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Original Investigation |

The Cost of Facial Deformity A Health Utility and Valuation Study

Jacob K. Dey, BS1; Lisa E. Ishii, MD, MHS1; Andrew W. Joseph, MD, MPH1; Jennifer Goines, BS2; Patrick J. Byrne, MD, MBA1; Kofi D. O. Boahene, MD1; Masaru Ishii, MD, PhD3
[+] Author Affiliations
1Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology–Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
2Morehouse School of Medicine, Atlanta, Georgia
3Division of Rhinology, Department of Otolaryngology–Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
JAMA Facial Plast Surg. 2016;18(4):241-249. doi:10.1001/jamafacial.2015.2365.
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Published online

Importance  The impact of facial defects on quality of life as perceived by society and the value society places on facial reconstruction are important outcomes measures.

Objective  To measure the health state utility and dollar value of surgically reconstructing facial defects as perceived by society.

Design, Setting, and Participants  A randomized observational study conducted in an academic tertiary referral center using a socioeconomically diverse group of 200 casual observers.

Main Outcomes and Measures  Observers viewed images of faces with defects of varying sizes and locations before and after surgical reconstruction. Observers imagined if the defect in each image were on their own face and rated (1) their health state utility with the defect and (2) how much they would be willing to pay to have the defect surgically repaired to normal (perfect repair). Established health state utility and contingent valuation metrics were used.

Results  Data from 200 observers were analyzed. Facial defects significantly decreased perceived health state utility with the greatest penalty attributed to large and centrally located defects. Surgical reconstruction of the facial defects increased health state utility to near-normal ranges for all groups except large central defects. Participants were willing to pay an average of $1170 (95% CI, $767-$1572) to repair a de novo small peripheral defect; they were willing to pay $4274 more than the average (95% CI, $3296-$5251) to repair a large defect and $2372 more (95% CI, $1379-$3366) to repair a central defect. Using these valuation and health utility data, we calculated willingness to pay per quality-adjusted life-year (WTP/QALY), a value-related metric. Mean WTP/QALY ratios ranged from $639/QALY for repairing small peripheral defects to $2838/QALY for repairing large central defects, well below all cost-effectiveness thresholds.

Conclusions and Relevance  Casual observers perceived that facial defects significantly decrease quality of life, an effect improved by reconstructive surgery. Measuring WTP and calculating WTP/QALY provides novel data to assess the social importance and value of facial reconstructive surgery. To our knowledge, these are the first data demonstrating that surgical reconstruction of facial defects is a high-value intervention as perceived by society. These findings have implications for a broad range of stakeholders, including patients, surgeons, health policy makers, and payers.

Level of Evidence  NA.

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Figure 1.
Plots From the Structural Equation Model Illustrating the Impact of Reconstructive Surgery

A, Impact on defect severity. B, Impact on attractiveness. C, Impact on Box-Cox willingness to pay.

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Figure 2.
Willingness to Pay (WTP) vs Normalized Severity Scale

For each graph, the middle line represents the mean bounded by upper and lower lines representing the 1 SD intervals above and below the mean. A, The interobserver variation in baseline WTP with increasing severity. B, The interobserver variation in rate of change in WTP with increasing severity.

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