How should quality-of-life data be incorporated into a cost analysis of breast reconstruction? A consideration of implant versus free TRAM flap procedures.

Background: Although studies have compared the costs of implant and transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction, none has considered how quality-of-life data would affect such an analysis.

Methods: A Markov decision analytic model was used. Medical costs associated with the two procedures were obtained from the Healthcare Cost and Utilization Project based on International Classification of Diseases, Ninth Revision (ICD-9) codes. The diagnosis-related group code associated with each ICD-9 code was referenced in Medicare's MedPAR database. A cost-to-charge ratio was calculated using hospital charges covered by Medicare and Medicare reimbursements for each diagnosis-related group code. This ratio was multiplied by the Healthcare Cost and Utilization Project database mean charge. Hypothetical utilities were used to perform a sensitivity analysis and determine the effects of quality-of-life data on costs.

Results: The mean lifetime cost was $14,080 for a free TRAM flap and $16,940 for an implant, a $2860 difference. Based on a sensitivity analysis, however, this cost difference decreased as age at initial procedure increased. Furthermore, a consideration of patient utility that increased the health-related quality-of-life score (based on a scale of 0 to 1) for implants even slightly relative to free TRAM flaps made the implants cost effective. The health-related quality-of-life difference needed to generate a cost per quality-adjusted life-year for breast implants below an acceptable threshold was extremely small (0.64 percent).

Conclusions: To fully evaluate the cost difference between these procedures, a cost-effectiveness analysis must be performed that incorporates quality-of-life data. Such data would significantly affect assessments of the cost difference between implant and autogenous tissue reconstruction.