by Jablonka,
Eric M.; Lamelas, Andreas M.; Kanchwala, Suhail K.; Rhemtulla, Irfan; Smith,
Mark L
Background: The number of free flap take-backs and successful salvages following
microsurgical breast reconstruction decreases as time from surgery increases.
As a result, the cost of extended inpatient monitoring to achieve a successful
flap salvage rises rapidly with each postoperative day. This study introduces a
simplified cost-utility model of inpatient flap monitoring and identifies when
cost-utility exceeds the thresholds established for other medical treatments.
Methods: A retrospective review of a prospectively maintained database was
performed of patients who underwent microsurgical breast reconstruction to
identify flap take-back and salvage rates by postoperative day. The number of
patients and flaps that needed to be kept on an inpatient basis each day for
monitoring to salvage a single failing flap was determined. Quality-of-life
measures and incremental cost-effectiveness ratios for inpatient flap
monitoring following microsurgical breast reconstruction were calculated and
plotted against a $100,000/quality-adjusted life-year threshold. Results: A total of 1813 patients (2847
flaps) were included. Overall flap take-back and salvage rates were 2.4 percent
and 52.3 percent, respectively. Of the flaps taken back, the daily take-back
and salvage rates were 56.8 and 60.0 percent (postoperative day 0 to 1), 13.6
and 83.3 percent (postoperative day 2), 11.4 and 40.0 percent (postoperative
day 3), 9.1 and 25.0 percent (postoperative day 4), and 9.1 and 0.0 percent
(>postoperative day 4), respectively. To salvage a single failing flap each
day, the number of flaps that needed to be monitored were 121 (postoperative
day 0 to 1), 363 (postoperative day 2), 907 (postoperative day 3), 1813
(postoperative day 4), and innumerable for days beyond postoperative day 4. The
incremental cost-effectiveness ratio of inpatient flap monitoring begins to
exceed a willingness-to-pay threshold of $100,000/quality-adjusted life-year by
postoperative day 2.
Conclusion: The health care cost associated with inpatient flap monitoring
following microsurgical breast reconstruction begins to rise rapidly after
postoperative day 2.
