title: Is Single-Stage Prosthetic Reconstruction Cost Effective? A Cost-Utility Analysis for the Use of Direct-to-Implant Breast Reconstruction Relative to Expander-Implant Reconstruction in Postmastectomy Patients.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  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.
authors.affiliation: 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.
authors.forename: Naveen M
authors.initials: NM
authors.lastname: Krishnan
authors.affiliation: 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.
authors.forename: John P
authors.initials: JP
authors.lastname: Fischer
authors.affiliation: 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.
authors.forename: Marten N
authors.initials: MN
authors.lastname: Basta
authors.affiliation: 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.
authors.forename: Maurice Y
authors.initials: MY
authors.lastname: Nahabedian
mesh_terms: D019928:Breast Implantation; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000191:economics* / Q000379:methods*; D008408:Mastectomy; D011183:Postoperative Complications; D011788:Quality of Life; D015625:Tissue Expansion Devices