Cost of hospital admission after autologous breast reconstruction and factors associated with increased cost: a population-based cohort study

Background: Demand for reconstructive surgery postmastectomy has risen, prompting evaluation of its economic impact in a publicly funded health care system. We sought to explore factors associated with increased costs of hospital admission following autologous breast reconstruction. Methods: We conducted a retrospective cohort study involving patients who underwent autologous breast reconstruction in Ontario, Canada (2005 to 2020). Patients received either a pedicled transverse rectus abdominis myocutaneous (TRAM) flap or free tissue transfer. We analyzed costs from the hospital perspective, from admission to discharge. We used generalized linear models with a γ distribution to identify cost-associated factors. Results: Of 2634 patients, 378 (14.4%) underwent pedicled TRAM and 2256 (85.7%) underwent free flap reconstruction. The median cost of hospital admission was $8816 (interquartile range $3383 to $90 974). Univariate analysis identified cost drivers including length of stay, reconstruction type, age, income quintile, laterality, and emergency reoperation. Multivariable analysis showed increased costs associated with free flap reconstruction (13% increase, 95% confidence interval [CI] 5% to 22%; p < 0.001), age older than 70 years (31% increase, 95% CI 7% to 61%; p < 0.01), lower income quintile (10% increase, 95% CI 3% to 18%; p = 0.01), and bilateral reconstruction (11% increase, 95% CI 1% to 23%; p = 0.03). Hospital type, geographic region, timing of reconstruction, comorbidities, and rurality were not significantly associated with cost. Conclusion: Free flap reconstruction, bilateral procedures, and advanced age are key drivers of hospital admission costs. These findings may inform policy and resource-allocation strategies in publicly funded systems to optimize value in breast reconstruction care.