"Gender Affirming Care in a Public Health Payer System: A Cost Utility Analysis of Top Surgery".

Abstract

Gender affirming surgery can improve the mental and physical health of transgender and gender diverse (TGD) adults. Examination of these impacts through economic evaluation has yet to be conducted in a publicly funded healthcare system. A Markov model was used to inform the cost-utility analysis over a twenty-year time horizon. Uncertainty was assessed using probabilistic sensitivity analysis. Time horizon was varied in a scenario analysis. The analysis took the Ontario public payer perspective with costs reported in 2024 Canadian dollars ($1 CAD = $0.86 USD per purchasing power parities OECD 2022). Costs, utilities, and probability states were derived from health authority reports and the literature. The cohort included TGD adults in Ontario who want top surgery. Provision of top surgery was compared to no surgery. Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) were primary outcome measures. Top surgery would be considered cost-effective if the ICER was below the typical willingness to pay (WTP) threshold of $50,000 per QALY (discounted at 1.5% per annum). The cohort consisted of 1000 TGD individuals, representative of current Ontario top surgery waitlists. Top surgery was dominant (incremental cost -$2,857, incremental effectiveness 0.59 QALYs) compared to no surgery over a twenty-year time horizon. Results were robust with surgical intervention being cost-effective in 58% (dominant in 52%) of the 10,000 Monte Carlo simulations. Findings suggest that top surgery is a cost-effective intervention at conventional WTP thresholds. There may be system level benefit to providing access to care for waitlisted patients.