DS24 The cost-saving potential of secondary intention healing vs. full-thickness skin grafting for dorsal hand skin cancer excision in the NHS

Abstract

Secondary intention healing (SIH) is a safe, well-tolerated technique following excision of cutaneous malignancies on the dorsum of the hand, with reported cosmetic outcomes comparable with full-thickness skin grafting (FTSG). Despite SIH being less resource intensive than FTSG, the incremental NHS cost difference between the reconstruction strategies has not been quantified. We estimated the per case incremental cost difference to the NHS between the excision of dorsal hand cutaneous carcinomas reconstructed by SIH vs. FTSG using a hypothetical decision-­dependent costing model. A cost-minimization analysis was conducted from the NHS provider perspective, assuming comparable clinical outcomes between SIH and FTSG. A marginal costing approach identified resources that differ between the reconstruction strategies. Model inputs were derived from dermatological surgery literature, National Cost Collection outpatient procedure costs, NHS workforce cost data and NHS Supply Chain consumables pricing for contextual validation. The key assumptions were that SIH excisions could be performed in a side room by a registrar or equivalent grade over 30 min with one to two postoperative reviews, whereas FTSG excisions are performed in a fully equipped dermatology procedure room by an experienced consultant surgeon over 60 min, with graft-specific consumables and two to three postoperative reviews. A 10% graft failure rate was incorporated using an expected-value approach, assuming predominantly conservatively managed partial graft loss. Variation in procedure duration, staffing and follow-up intensity informed upper and lower cost bounds. The estimated marginal cost of excision managed by SIH was £95–140 per case, compared with £580–720 per case for excision with FTSG. This corresponds to an estimated per case cost saving of £440–625 (approximately four- to sixfold lower cost) when SIH replaces FTSG. Reconstruction by SIH for dorsal hand skin cancer excision could deliver substantial cost savings for the NHS compared with FTSG, while maintaining comparable clinical outcomes, supporting more efficient use of dermatological surgery resources.