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. 2008 Summer;16(2):77-84.
doi: 10.1177/229255030801600201.

A comparison of the superficial inferior epigastric artery flap and deep inferior epigastric perforator flap in postmastectomy reconstruction: A cost-effectiveness analysis

Achilleas Thoma  1 , Leigh Jansen, Sheila Sprague, Eric Duku P Stat
Affiliations

A comparison of the superficial inferior epigastric artery flap and deep inferior epigastric perforator flap in postmastectomy reconstruction: A cost-effectiveness analysis

Achilleas Thoma et al. Can J Plast Surg. 2008 Summer.

Abstract
in English, French

Purpose: To perform a cost-effectiveness analysis comparing the superficial inferior epigastric artery (SIEA) and deep inferior epigastric perforator (DIEP) flaps in postmastectomy reconstruction.

Methods: A decision analytic model with seven clinically important health outcomes (health states) was used, incorporating the Ontario Ministry of Health's perspective. Direct medical costs were estimated from a university-based hospital. The utilities of each health state converted into quality-adjusted life years (QALYs) were obtained from previously published data. Health state probabilities were computed from a systematic literature review. Analyses yielded SIEA and DIEP expected costs and QALYs allowing calculation of the incremental cost-utility ratio (ICUR). One-way sensitivity analyses were conducted under five plausible scenarios, assessing result robustness.

Results: Five SIEA and 27 DIEP studies were identified. The baseline SIEA expected cost was slightly higher than that for the DIEP ($16,107 versus $16,095), with slightly higher QALYs (33.14 years versus 32.98 years), giving an ICUR of $77/QALY. Taking into account conversions from SIEA to DIEP, the ICUR increased to $4,480/QALY. Sensitivity analysis gave ICURs ranging from $2,614/QALY to 'dominant', all consistent with the adoption of the SIEA over the DIEP.

Conclusion: The best available evidence suggests the SIEA is a cost-effective procedure. However, given the high SIEA to DIEP conversion rates and small marginal differences in cost and effectiveness, the ICUR may be sensitive to minor changes in costs or QALYs. The 'truth' can only be obtained from a randomized, controlled trial comparing both techniques side by side, simultaneously capturing the costs of the competing interventions.

OBJECTIF :: Effectuer une analyse coût-efficacité comparant un lambeau de l’artère épigastrique inférieure superficielle (SIEA) à un lambeau perforant de l’artère épigastrique inférieure profonde (DIEP) pour la reconstruction après une mastectomie.

MÉTHODOLOGIE :: Les auteurs ont utilisé un modèle d’analyse décisionnelle comportant sept issues de santé importantes d’un point de vue clinique (états de santé), incluant la perspective du ministère de la Santé de l’Ontario. Ils ont estimé les coûts médicaux directs d’après un hôpital universitaire. Ils ont obtenu l’utilité de chaque état de santé converti en années de vie pondérées par la qualité (AVPQ) dans des données déjà publiées. Ils ont calculé les probabilités relatives aux états de santé au moyen d’une analyse bibliographique systématique. Les analyses ont fourni les coûts prévus des SIEA et des DIEP ainsi que de l’AVPQ et ont ainsi permis le calcul du ratio coût-utilité incrémentiel (RCUI). Ils ont procédé à des analyses de sensibilité unidirectionnelles en vertu de cinq scénarios plausibles, afin d’évaluer la solidité des résultats.

RÉSULTATS :: Les auteurs ont repéré cinq SIEA, 27 DIEP et des études. Le coût prévu de base du SIEA était légèrement plus élevé que celui du DIEP (16 107 $ par rapport à 16 095 $) et s’associait à des AVPQ légèrement plus positives (33,14 ans par rapport à 32,98 ans), pour un RCUI de 77 $/AVPQ. Compte tenu de la conversion du SIEA au DIEP, le RCUI augmentait à 4 480 $/AVPQ. L’analyse de sensibilité a donné des RCUI variant entre 2 614 $/AVPQ et « dominant », en harmonie avec l’adoption du SIEA plutôt que du DIEP.

CONCLUSION :: Les meilleures données disponibles indiquent que le SIEA est une intervention rentable. Cependant, étant donné les taux de conversion élevés de SIEA à DIEP et les petites différences marginales du point de vue du coût et de l’efficacité, le RCUI est peut-être sensible à des modifications mineures des coûts ou de l’AVPQ. On obtiendra la « vérité » seulement à partir d’un essai aléatoire et contrôlé comparant conjointement les deux techniques afin de saisir simultanément le coût de ces interventions concurrentielles.

Keywords: Breast reconstruction; Cost-effectiveness; Cost-utility analysis; Postmastectomy; Quality-adjusted life years.

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Figures

Figure 1)
Figure 1)
Comparison of cost and effectiveness. Adapted from reference
Figure 2)
Figure 2)
Superficial inferior epigastric artery (SIEA) flap model structure and results. Costs are in Canadian dollars (CDN$1 = US$0.85 as of March 15, 2007)
Figure 3)
Figure 3)
Deep inferior epigastric perforator (DIEP) flap model structure and results. Costs are in Canadian dollars (CDN$1 = US$0.85 as of March 15, 2007)
Figure 4)
Figure 4)
Effectiveness model results. Costs are in Canadian dollars (CDN$1 = US$0.85 as of March 15, 2007). DIEP Deep inferior epigastric perforator flap; ICUR Incremental cost-utility ratio; QALY Quality-adjusted life year; SIEA Superficial inferior epigastric artery flap
Figure 5)
Figure 5)
Baseline results on the cost-effectiveness plane. ICUR Incremental cost-utility ratio; QALY Quality-adjusted life year
See this image and copyright information in PMC

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