[Between the Clinical Gold Standard and Economic Challenges: A Case-Cost Analysis of the Cost-Effectiveness of Autologous Breast Reconstruction].

Abstract

Background: Autologous breast reconstruction using the Deep Inferior Epigastric Perforator (DIEP) flap is considered an established standard procedure due to its preservation of the rectus muscles, natural aesthetic results, and high patient satisfaction. At the same time, it is resource-intensive. Case-specific health economic data on cost-effectiveness within the German DRG system have been limited to date.

Materials and methods: A retrospective, single-center case-cost analysis of 18 female patients who underwent unilateral DIEP flap reconstruction in 2023 without perioperative complications or DRG-relevant secondary diagnoses. The study captured directly attributable medical costs for the preoperative, perioperative, and post-hospitalization phases. Revenue analysis was performed using the aG-DRG J01Z, with nursing fees considered separately. In addition, five expert interviews were qualitatively evaluated.

Results: The average total direct costs amounted to €9829.07 per patient. The largest share of costs was attributable to the perioperative phase, particularly the surgical phase, which accounted for €5792.27. When considering direct costs, the average DRG revenue of €14,017.05 resulted in a positive contribution margin of €4192.65. Assuming indirect costs of up to 50%, total costs rose to €14,738.94, resulting in a deficit of €721.89 when DRG reimbursement was the sole source of revenue. Only with the additional nursing fee of €1606.85 did a small positive overall balance of €884.97 per case result.

Conclusion: Under the conditions described, unilateral DIEP flap surgery may barely break even in the German DRG system, assuming a selected best-case scenario. However, its economic viability remains fragile and is significantly influenced by indirect costs, nursing fees, process standardization, and structural overhead costs. Future reimbursement models should take greater account of process complexity, center structures, and patient-specific long-term outcomes.