Cost-volume Analysis of Deep Inferior Epigastric Artery Perforator Flaps for Breast Reconstruction in the United States

Background: Deep inferior epigastric artery perforator flaps are increasingly utilized over other autolo-gous methods of breast reconstruction. We evaluated the relationship between annual hospital volume and costs after breast reconstruction with the deep inferior epigastric artery perforator flap. Methods: All female patients undergoing elective implant or autologous tissue breast reconstruction were identified using the 2016-2019 Nationwide Readmission Database. Annual hospital volume of deep inferior epigastric artery perforator reconstructions was tabulated and modeled using restricted cubic splines. In-stitutions were categorized into high-and low-volume based on the inflection point of the spline between annual caseload and costs. The association between high volume status and costs, complications, length of stay, and 30-day nonelective readmission was assessed using multivariable regression. Results: Of an estimated 94,524 patients meeting inclusion criteria, 33,046 (34.6%) underwent deep inferior epigastric artery perforator flap reconstruction. Deep inferior epigastric artery perforator flap utilization increased from 31% in 2016 to 40% in 2019 (P < .001) among inpatient breast reconstructions. High-volume hospitals more frequently performed bilateral reconstructions (43.3 vs 37.7%, P =.021) but had similar rates of concurrent mastectomy (28.7 vs 30.6%, P = .46), relative to low-volume hospitals. The median cost of deep inferior epigastric artery perforator reconstruction was lower ($29,900 [interquartile range: 22,400-37,40 0] vs $31,600 [interquartile range: 22,500-44,900], P = .036) at high-volume hos-pitals compared to low-volume. On adjusted analysis, high-volume status was associated a $3,800 (95% confidence interval:-6,200 to-1,400) decrement in hospitalization costs, and reduced odds of periop-erative complications (adjusted odd ratio: 0.68 95% confidence interval: 0.54-0.86). High-volume status was not associated with length of stay or likelihood of unplanned readmission. Conclusion: The present study demonstrated an inverse cost-volume relationship in deep inferior epigastric artery perforator flap breast reconstruction. In line with goals of value-based health care delivery, our findings may inform referral patterns to suitable centers for deep inferior epigastric artery perforator breast reconstruction.(c) 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).