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Economic viability of_autologous_breast_reconstruction_final
- 2. Pouria Moradi Alexander Hills Duncan Atherton Simon Wood Charing Cross Hospital, London ASC, Perth 2010
- 3. Aims • Assess the financial implications of breast reconstruction • Establish whether the current gold standard of DIEP is economically viable
- 4. Materials and methods • Retrospective audit of: – Procedure – Length of stay – Reconstructive amendments/corrections – Cost • For 1 surgeon, at 1 unit, between 2000-07
- 5. • Review of surgical diaries cross referenced against electronic patient records
- 6. Results • 274 patients • Average age 48 years • 278 primary breast reconstructions • 366 secondary procedures • Minimum of 1 year follow up • Mean 3 year follow up
- 7. Total number and type of breast reconstruction
- 8. Breast reconstruction type vs Length of stay (days) Mean Median Cost per £1,183 £2,475 £2,888 £ 2,200 Median LOS
- 9. Overall mean number of revisions per breast reconstruction
- 10. Total number of secondary procedures conducted Implant Symmetrisation Wound care
- 11. Total number of secondary procedures conducted Implant Symmetrisation Wound care
- 12. What is the tariff for each procedure?
- 13. What is the tariff / income for each procedure?
- 14. Tariff for additional procedures
- 15. What are the financial implications of the additional procedures?
- 16. What is the actual cost? THEATRE TIME • Half day list £3200 » Anaesthetic consultant » ODP Nurse (Band 6) » Theatre nurses (Band 6) » Theatre nurse HCA (Band 2) » Recovery Nurse (Band 6) » A&C Support » Limited non pay consumables • So a DIEP/TRAM on a full list - £6400 • LD and implant - £3200 • Implant reconstruction - £1700
- 17. What other costs? • In patient stay (£275 per night) • DIEP/TRAM - 19 hours of one to one nursing - £253 (vs £600 for ITU) • OPD attendances (New £152, FU £78) • (Mastectomy) • LD/Implants - Prosthesis – (£250 – £700)
- 19. Tariff Disparity • Paid solely for the principle procedure • Separately the mastectomy tariff is £2623 and axillary surgery £2549 (Total £5172) – In 2009-10 with HRG4 coding it will vary from £5132-7015 – As not coded - no research grant for masectomy (£480) • Immediate reconstruction financially discouraged
- 20. Data Summary
- 21. Conclusions • Our belief that autologous reconstruction offers better symmetry at 4-5 years • Weight change impact on symmetry greater with implants • Minimal number of procedures – Autologous less secondary procedures than Implants – Socio-economic costs related to repeat operations
- 22. Conclusions
- 23. Conclusions • Tariff system does not encourage immediate or bilateral reconstruction
Notes de l'éditeur
- Good morning, I’m Alexander Hills and today I am going to talk on ‘the economic viability of autologous breast reconstruction’
- Our aim was to look at breast reconstruction as a whole and assess the financial implications of choosing one technique over another through this we aimed to establish whether DIEP, as the current AESTHETIC gold standard, was economically viable
- To do this we conducted a retrospective audit looking at the primary procedures, length of stay, subsequent reconstructive amendments and cost It was based on one surgeons data, at one unit between 2000 and 2007
- The data was extracted from surgical diaries and cross referenced against electronic patient records
- We had 274 patients, with an average age of 48 years between them. These patients underwent a total of 278 primary reconstructions and a total of 366 secondary procedures They had a minimum follow up of 1 year, and a mean follow up of 3 years
- This key graph outlines how our practice changed over the 7 years Looking at the grey bars, you can see how the practice of TRAMS has gradually faded following the introduction of the DIEP in 2004, shown here in blue, which quickly become the technique of choice. Likewise, if you now look at purple bars, representing Latissimus Dorsi’s, you can see how they were by far the most commonly performed breast reconstruction up until the introduction of the DIEP. Finally, if I can draw your attention to the implants, in pink at the bottom, you can see their numbers have stayed relatively stable. 73 implants, 98 LD’s, 39 TRAM’s and 68 DIEP’s were performed
- This is another key slide. It summarises the Length of stay between the various procedures, with the coloured boxes on the graph representing the mean, and the blue lines the median length of stay. The bar along the bottom shows the subsequent median cost, based on the cost of a standard bed at our unit per night . As you can see implants have a much shorter length of stay and as such a much lower median cost.
