Reconstruction After Salvage Total Laryngectomy: A Cost-effectiveness Analysis.
OBJECTIVE
To determine the most cost-effective reconstruction method after salvage total laryngectomy.


STUDY DESIGN
Cost-effectiveness analysis.


SETTING
Tertiary care hospitals with head and neck oncologic and reconstructive surgeons.


SUBJECTS AND METHODS
We constructed a Markov-based decision model to compare reconstruction by primary closure to pectoralis flap and free flap after salvage total laryngectomy. The model simulated disease with transition probabilities and health utilities found in primary literature and estimated the average overall cost of each reconstructive method using Medicare billing codes. Effectiveness was compared using quality-adjusted life years (QALYs). One-way and probabilistic sensitivity analyses were performed to scrutinize the conclusions of our model. Reconstruction methods were compared using incremental cost-effectiveness ratios (ICERs). In the United States, less than $150,000 per QALY gained is considered cost-effective (2019 US dollars).


RESULTS
Our base case analysis revealed that primary closure was less expensive ($44,370) and yielded more QALYs (0.91) than both pectoralis ($45,163, 0.81 QALYs) and free flap ($46,244, 0.85 QALYs), making it the most cost-effective option. Between flaps, free flap was cost-effective over pectoralis flap (ICER = $27,025/QALY gained). Sensitivity analyses showed primary closure as cost-effective 69% of the time over either flap. These conclusions were sensitive to the health utilities (quality of life) of each method of reconstruction.


CONCLUSION
Tissue flaps to augment closure after salvage total laryngectomy are not always the most cost-effective reconstructive option. The long-term morbidity of flap surgery oftentimes outweighs the benefit of lowering fistula rates after surgery. Careful consideration must be taken when advising patients of their reconstructive options.
['Acevedo|Joseph R|JR|', 'Yu|Jeffrey C|JC|', 'Cameron|Brian|B|', 'Nurimba|Margaret|M|', 'Hay|Joel W|JW|', 'Kokot|Niels C|NC|']
D000368:Aged D003362:Cost-Benefit Analysis D005260:Female D006801:Humans D007822:Laryngeal Neoplasms D007825:Laryngectomy D008297:Male D008390:Markov Chains D006278:Medicare D019057:Quality-Adjusted Life Years D019651:Reconstructive Surgical Procedures D016879:Salvage Therapy D013524:Surgical Flaps D014481:United States
free flaps quality of life epidemiology/outcomes research head and neck cancer head and neck surgery health economics health policy microvascular reconstructive surgery