SP12. Providing Gender Affirming Care In A Public Health Payer System: Health Policy Implications From A Cost-utility Analysis Of Top Surgery
Bibliographic record
Abstract
Purpose: Gender affirming surgery can have significant positive clinical impacts by improving mental and physical health for transgender and gender diverse (TGD) individuals desiring surgery. Top surgery (i.e., chest reconstructive mastectomy or augmentation) is a safe and commonly performed surgery for TGD individuals. While a previous study has conducted economic evaluations of gender affirming care from the perspective of a United States insurance provider, focused examination of the cost and utility impacts of gender affirming surgical care have yet to be appraised in a publicly funded healthcare system. This study aimed to examine these impacts in a Canadian healthcare system contextualized with potential health policy implications. Methods: A cost-utility analysis (CUA) was conducted. The CUA examined incremental cost per quality adjusted life year (QALY), a standardized measure of patient intervention impact, gained through the provision of gender affirming top surgery. A Markov model was used to estimate the health care costs and QALYs gained from top surgery compared to no surgery. Sub-groups with and without hormone therapy were included to represent current estimates of TGD patients’ hormone use. A cohort of 1000 prospective adult TGD patients were used to represent current surgical waitlist estimates. Once they entered the model, patients experienced outcomes over one-year cycles for ten cycles. A half cycle correction was applied to the model. Given provincial funding differences, the analysis used the Ontario public payer perspective with costs reported in 2022 Canadian dollars. Costs, QALYs, and probability states were derived from health authority reports and the literature. A probabilistic sensitivity analysis was conducted to assess robustness of results, applying standard distributions to each variable in the model and running 10,000 Monte Carlo simulations. Results: Top surgery is considered cost-effective compared to no surgery over a ten-year time horizon when considering the impacts of mental health, suicidal ideation, and smoking, using a typical willingness to pay threshold of $50,000/QALY. The ten-year incremental cost effectiveness ratio, measuring intervention costs per QALY, was $-81,183.56 per QALY gained, with a net monetary benefit of $394,050.00. Results were robust with 97.5% of the Monte Carlo simulations finding surgical intervention cost effective in the probabilistic sensitivity analysis. Further top surgery was dominant in 75.4% of these simulations. Conclusions: Economic evaluation findings suggest that when mental and physical health benefits are considered, top surgery is cost-effective when compared to no surgery for adult TGD individuals in Ontario. Considering these additional patient health states can more accurately assess system level impacts of gender affirming surgical care provision. By using a cohort size representative of the current surgical waitlist numbers, these findings suggest there may be system level benefit to prioritizing providing access to care for waitlisted patients. Further research may include evaluation of other provincial health systems and incorporation of patient lived experience to identify outcomes not routinely accounted for in current economic evaluation models.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.003 | 0.001 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.002 | 0.000 |
| Bibliometrics | 0.002 | 0.005 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.001 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".