A Comparison of Acellular Dermal Matrix to Autologous Dermal Flaps in Single-Stage, Implant-Based Immediate Breast Reconstruction: A Cost-Effectiveness Analysis

Hanover and Lebanon, N.H. From the Geisel School of Medicine at Dartmouth, Division of Plastic Surgery, Department of Surgery, Dartmouth Hitchcock Medical Center, and the Tuck School of Business at Dartmouth.
Plastic and Reconstructive Surgery (Impact Factor: 2.99). 05/2013; 131(5):953-61. DOI: 10.1097/PRS.0b013e3182865a24
Source: PubMed


: The use of acellular dermal matrix has allowed for single-stage immediate breast reconstruction after mastectomy at a significantly decreased cost compared with two-stage expander/implant reconstruction. The use of a pedicled autologous dermal flap in the same fashion as acellular dermal matrix in women with larger, ptotic breasts has also allowed for single-stage immediate breast reconstruction with similarly low complication rates and without the added procedural cost of using acellular dermal matrix. There have been no prior studies evaluating whether the added procedural cost for acellular dermal matrix is cost-effective relative to using an autologous dermal flap in single-stage immediate breast reconstruction following mastectomy.
: A comprehensive literature review was conducted to identify published complication rates for single-stage, implant-based immediate breast reconstruction using either acellular dermal matrix or an autologous dermal flap. The probabilities of the most common complications were combined with Medicare Current Procedural Terminology reimbursement codes and expert utility estimates to fit into a decision model to evaluate the cost-effectiveness of acellular dermal matrix.
: The decision model revealed a baseline cost difference of $261.72 and a 0.001 increase in the quality-adjusted life years when using acellular dermal matrix, yielding an incremental cost-utility ratio of $261,720 per quality-adjusted life year. Sensitivity analysis showed that acellular dermal matrix was not cost-effective when the complication rate for autologous dermal flaps was below 20 percent.
: The authors' study demonstrates that acellular dermal matrix is not a cost-effective technology in patients who can have an autologous dermal flap in single-stage immediate breast reconstruction.

24 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: The standard treatment of partial-thickness burns includes topical silver products such as silver sulfadiazine (SSD) cream and enclosed dressings including silver-impregnated foam (Mepilex Ag; Molnlycke Health Care, Gothenburg, Sweden) and silver-laden sheets (Aquacel Ag; ConvaTec, Skillman, NJ). The current state of health care is limited by resources, with an emphasis on evidence-based outcomes and cost-effective treatments. This study includes a decision analysis with an incremental cost-utility ratio comparing enclosed silver dressings with SSD in partial-thickness burn patients with TBSA less than 20%. A comprehensive literature review was conducted to identify clinically relevant health states in partial-thickness burn patients. These health states include successful healing, infection, and noninfected delayed healing requiring either surgery or conservative management. The probabilities of these health states were combined with Medicare CPT reimbursement codes (cost) and patient-derived utilities to fit into the decision model. Utilities were obtained using a visual analog scale during patient interviews. Expected cost and quality-adjusted life years (QALYs) were calculated using the roll-back method. The incremental cost-utility ratio for enclosed silver dressing relative to SSD was $40,167.99/QALY. One-way sensitivity analysis of complication rates confirmed robustness of the model. Assuming a maximum willingness to pay $50,000/QALY, the complication rate for SSD must be 22% or higher for enclosed silver dressing to be cost effective. By varying complication rates for SSD and enclosed silver dressings, the two-way sensitivity analysis demonstrated the cost effectiveness of using enclosed silver dressing at the majority of complication rates for both treatment modalities. Enclosed silver dressings are a cost-effective means of treating partial thickness burns.
    Journal of burn care & research: official publication of the American Burn Association 10/2013; 35(4). DOI:10.1097/BCR.0b013e3182a36916 · 1.43 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: While autologous breast reconstruction was considered the procedure of choice for immediate breast reconstruction, there has been a shift towards implant-based breast reconstruction (IBBR) in recent years. The proven safety of silicone breast implants and the development of biological matrices and synthetic meshes have contributed to the growing popularity of this approach. Although these different products are widely used, only limited clinical data are available with regard to breast surgery. The aim of this review was to give an overview of available biological matrices and synthetic meshes and discuss their use in clinical practice.
    Geburtshilfe und Frauenheilkunde 11/2013; 73(11):1100-1106. DOI:10.1055/s-0033-1350930 · 0.94 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Use of human acellular dermal matrix (ADM) during prosthetic breast reconstruction has increased. Several ADM products are available produced by differing manufacturing techniques. It is not known if outcomes vary with different products. This study reports the complication prevalence following use of a tutoplast-derived ADM (T-ADM) in prosthetic breast reconstruction. We performed a retrospective chart review of 203 patients (mean follow-up times 12.2 months) who underwent mastectomy and immediate prosthetic breast reconstruction utilizing T-ADM, recording demographic data, surgical indications and complication (infection, seroma, hematoma, wound healing exceeding three weeks and reconstruction failure). During a four-year period, 348 breast reconstructions were performed Complications occurred in 16.4% of reconstructed breasts. Infection occurred in 6.6% of breast reconstructions (3.7% - major infection, requiring intravenous antibiotics and 2.9% minor infection, requiring oral antibiotics only). Seromas occurred in 3.4% and reconstruction failure occurred in 0.6% of breast reconstructions. Analysis suggested that complication prevalence was significantly higher in patients with a BMI >30 (p=0.03). The complication profile following T-ADM use is this series is comparable to that reported for with other ADM products. T-ADM appears to be a safe and acceptable option for use in ADM-assisted breast reconstruction.
    Journal of Plastic Reconstructive & Aesthetic Surgery 01/2014; · 1.42 Impact Factor
Show more