Cost-Trajectory Framework for Total Episode Expenditure in Complex Wound Reconstruction: The CASCADE (Cost Analysis of Surgical Complications and Downstream Expenditure) Model.

Abstract

Complex wound reconstruction may progress through stage-dependent clinical and economic trajectories in which wound failure leads to infection, reoperation, prolonged hospitalization, post-acute care, outpatient wound management, and possible readmission. Procedural-cost evaluation may not fully capture these downstream consequences in high-risk reconstructive settings. This paper presents the CASCADE (Cost Analysis of Surgical Complications and Downstream Expenditure) model, a conceptual, literature-derived decision framework rather than a primary data analysis or statistically validated predictive model. CASCADE applies an expected-value framework to evaluate the reconstructive strategy at the index operation, using three bounded inputs: failure probability (P), failure trajectory cost (C), and incremental reconstruction cost (ΔC). These inputs are structured into the decision rule ΔC < ΔP × C. A Clinical Risk Score (CRS) is used to standardize the assignment of cases into risk tiers. Across illustrative high-risk wound environments, failure trajectories may increase total episode expenditure from approximately $80,000-$150,000 after successful reconstruction to $400,000-$1,000,000+ after failure-driven care. These values are literature-informed illustrative estimates used to parameterize the framework, not observed case-level measurements. Sensitivity analysis demonstrates that at CRS ≥6, the CASCADE decision threshold often exceeds typical incremental reconstructive procedure costs across plausible input combinations. CASCADE provides a reproducible, bidirectional framework for trajectory-based cost evaluation in complex wound reconstruction. It may support surgical decision-making, institutional planning, and reimbursement analysis when total episode cost, rather than index procedural cost alone, is the appropriate unit of economic evaluation. The framework evaluates cost relationships but does not define reimbursement levels and requires future validation against institutional or claims-based datasets.