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PURPOSE
Patients with large facial defects have traditionally been treated with autologous reconstruction, requiring multiple staged procedures. Face transplantation is an emerging modality for the treatment of these defects using allografts and immunosuppression. This study analyzes the cost of face transplantation in comparison to conventional reconstruction and discusses appropriate cost evaluation strategies for emerging procedures.
METHODS
Billing and medical records were queried for codes related to conventional facial reconstruction procedures performed at a single institution over a period of 10 years. Inclusion criteria included having a major defect (missing 50-100% of one or more facial subunits, or greater than 25% of total face surface area) and having the index reconstruction procedure performed at our institution. Additionally, patients who have undergone face transplantation at our institution were included in the transplantation group. Case-specific hospital costs were obtained from internal accounting data. Provider costs were estimated using published national means for each billing code. Organ procurement fees and future immunosupression drug costs were estimated based on actual costs and anticipated future contractual costs. Primary outcomes included peri-procedure costs, one-year total costs, and two-year estimated costs. Univariate and multivariate analysis for cost drivers was performed, as well as a subset analysis for costs stratified by patient characteristics and type of injury (including region of facial injury and origin of injury). Because most traditional reconstruction patients had smaller facial defects compared to the transplant patients, a generalized linear regression model was created to estimate reconstruction costs for a hypothetical patient with defects equivalent to the transplant patients. All data analysis was performed using SAS statistical software (SAS Institute, Cary, NC).
RESULTS
Among the 2034 face reconstruction patients examined, 72 were eligible for inclusion in the conventional reconstruction group. Three face transplantation patients were included in the transplantation group. Total one-year hospital costs for the transplant group were significantly higher than the conventional reconstruction group at one year (mean \,052, median \,475 vs. mean \,848, median \,449, P<0.0001) and two years (mean \,052, median \,475 vs. mean \,743, median \,449, P<0.0001), with adjustment for inflation.
Costs in both groups were higher during the first month of treatment than in any other month.
Among reconstruction patients, higher costs were associated with facial defect involving the mandible region (p=0.0028), private insurance (P=0.0039), the presence of hypertension (P=0.0168), and the development of post-operative complications (P=0.0238). One-year costs for a hypothetical conventional patient with reconstruction of all facial subunits (as is done in full face transplantation) was \,158 (95% confidence interval, \,367-\,949).
CONCLUSIONS
Face transplantation is an emerging technique that can restore facial appearance and function to a level that can not be achieved with conventional reconstruction. Although transplantation is significantly more costly than traditional reconstruction, costs are comparable after adjustment for case severity. As with all early technologies and treatments, gains in efficiency and experience are expected to lower costs. Additionally, there may be differences in functional and quality of life benefits between these procedures that would impact the value of the resources utilized.