概率。结果显示 ERAS 具有优势，其成本低于常规护理且效果更好。敏感性分析显示，ERAS 的增量成本-效用比（ICUR）超过 50,000 美元/质量调整生命年（QALY）时，ERAS 变得不具有成本效益。常规护理要具有成本效益，其住院时间必须从 5.96 天减少到 3.36 天。蒙特卡罗分析表明，在一系列支付意愿值下，ERAS 是更具成本效益的选择。
尽管 ERAS 增加了药物和人员成本，但与常规护理相比，它的总体成本更低，且具有更好的结局。这些发现为 ERAS 在微血管乳房重建中的应用价值提供了更多的支持。时间驱动的活动基础成本法提供了详细的估计值，并且在质量改进计划中非常有用。