- I appreciate this is a busy of this key slide, It shows how the secondary procedures break down. We have divided up into implant, symmetrisation and wound care procedures I would like to draw your attention to how LD and implants dominate every group
- I appreciate this is a busy of this key slide, It shows how the secondary procedures break down. We have divided up into implant, symmetrisation and wound care procedures I would like to draw your attention to how LD and implants dominate every group
- These ‘top up’ fees come from four main areas; ‘ Market forces factor’ – which is effectively a subsidy for performing the procedure in London Research grants, Teaching and… Co-morbidities. Which for the purposes of this study we have assumed these to be equal. and it is worth noting at this point that market force make up a substantial part of the income- accounting for approximately 20- 30% of these procedures final tariff, a fee that you would be substantially lower in areas out side of likes of London
- These ‘top up’ fees come from four main areas; ‘ Market forces factor’ – which is effectively a subsidy for performing the procedure in London Research grants, Teaching and… Co-morbidities. Which for the purposes of this study we have assumed these to be equal. and it is worth noting at this point that market force make up a substantial part of the income- accounting for approximately 20- 30% of these procedures final tariff, a fee that you would be substantially lower in areas out side of likes of London
- Moving on, this is how the secondary procedures tariffs breakdown
- Based on this, we worked out average tariff for the additional procedures If we take the implant as an example we can see that for every primary procedure you perform, you have to do a further 1.6 COMPLEX operations, such as implant exchange, equating to an additional £3,652, on top of the original tariff. DIEP’s only require 1 further SIMPLER operation, such as scar revision equating to a much lower additional tariff at £1,851.
- So those were the tariffs being paid to the hospital, what about the actual costs to the hospital? Taking the theatre costs as those outlined here, it works out at £3,200 for a half day list. Therefore a DIEP or TRAM equates to £6,400, LD’s £3,200 and implants £1,700
- Then we add on our additional costs of hospital stay, one to one nursing, the standard outpatient attendances and, in the case of procedures with implants, the cost of implants.
- The first column shows how much we get paid, the second, how much it costs us As you can see on the primary procedure alone, the trust is making a loss on all the procedures except the LD
- At this point I just want to take stock that these costs are only conservative estimates This is because these are largely cancer operations which have other procedures performed at the same time And…as we only get paid for the principle procedure we miss out out on income we would otherwise receive if done separately. Such as a further £2,600 for a masectomy, …and…we also miss out on income from other areas, like research. Which, using masectomy as an example again, is around £480. Significantly the tariff system also neglects the cost of any contralateral procedures done at the same time. As a result the current tariff system is financially discouraging the ideal of immediate reconstruction as well as bilateral procedures
- This slide is a summary of our data By a relatively short follow up of 3 years, once you account for the cost of secondary procedures there is only £3,000 diffeence between implant and DIEP, that is the cost of one further implant exchange And.. The LD is only £600 shy of of the a DIEP, the equivalent of a few additional out patient appointments
- Many would agree that we should aim for the best aesthetic outcome through the minimal number of procedures… to these ends at our data at 3 years has shown autologous procedures such as DIEP are the have the least number of revisions and for them to be relatively stable We also know that in the longer term weight change impacts on the symmetry in those with implants to a greater degree than tissue reconstructions Our belief is that autologous reconstruction offers better symmetry at 4-5 years, something we are looking to formally validate. Most would agree that we should aim to achieve the best symmetry and long term results possible using the minimal number of procedures To these ends there are numerous papers supportive of autologous reconstruction being the gold standard Currently our data set has a mean of 3 years follow up, however, when we look at longer term studies like kroll and beahm they project that implants are likely to require even more future surgeries, and, consensus alongside current data suggests that DIEP’s will remain relatively stable. Extrapolating this forward it is likely that with follow up there will be a breakeven point where DIEP will be more cost effective than implants.
- Financially…we have found that the LD’s has effectively reached cross over with the DIEP- with the DIEP being more cost effective at 3 years However the with regards to the absolute costs of implants, they remain cheaper than autologous breast reconstruction at a mean FU of 3 years , albeit minimally so, But when looking at projected costs, as implants have been shown to continue to require further operations into the future, and as DIEPs remain relatively stable, there is going to be a cross over regarding financial viability, Kroll in 1996 placed this cross over at around 4 years for a TRAM against an implant, however we project on the basis of our data it to be slightly more than this for a DIEP. As such our data is supportive of autologous reconstuctions being both better and more cost effective in the longer term
- Finally… we also found that the current tariff system is not supportive of either immediate, or bilateral, breast reconstruction