A Nationwide Analysis of Cost Variation for Autologous Free Flap Breast Reconstruction

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Cost variation among hospitals has been demonstrated for surgical procedures. Uncovering these differences has helped guide measures taken to reduce health care spending. To date, the fiscal consequence of hospital variation for autologous free flap breast reconstruction is unknown.


To investigate factors that influence cost variation for autologous free flap breast reconstruction.

Design, Setting, and Participants

A secondary cross-sectional analysis was performed using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2008 to 2010. The dates of analysis were September 2016 to February 2017. The setting was a stratified sample of all US community hospitals. Participants were female patients who were diagnosed as having breast cancer or were at high risk for breast cancer and underwent autologous free flap breast reconstruction.

Main Outcomes and Measures

Variables of interest included demographic data, hospital characteristics, length of stay, complications (surgical and systemic), and inpatient cost. The study used univariate and generalized linear mixed models to examine associations between patient and hospital characteristics and cost.


A total of 3302 patients were included in the study, with a median age of 50 years (interquartile range, 44-57 years). The mean cost for autologous free flap breast reconstruction was $22 677 (interquartile range, $14 907-$33 391). Flap reconstructions performed at high-volume hospitals were significantly more costly than those performed at low-volume hospitals ($24 360 vs $18 918, P < .001). Logistic regression demonstrated that hospital volume correlated with increased cost (Exp[β], 1.06; 95% CI, 1.02-1.11; P = .003). Fewer surgical complications (16.4% [169 of 1029] vs 23.7% [278 of 1174], P < .001) and systemic complications (24.2% [249 of 1029] vs 31.2% [366 of 1174], P < .001) were experienced in high-volume hospitals compared with low-volume hospitals. Flap procedures performed in the West were the most expensive ($28 289), with a greater odds of increased expenditure (Exp[β], 1.53; 95% CI, 1.46-1.61; P < .001) compared with the Northeast. A significant difference in length of stay was found between the West and Northeast (odds ratio, 1.25; 95% CI, 1.17-1.33).

Conclusions and Relevance

There is significant cost variation among patients undergoing autologous free flap breast reconstruction. Experience, as measured by a hospital’s volume, provides quality health care with fewer complications but is more costly. Longer length of stay contributed to regional cost variation and may be a target for decreasing expenditure, without compromising care. In the era of bundled health care payment, strategies should be implemented to eliminate cost variation to condense spending while still providing quality care.

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